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1.
Camilo?Boza Felipe?León Erwin?Buckel Arnoldo?Riquelme Fernando?Crovari Jorge?Martínez Rajesh?Aggarwal Teodor?Grantcharov Nicolás?Jarufe Julián?Varas
Background
Multiple simulation training programs have demonstrated that effective transfer of skills can be attained and applied into a more complex scenario, but evidence regarding transfer to the operating room is limited.Objective
To assess junior residents trained with simulation performing an advanced laparoscopic procedure in the OR and compare results to those of general surgeons without simulation training and expert laparoscopic surgeons.Methods
Experimental study: After a validated 16-session advanced laparoscopy simulation training program, junior trainees were compared to general surgeons (GS) with no simulation training and expert bariatric surgeons (BS) in performing a stapled jejuno-jejunostomy (JJO) in the OR. Global rating scale (GRS) and specific rating scale scores, operative time and the distance traveled by both hands measured with a tracking device, were assessed. In addition, all perioperative and immediate postoperative morbidities were registered.Results
Ten junior trainees, 12 GS and 5 BS experts were assessed performing a JJO in the OR. All trainees completed the entire JJO in the OR without any takeovers by the BS. Six (50 %) BS takeovers took place in the GS group. Trainees had significantly better results in all measured outcomes when compared to GS with considerable higher GRS median [19.5 (18.8–23.5) vs. 12 (9–13.8) p < 0.001] and lower operative time. One morbidity was registered; a patient in the trainees group was readmitted at postoperative day 10 for mechanical ileus that resolved with medical treatment.Conclusion
This study demonstrated transfer of advanced laparoscopic skills acquired through a simulated training program in novice surgical residents to the OR.2.
Introduction
Short-stem THA has become increasingly popular over the last decade. However, implantation technique differs from conventional THA and thus possibly involves a distinct learning curve. The purpose of this study was to evaluate the value of intraoperative radiography and the influence of the surgeon’s experience on intraoperative adjustments in short-stem THA.Methods
A total of 287 consecutive short-stem THAs, operated by a total of 24 senior consultants, consultants and residents in training, were prospectively included. Intraoperative radiography was performed after trial reduction. Preoperative planning and intraoperative outcome with regard to positioning, sizing of components as well as resulting offset and leg length were compared. Frequency, reason and type of intraoperative adjustments were documented in relation to the surgeon’s experience. Operation time was assessed.Results
One hundred and fifty-six (54.4%) procedures were carried out by one of three senior consultants, and a total of nine consultants and 12 residents in training performed 105 (36.6%) and 26 (9.0%) operations, respectively. In 121 cases (42.2%), intraoperative adjustments were made following intraoperative radiography. Intraoperative adjustments of one or more components were made by senior consultants in 51 cases (32.7%), by consultants in 53 cases (50.5%) and by residents in 17 cases (65.4%), respectively. The most common cause was undersizing of the stem. Operation time varied markedly between groups of surgeons.Discussion
Short-stem THA involves a learning curve. Intraoperative radiography is decisive for prevention of malpositioning and undersizing of components, as well as loss of offset and leg length discrepancies. Hence, it should be considered mandatory, especially for less experienced surgeons.3.
Background
Tutorial assistance is related to extra time and cost, and the hospitals’ financial compensation for this activity is under debate. We therefore aimed at quantifying the extra time and resulting cost required to train one surgical resident in the operating theatre for board certification in Switzerland as an example of a training curriculum involving several surgical subspecialties. Additionally, we intended to quantify the percentage of tutorial assistance.Methods
We analysed 200,700 operations carried out between 2008 and 2012. Median duration of procedure categories was calculated according to four different seniority levels. The extra time if the procedure was performed by residents, and resulting cost were analysed. The percentage of procedures carried out by residents as compared to more experienced surgeons was assessed over time.Results
On average, residents performed about a third of all operations including typical teaching procedures like appendectomies. An increase in duration and cost of well-defined procedures categories, e.g. cholecystectomies was demonstrated if a resident performed the procedure. In less well-defined categories, residents seemed to perform less difficult procedures than senior consultants resulting in shorter durations of surgery.Conclusions
The financial impact of tutorial assistance is important, and solutions need to be found to compensate for this activity. The low percentage of procedures performed by trainees may make it difficult to fulfil requirements for board certification within a reasonable period of time. This should be addressed within the training curriculum.4.
