Objective assessment of technical skills in cardiac surgery.

OBJECTIVE: Reduced training time combined with no rigorous assessment for technical skills makes it difficult for trainees to monitor their competence. We have developed an objective bench-top assessment of technical skills at a level commensurate with a junior registrar in cardiac surgery. METHODS: Forty cardiothoracic surgeons were recruited for the study, consisting of 12 junior trainees (year 1-3), 15 senior trainees (year 4-6) and 13 consultants. The assessment consisted of four key tasks on standardised bench-top models: aortic root cannulation, vein-graft to aorta anastomosis, vein-graft to Left Anterior Descending (LAD) anastomosis and femoral triangle dissection. An expert surgeon was present at each station to provide passive assistance and rate performance on a validated global rating scale giving rise to a total possible score of 40. Three expert surgeons repeated the ratings retrospectively, using blinded video recordings. Data analysis employed non-parametric tests. RESULTS: Both live and video scores differentiated significantly between performances of all groups of surgeons for all four stations (P < 0.01) (median live and video score for LAD; Junior 19,17; Senior 29,22; Consultant 36,28). Correlations between live and blinded rating were high (r = 0.67-0.84; P < 0.001) as was inter-rater reliability between the three expert video raters (alpha = 0.81). CONCLUSIONS: The use of bench-top tasks to differentiate between cardiac surgeons of differing technical abilities has been validated for the first time. Furthermore, it is unnecessary to perform post-hoc video rating to obtain objective data. These measures can provide formative feedback for surgeons-in-training and lead to the development of a competency-based technical skills curriculum.     

Preoperative risk assessment in vascular surgery patients

The patient scheduled for peripheral vascular surgery is an increased anaesthetic challenge, mainly because of coexisting generalized cardiovascular atherosclerotic involvement leading to a high risk of perioperative cardiac complications. In clinical practice it is of importance preoperatively to predict, as accurately as possible, the potential risk of complications so that proper risk-reducing measures can be taken. Relevant clinical data, which have been included by Goldman and Detsky in multifactorial cardiac risk indices, are of potential value for differentiating between patients at low, intermediate, or high risk of perioperative cardiac morbidity and mortality. Patients with low risk scores can be accepted for surgery without further testing, thereby allowing more extensive cardiac testing, such as ambulatory ECG monitoring, exercise stress testing, echocardiography, dipyridamole thallium imaging, or coronary angiography, to be reserved for patients with higher risk scores or overt cardiac problems. The risk stratification is of importance not only for decisions on preoperative prophylactic therapeutic measures (e.g. optimization of medical therapies, coronary artery revascularization), but also for decisions on intraoperative anaesthetic management and postoperative care.     

The surgical error examination is a novel method for objective technical knowledge assessment

BACKGROUND: Objective analysis of surgical skill is necessary. A novel method of assessment using simple error analysis in synthetic models is examined for construct validity. METHODS: Two examination protocols were devised using synthetic models. These contained either a purpose made error or were representative of good surgical practice. Protocol one contained models of skin closure and minor operations. Protocol two in addition more complex procedures. Face validity was established by the approval of senior surgeons. Junior surgeons were recruited to undertake the assessment. A p value of less than 0.05 was deemed to be significant. RESULTS: Eighty-nine surgeons were recruited. Both protocol one and two were able to discriminate between groups at statistically significant levels. CONCLUSIONS: Construct validity has been established by showing that error analysis is able to distinguish surgeons with varying levels of experience.     

Preoperative assessment of patients for vascular surgery

Effective preoperative evaluation of patients undergoing major vascular surgery presents a significant multidisciplinary challenge. A focussed preoperative evaluation targeted to organ systems can help mitigate the combined effects of inherently high-risk surgical procedures undertaken in an increasingly comorbid patient population. Careful history and examination supported by appropriate investigations and specialist input remains the cornerstone of this process, with risk increasingly quantified by dedicated scoring systems. In addition, the role and evidence base for objective assessment of functional capacity continues to build with cardiopulmonary exercise testing (CPET) now widely employed in vascular pre-assessment across the UK. When employed in a timely manner, complete preoperative assessment allows more informed decision-making surrounding surgery, frank discussion of risk with the patient and effective utilization of critical care resources if required.     