Cleffken B Postelmans J Olde Damink S Nap M Schreutelkamp I van der Bijl H 《World journal of surgery》2007,31(9):1731-1736
Background
The aim of this study was to evaluate the influence of operative experience in obtaining tumor-free margins in breast-conserving therapy. In the case of palpable breast cancers, lumpectomies can safely be performed by any surgical resident. For nonpalpable breast cancers, lumpectomies should be treated only by senior residents or attending surgeons, even if supervision during the operation is given by an attending surgeon for junior residents. Radicality of breast carcinoma excision, defined by the tumor-free margin of the removed specimen has been determined to be the major prognostic factor for local recurrence. The aim of this study was to evaluate the influence of operative experience in obtaining tumor-free margins in breast-conserving therapy (BCT). Can lumpectomy for breast carcinoma be performed by surgical residents safely?Methods
All lumpectomies for breast carcinoma between 1999 and 2003 were included out of a prospective database of a single institution. Radicality of resection and patient and histopathologic tumor characteristics were analyzed for 660 lumpectomies. Operative experience of the surgeon performing the lumpectomy was staged as junior residents (JR, years 1–3 in residency), senior residents (SR; years 4–6 in residency), and attending surgeon (AS).Results
A significant difference in obtaining tumor-free margins for palpable tumors was found between ASs (81%) vs. SRs assisted by another resident (92%). For nonpalpable tumors, a significant difference was found in two groups: (1) SRs assisted by another surgical resident (86%) vs. JRs assisted by another surgical resident (61%) and (2) ASs (83%) vs. JRs assisted by another resident (61%) or assisted by an AS (73%).Conclusion
Surgical residents can safely perform BCT in patients with palpable breast cancer. The level of experience has no statistical significance for palpable tumors in a high-volume center. Nonpalpable lesions should be treated only by SRs or ASs.5.
Background
The surgical management of renal cell carcinoma with invasion of the renal vein or inferior vena cava is associated with significant rates of perioperative morbidity and mortality. In this report we propose a surgical checklist aimed at reducing adverse events associated with the resection of these tumors.Methods
This review describes the development of an evidence- and experience-based surgical checklist aimed at improving the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy.Results
Reducing the risk of complications during the surgical management of renal tumors with venous invasion begins with appropriate pre-operative imaging aimed at defining the cranial extent of the tumor thrombus, thus facilitating accurate preoperative planning. Other key elements of the checklist are aimed at ensuring clear and precise pre-, intra- and postoperative communication between members of the multidisciplinary-care team.Conclusion
A standardized surgical checklist may help to increase the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy. Future validation studies are required to determine the clinical feasibility and post-implementation safety profile of this new checklist.6.
Purposes
Researchers studying trauma have found that physicians are able to perform a focused assessment with sonography for trauma (FAST) with minimal training and achieve ideal accuracy. However, there are currently no consensus or standard guidelines regarding the performance of this assessment. The aim of our study was to clarify the value of FAST performed by well-qualified senior general surgery residents in cases of suspected blunt abdominal trauma, which presents an important diagnostic problem in emergency departments.Methods
This was a retrospective study in the emergency department (ED) of our hospital performed from January 2011 to September 2013. Patients were included if they (1) had undergone a FAST examination performed by qualified residents and (2) had received subsequent formal radiographic or surgical evaluations. The results were compared against subsequent surgical findings or formal Department of Radiology reference standards.Results
Among the 438 patients enrolled, false-negative results were obtained in 8 and false-positive results in 5. Only one patient was missed and required laparotomy to repair a small intestine perforation. The sensitivity and specificity were 87 and 99%, respectively; the accuracy was 97%.Conclusions
Senior general surgery residents can be trained to perform accurate FAST examinations on trauma patients.7.
Ziyu Li Fei Shan Yinkui Wang Shuangxi Li Yongning Jia Lianhai Zhang Daoxin Yin Jiafu Ji 《Surgical endoscopy》2016,30(10):4265-4271
Background
To compare the safety and efficacy of laparoscopic distal gastrectomy (LDG) versus open distal gastrectomy (ODG) in treating locally advanced distal gastric cancer after neoadjuvant chemotherapy (NACT).Methods
Forty-four patients with locally advanced distal gastric cancer were enrolled. The patients received neoadjuvant chemotherapy before undergoing surgery. Twenty patients were allocated into LDG after NACT group and 24 patients into ODG after NACT group. Radicalness of oncological resection, surgical safety and recovery were measured and compared.Results
All operations were successfully performed without severe postoperative complications. There were no significant differences in blood loss, mean operation time, complications, distal and proximal resection margin, and number of retrieved lymph nodes between LDG and ODG groups, but LDG group had shorter length of incision and the first aerofluxus time.Conclusion
Laparoscopic distal gastrectomy after NACT has comparable results with open distal gastrectomy in safety and efficacy in the short term.8.
Su Mi Kim Ho Geun Youn Ji Yeong An Yoon Young Choi Sung Hoon Noh Seung Jong Oh Tae Sung Sohn Sung Kim 《Journal of gastrointestinal surgery》2018,22(5):785-791
Purpose
The purpose of this study was to estimate surgical outcomes of elderly patients older than 80 years who received laparoscopic or open gastrectomy for gastric cancer and to identify risk factors for postoperative complications.Methods
Two hundred forty-two elderly patients older than 80 years underwent gastric cancer surgery between January 2010 and December 2016 in three tertiary hospitals. They were divided into two groups: laparoscopic gastrectomy (N?=?59) and open gastrectomy (N?=?183). The surgical outcomes and risk factors for postoperative complication were evaluated.Results
Among the elderly patients, 24.4% showed an ASA score of 3 or 4, and 20.7% showed a Charlson comorbidity index (CCI) score of 2 or more. 46.3% of patients had hypertension and 15.3% had diabetes. The laparoscopic gastrectomy group showed similar operation time, less intraoperative blood loss, and faster postoperative gastrointestinal recovery compared to the open gastrectomy group. The incidence of postoperative complications was 30.1% in the open group and 22.0% in the laparoscopic group (P?=?0.249). One patient died for pulmonary complication in the open gastrectomy group. In multivariate analysis, older age, male, higher CCI score, and open approach were found to be correlated with increased risk for postoperative complications.Conclusions
Although elderly patients over 80 years had a high incidence of comorbidity, gastric cancer surgery can be safely performed. The laparoscopic approach might be feasible for open surgery in improving quality of life in these patients, given a faster postoperative intestinal recovery period, with similar risk for postoperative complications.9.
Introduction
Chronic subdural hematoma (cSDH) is a common condition that causes significant morbidity and mortality. In rural sub-Saharan Africa, there are very few neurosurgeons. Yet, cSDH is treatable by relatively simple surgical intervention with potential for rapid clinical improvement.Methods
We conducted a retrospective chart review of all patients with cSDH who underwent burr-hole trephination at Tenwek Hospital, Kenya, between July 2014 and July 2016. We extracted and compared the clinical presentation, risk factors, operative details, and outcomes.Results
A total of 119 patients were identified with a mean age of 61.3 years. The majority were men (80%). The main predisposing factors were trauma (54.6%) and alcohol intake (34.4%). Patients were generally managed with two burr-holes, irrigation, and a subdural drain, remaining for a median of 2 days. Operations were assisted by general surgery residents under direct supervision of senior residents (46), general surgeons (65), and neurosurgeons (8). Complications included recurrence (5.2%), subdural empyema (2.5%), postoperative seizures (3.4%), and mortality (6.7%). Improvement of symptoms was noted in 91% of all patients.Conclusion
Operative management of cSDH can be safely performed in rural facilities by general surgeons familiar with the procedure and with the institutional resources. The majority of patients had satisfactory outcomes.10.