减重与代谢手术病人垂体磁共振检查临床适用性评价

目的 探讨垂体磁共振（MR）检查在减重与代谢手术病人中常规开展的必要性及其应用条件。方法 回顾性分析2016年1月1日至2019年12月31日首都医科大学附属北京友谊医院普通外科中心减重与代谢外科收治的行垂体MR检查的312例代谢综合征病人的临床资料。将MR检查结果根据影响临床决策的程度分为Ⅰ~Ⅴ类。统计垂体MR检查的整体阳性率、检查目的相关阳性率、影响临床决策阳性率。结果 垂体MR检查结果中Ⅰ类263例（84.3%）,Ⅱ类15例（4.8%）,Ⅲ类21例（6.7%）,Ⅳ类3例（1.0%）,Ⅴ类10例（3.2%）。整体阳性率为15.7%（49/312）;检查目的相关阳性率为7.7%（24/312）;影响临床决策阳性率为0.6%（2/312）,包括垂体大腺瘤1例、脑肿瘤1例。 结论 对于减重与代谢手术病人,因垂体MR平扫检查阳性率低,为临床提供价值较小,极少影响临床决策,不推荐常规开展;对于临床怀疑垂体病变所致继发性肥胖或病人,推荐垂体MR增强检查;对于伴中枢神经系统症状病人,推荐颅脑MR增强检查。     

Algorithm of cardiac risk assessment before vascular surgery

THE OBJECT: to detect the informative value of algorithm of cardiac risk assessment recommended by American Heart Association compared with original standard enlarged protocol. Overall 456 patients underwent vascular operations. First group consisted of 198 patients who were examined according original enlarged protocol; other 258 patients (2nd group) were examined with AHA protocol. At 1st group 41% patients didn't need myocardial revascularization (according coronarography results), preventive coronary bypass surgery was performed at 32% patients. At 2nd group coronarography was performed at 133 (51%) patients according risk factors stratification and stress-examination results. Preventive coronary bypass surgery was performed at 97 patients; 27 patients refused this recommendation. Enlarged protocol increases in 2.6 times the odds of unnecessary invasive procedure. It is concluded that AHA algorithm permits to reduce in 2 times and more the number of invasive diagnostic procedures compared with standard enlarged protocol; AHA algorithm increases the clinical and economic effectiveness.     

Preoperative assessment of patients for major vascular surgery

Effective preoperative evaluation of patients prior to major vascular surgery remains a significant multidisciplinary challenge. Focussed preoperative evaluation targeted to organ systems can mitigate the combined effects of inherently high-risk surgical procedures undertaken in a patient population with well-recognized comorbidity. Careful history and examination, supported by appropriate investigations and specialist input, remains the cornerstone of this process, with risk increasingly quantified by dedicated scoring systems. In addition, the objective assessment of functional capacity is now common in UK units with cardiopulmonary exercise testing widely employed and considered a ‘gold standard’ by many. When employed in a timely manner, complete preoperative assessment allows more informed perioperative decision-making, frank discussion of risk with the patient and effective utilization of critical care resources if required.     

Preoperative assessment of patients for major vascular surgery

Effective preoperative evaluation of patients prior to major vascular surgery remains a significant multidisciplinary challenge. Focused preoperative evaluation targeted to organ systems can mitigate the combined effects of inherently high-risk surgical procedures undertaken in a patient population with well-recognized comorbidity. Careful history and examination, supported by appropriate investigations and specialist input, remains the cornerstone of this process, with risk increasingly quantified by dedicated scoring systems. In addition, the objective assessment of functional capacity is now common in UK units with CPET testing widely employed and considered a ‘gold standard’ by many. When employed in a timely manner, complete preoperative assessment allows more informed perioperative decision-making, frank discussion of risk with the patient and effective utilization of critical care resources if required.     