Denny Yu Bethany Lowndes Cornelius Thiels Juliane Bingener Amro Abdelrahman Rebecca Lyons Susan Hallbeck 《World journal of surgery》2016,40(7):1565-1574
Background
Surgical performance, provider health, and patient safety can be compromised when workload demands exceed individual capability on the surgical team. The purpose of this study is to quantify and compare intraoperative workload among surgical team members.Methods
Observations were conducted for an entire surgical day for 33 participating surgeons and their surgical team at one medical institution. Workload (mental, physical, case complexity, distractions, and case difficulty) was measured for each surgical team member using questions from validated questionnaires. Statistical analyses were performed with a mixed effects model.Results
A total of 192 surgical team members participated in 78 operative cases, and 344 questionnaires were collected. Procedures with high surgeon mental and physical workload included endovascular and gastric surgeries, respectively. Ratings did not differ significantly among surgeons and residents, but scrub nurses physical demand ratings were 14–22 (out of 100) points lower than the surgeons, residents, and surgical assistants. Residents reported the highest mental workload, averaging 19–24 points higher than surgical assistants, scrub nurses, and circulating nurses. Mental and physical demands exceeded 50 points 28–45 % of the time for surgeons and residents. Workload did not differ between minimally invasive and open techniques.Conclusion
The workload questionnaires are an effective tool for quantifying intraoperative workload across the surgical team to ensure mental and physical demands do not exceed thresholds where performance may decrease and injury risk increase. This tool has the potential to measure the safety of current procedures and drive design of workload interventions.11.
Background
Given the current and future security situation, it appears necessary to reform the training and appointment of senior emergency physicians and to harmonize these nationwide. The goal of the authors is to describe the current situation, identify needs for action and possible solutions, and thus to encourage discussions in authoritative bodies.Methods
Presentation of the current training and appointment practice, using the current situation in Bavaria as an example.Results
The aim is to establish a uniform and updated training of future senior emergency physicians, so that they can more efficiently fulfill future positions.Discussion
The current training of senior emergency physicians needs urgent revision with regard to general security policy development and the integrated security of the German authorities.12.
Nathan Burnside 《General thoracic and cardiovascular surgery》2018,66(7):411-414
Objectives
Cardiothoracic surgery is a small specialty, often with a limited presence on the undergraduate curriculum. In the past, there was a heavy reliance on postgraduate exposure to inform career choice. Recent changes in recruitment to the specialty in the United Kingdom may reduce exposure of the best trainees to the specialty, and reduce the quality of future surgeons. This study will evaluate the impact of junior surgical jobs on future career preferences.Methods
We asked all 126 core surgical trainees in the Northern Ireland Deanery their surgical specialty preferences over 2 years. Trainees were asked for their first and second preferences on each occasion. In total 502 first and second preferences were declared. Past and present postings were then correlated with this information to see if working in a cardiothoracic unit impacted on specialty preference choices.Results
Cardiothoracic surgery is the least popular of all the surgical specialties amongst junior surgical trainees (3.6%)—with general surgery, breast surgery, and orthopaedic surgery, drawing 53% of trainees. In trainees who had previously worked in cardiothoracic surgery, 75% expressed a wish to return to the specialty, making it the most dominant.Conclusions
The role of junior surgical jobs in the specialty is immensely important on career choice. Moving to a more junior recruitment may exclude excellent candidates who have simply not experienced cardiothoracic surgery.13.
Feng Zhu Dengyu Feng Tenghui Zhang Lili Gu Weiming Zhu Zhen Guo Yi Li Jianfeng Gong Ning Li Jieshou Li 《Journal of gastrointestinal surgery》2018,22(9):1593-1602
Background
The comprehensive complication index (CCI) is a novel approach to evaluate complications. However, application of the CCI in inflammatory bowel disease (IBD) population is scarce and the difference between the CCI and the Clavien-Dindo classification (CDC) remains unknown. The aim of this study was to compare the CCI to the conventional CDC by applying the CCI among the IBD patients.Methods
The data of 426 IBD patients who underwent surgery between September 1, 2015 and August 31, 2017 were collected. Univariate and multivariate analyses were conducted to identify risk factors for postoperative complications. The efficacy of CCI and CDC was compared using correlation analysis and logistic regression. Cumulative sum control (CUSUM) models were applied to monitor the CCI continuously.Results
Totally, 297 complications occurred in 144 (33.8%) patients. The rate of severe complications (CDC grade?≥?III) was 12.9% and the mean CCI was 9.8?±?15.5. Preoperative glucocorticoids usage and previous abdominal surgery were related to higher CCI value (p?=?0.002, p?=?0.006, respectively) but not related to higher incidence of severe complications (CDC grade?≥?III) (p?=?0.117, p?=?0.177, respectively). In patients with multiple complications, the CCI demonstrated a stronger correlation with hospital stay (ρ?=?0.604, p?<?0.001) than CDC (ρ?=?0.508, p?<?0.001). Higher CCI value (p?<?0.001, OR 1.161, 95% CI 1.093–1.234) and the CDC grade (p?<?0.001, OR 3.811, 95% CI 2.283–6.362) were risk factors for prolonged LOS. In the CUSUM-CCI model of IBD surgery, a gradual decrease was observed over time.Conclusions
The CCI and the CDC are both risk factors for prolonged postoperative LOS after surgery for IBD patients. The CCI is more strongly correlated with postoperative LOS than is the conventional CDC. The CUSUM-CCI model is effective in monitoring surgical quality.14.
Background
The tasks involved in reconstructing the urethra after failed hypospadias repair range from correction of a trivial meatal stenosis to reconstruction of the entire anterior urethra.Objectives
To describe pathological findings in the urethra after failed hypospadias repair and the respective surgical methods used for their correction.Materials and methods
The various pathological findings after unsuccessful hypospadias surgery are classified according to their location and complexity.Results
The general rules of reconstruction that should be applied in each particular situation are described.Conclusions
Successful reconstruction of the urethra in patients with failed hypospadias surgery requires experience and good knowledge of the anatomy of the normal and hypospadic urethra and penis. Mastery of plastic surgical techniques and profound knowledge of the various surgical methods of hypospadias surgery are essential.15.
16.
Rodolfo Milani Matteo Frigerio Stefano Manodoro Alice Cola Martina Sicuri Federico Spelzini 《International urogynecology journal》2016,27(5):821-823
Introduction and hypothesis
Rectovaginal fistula repair is one of the most challenging gynecological surgical procedures. This video is intended to serve as a tutorial for surgical repair.Methods
An 80-year-old woman who developed a traumatic suprasphincteric rectovaginal fistula was managed through layered transvaginal repair without flaps.Results
Anatomy restoration was completed without complications.Conclusion
The procedure described in this video was effective and safe. Vaginal route should be considered as a valid surgical approach for rectovaginal fistula repair.17.