Preoperative cardiac assessment in patients undergoing major vascular surgery

The aim of this study was to evaluate the effectiveness of a preoperative standardized cardiac assessment in patients undergoing major vascular surgery. From January 2005 to December 2006, 1446 elective interventions for major vascular diseases (carotid stenosis, CS; abdominal aortic aneurysm, AAA; peripheral arterial obstructive disease, PAOD) were performed; 1090 out of these patients underwent preoperative diagnostic assessment on an outpatient basis. Thirty-day results in terms of cardiac mortality and morbidity rates were recorded. Patients suffered from a CS in 578 cases (53%), an AAA in 303 cases (27.8%) and a PAOD in 209 cases (19.2%). Four hundred thirty-two patients (39.6%) underwent further evaluation of cardiac functional capacity with non-invasive stress testing. Sixteen patients were successfully treated prior to vascular surgery. Thirty-day cardiac mortality and morbidity rates were 0.2% and 3.9%, respectively. A positive preoperative non-invasive stress testing did not affect 30-day cardiac outcomes. In conclusion, the use of an accurate preoperative cardiac assessment allowed us to obtain satisfactory perioperative results in patients undergoing major vascular surgery. Routine preoperative evaluation with non-invasive stress testing did not seem to improve perioperative cardiac results.     

The surgical clerkship: assessment of clinical competence

The surgical academic achievements of the third-year class at Jefferson Medical College have been reviewed, comparing scores on an objective final examination and clinical performance based on bedside observations. These comparisons reveal a low correlation between examination scores and bedside evaluations, suggesting that they may measure different components of competence, each being necessary as a portion of the total assessment of performance. The observations also challenge the validity of present techniques of reporting clinical competence.     

The technical aspects of rectal cancer surgery

Despite recent advances in perioperative chemoradiation for the treatment of rectal cancer, surgery remains the only curative therapy for most patients. Surgeries for rectal cancer are considered some of the most technically challenging operations for colorectal surgeons due to the anatomy of the pelvis, proximity to critical structures, and the widespread use of preoperative chemoradiation. This review will focus on the technical aspects of surgery for rectal cancer and appraise the current literature on select controversial topics.     

Pre-operative evaluation and risk assessment of patients undergoing vascular surgery

Cardiovascular complications of anaesthesia and surgery remain frequent and have short- and long-term consequences. Identification of high-risk patients is an essential step in the management of patients with cardiovascular disease who are not always fully investigated before admission for non-cardiac surgery. Clinical risk indices allow the risk of complications to be evaluated. However, many indices are inadequate in vascular surgical patients, and there is a need for objective testing of cardiac function and coronary reserve, as poor left ventricular function and reversible ischaemia during stress test are predictors of increased cardiac risk. These tests allow the patient's condition to be optimized. This may include coronary bypass surgery. Recently, biological markers of left ventricular dysfunction and of myocardial damage have been introduced. Brain natriuretic peptide concentration is inversely correlated with the ejection fraction, while troponins I and T are very valuable markers of myocardial damage.     

The first board examination in pediatric surgery

The inaugural certifying examination for special competence in pediatric surgery in North America was given by the American Board of Surgery (ABS) in April 1975, the day before the sixth meeting of the American Pediatric Surgical Association at a resort near San Juan, PR. The event came after failed applications before the ABS and the Advisory Board for Medical Specialties in 1957, 1961, and 1967. The specialty had matured with a scholarly publication devoted to the field (Journal of Pediatric Surgery, 1965), the establishment of standards for training and training programs (1966), and a society independent of pediatrics and devoted solely to pediatric surgery (American Pediatric Surgical Association, first meeting 1970). Harvey Beardmore had guided the successful campaign for a certificate for pediatric surgery under the aegis of the ABS that was approved in June 1972. Pediatric surgery had thus gained full recognition as a specialty of surgery.A group photograph of its participants became one of the iconic images in our specialty. Thanks to Jim and Nancy Hopkins of Windsor Heights, IA, and to their many friends and colleagues, nearly half (71 of 151) of the pediatric surgeons in the photo were identified, marking their places in the history of pediatric surgery.