Norman Ramirez Pablo Valentin Manuel García-Cartagena Solais Samalot Ivan Iriarte 《European journal of orthopaedic surgery & traumatology : orthopedie traumatologie》2016,26(5):441-446
Study design
A retrospective cohort study with IRB approval.Introduction
Significant blood loss remains an important concern in terms of the performance of the posterior spinal fusion in adolescent idiopathic scoliosis. Several strategies have been reported to minimize blood loss during surgery. In order to address the need to minimize blood loss without sacrificing the quality of the fusion, in our hospital, we adopted a two-step surgical approach. This surgical approach consist of the exposure and instrumentation of the lumbar region prior to and followed by an extension of the surgical incision to the thoracic region for its subsequent instrumentation. The main purpose of this study was to compare a two-step surgical approach with the one-step (standard) approach.Methods
This study was a review of all the data on consecutive posterior spinal fusion surgeries performed by a specific two-surgeon team during 2004–2013. Demographics, surgical variables, radiographic findings, and outcomes regarding blood loss, morbidity, and the duration of the procedure were evaluated.Results
Eighty-five patients underwent the standard surgical exposure, and 41 patients underwent the two-step surgical technique. With the exception of BMI, neither group showed any statistically preoperative variable significant differences. None of the postoperative outcome variables were statistically significant between both surgical approaches.Conclusions
No differences were detected in terms of using a two-step surgical approach versus the one-step standard surgical approach regarding perioperative blood loss, surgical time, or complications.Level of evidence
Level of evidence III.18.
Background
In the case of occupational accidents requiring ambulatory care, patients are treated by qualified accident insurance consultants who are specialists with particular expertise in occupational medicine. No formal system for quality assurance has yet been implemented for this sector of the German healthcare system.Objectives
The aim of the present study was to develop and test two instruments to assess patient satisfaction with care and the quality of routine reports prepared by accident insurance consultants.Material and methods
After an extensive review of existing instruments and qualitative interviews with patients, a standardized written patient satisfaction questionnaire was developed and psychometrically tested. In close collaboration with an expert panel, an online checklist to assess completeness and plausibility of relevant items in routine reports by accident insurance consultants was also developed. This peer review instrument was tested in several steps for feasibility and accuracy.Results
The final patient satisfaction questionnaire consisted of 38 items on various aspects of patient satisfaction. Statistical analyses indicated that relevant psychometric criteria were met. The peer review process was successfully implemented as a web application. Problems in reporting important details about accidents and the medical treatment could be identified with sufficient accuracy using the online checklist.Conclusion
The patient questionnaire and the peer review process developed and tested in this study are feasible and reliable measures for quality assurance in ambulatory care provided by accident insurance consultants. Results generated by both instruments can be included as summary reports in quality assurance reviews or for individual feedback to accident insurance consultants.19.
Background
Patients undergoing emergency surgery have a high risk for surgical complications and death. The Clavien-Dindo classification has been developed and validated in elective general surgical patients, but has not been validated in emergency surgical patients. The aim of the current study was to evaluate the Clavien-Dindo classification of surgical complications in emergency surgical patients and to study preoperative factors for risk stratification that should be included into a database of surgical complications.Methods
A cohort of 444 consecutive patients having emergency general surgery during a three-month period was retrospectively analyzed. Surgical complications were classified according to the Clavien-Dindo classification. Preoperative risk factors for complications were studied using logistic regression analysis.Results
Preoperatively 37 (8.3%) patients had organ dysfunctions. Emergency surgical patients required a new definition for Grade IV complications (organ dysfunctions). Only new onset organ dysfunctions or complications that significantly contributed to worsening of pre-operative organ dysfunctions were classified as grade IV complications. Postoperative complications developed in 115 (25.9%) patients, and 14 (3.2%) patients developed grade IV complication. Charlson comorbidity index, preoperative organ dysfunction and the type of surgery predicted postoperative complications.Conclusions
The Clavien-Dindo classification of surgical complications can be used in emergency surgical patients but preoperative organ dysfunctions should be taken into account when defining postoperative grade IV complications. For risk stratification patients’ comorbidities, preoperative organ dysfunctions and the type of surgery should be taken into consideration.20.