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Straatman J, Rahman SA, Carter NC, Mercer SJ, Knight BC, van Boxel GI, Pucher PH. Proctored adoption of robotic hiatus hernia surgery: outcomes and learning curves in a high-volume UK centre. Surg Endosc 2023; 37:7608-7615. [PMID: 37474827 PMCID: PMC10520141 DOI: 10.1007/s00464-023-10210-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 06/12/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND The adoption of new surgical technologies is inevitably accompanied by a learning curve. With the increasing adoption of robotic techniques in benign foregut surgery, it is imperative to define optimal learning pathways, to ensure a clinically safe introduction of such a technique. The aim of this study was to assess the learning curve for robotic hiatal hernia repair with a pre-defined adoption process and proctoring. METHODS The learning curve was assessed in four surgeons in a high-volume tertiary referral centre, performing over a 100 hiatal hernia repairs annually. The robotic adoption process included simulation-based training and a multi-day wet lab-based course, followed by robotic operations proctored by robotic upper GI experts. CUSUM analysis was performed to assess changes in operating time in sequential cases. RESULTS Each surgeon (A, B, C and D) performed between 22 and 32 cases, including a total of 109 patients. Overall, 40 cases were identified as 'complex' (36.7%), including 16 revisional cases (16/109, 14.7%). With CUSUM analysis inflection points for operating time were seen after 7 (surgeon B) to 15 cases (surgeon B). CONCLUSION The learning curve for robotic laparoscopic fundoplication may be as little as 7-15 cases in the setting of a clearly organized learning pathway with proctoring. By integrating these organized learning pathways learning curves may be shortened, ensuring patient safety, preventing detrimental outcomes due to longer learning curves, and accelerating adoption and integration of novel surgical techniques.
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Affiliation(s)
- Jennifer Straatman
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK.
| | - Saqib A Rahman
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Nicholas C Carter
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Stuart J Mercer
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Benjamin C Knight
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Gijsbert I van Boxel
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Philip H Pucher
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
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Bramhall SR, Mourad MM. Wrap choice during fundoplication. World J Gastroenterol 2019; 25:6876-6879. [PMID: 31908391 PMCID: PMC6938727 DOI: 10.3748/wjg.v25.i48.6876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/03/2019] [Accepted: 12/22/2019] [Indexed: 02/06/2023] Open
Abstract
Gastro-oesphageal reflux disease is an increasing health burden. The mainstay of treatment has conventionally been medical therapy but since the introduction of laparoscopic surgery laparoscopic anti-reflux surgery has been increasingly used for intractable symptoms or in patients unwilling to take long term medication. The Nissen 360 degree wrap has traditionally been considered the gold standard operation but can be associated with significant complications. These complications include “gas bloat” and dysphagia and can occur relatively frequently. Various modifications have been described to the original operation and some of these have been described. In addition alternative wraps have been described which seem to have a reduced incidence of complications associated with their use. This editorial discusses the various types of wrap that can be performed and the minimum requirements of the surgical technique. The evidence from a recent meta-analysis of the randomised data has suggested that an anterior wrap is associated with a lower rate of complications and gives just as good control of reflux symptoms. The advantages and disadvantages of an anterior wrap are discussed. The lack of long term follow up data concerns some practitioners and at the moment the choice of wrap carried out still rests with the individual surgeon.
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Affiliation(s)
- Simon R Bramhall
- Department of Surgery, The County Hospital, Hereford HR1 2ER, United Kingdom
| | - Moustafa M Mourad
- Department of Surgery, Worcester Royal Infirmary, Worcester WR5 1DD, United Kingdom
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Weitzendorfer M, Spaun GO, Antoniou SA, Witzel K, Emmanuel K, Koch OO. Clinical feasibility of a new full-thickness endoscopic plication device (GERDx™) for patients with GERD: results of a prospective trial. Surg Endosc 2018; 32:2541-2549. [PMID: 29602998 PMCID: PMC5897467 DOI: 10.1007/s00464-018-6153-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 03/21/2018] [Indexed: 01/08/2023]
Abstract
Background Previous studies suggest clinical effectiveness of endoscopic full-thickness plication in selected patients with gastroesophageal reflux disease (GERD). The aim of this study was to assess the clinical safety and efficiency of the GERDx™ device by evaluating clinical parameters, reflux symptom scores, and quality of life (QoL). Methods Prospective one-arm trial evaluating the outcome of forty patients with GERD subjected to endoscopic plication with the GERDx™ device. We included patients with at least one typical reflux symptom despite treatment with a PPI for > 6 months, pathologic esophageal acid exposure, hiatal hernia of size < 2 cm, and endoscopic Hill grade II–III. Evaluation of Gastrointestinal Quality of Life Index (GIQLI), symptom scores, esophageal manometry, and impedance-pH-monitoring were performed at baseline and at 3 months after surgery. (Trial Registration: ClinicalTrials.gov NCT 01798212.) Results There were no intraoperative complications. Four out of forty patients experienced postoperative complications requiring intervention. Seven of forty patients were subjected to laparoscopic fundoplication 3 months after endoscopic plication due to persistent symptoms and were lost to further follow-up. Thirty out of forty patients were available at 3-month follow-up. There was an improvement of the GIQLI score, from a mean of 92.45 ± 18.47 to 112.03 ± 13.11 (p < 0.001). The general reflux-specific score increased from a mean of 49.84 ± 24.83 to 23.93 ± 15.63 (p < 0.001), and the DeMeester score from a mean of 46.48 ± 30.83 to 20.03 ± 23.62 (p < 0.001). There was no significant change in manometric data after intervention. Three of thirty patients continued daily antireflux medication. Conclusions Endoscopic plication with the GERDx™ device reduced distal acid exposure of the esophagus, reflux-related symptoms, and improved GIQLI scores with minimal side effects in a selected cohort of patients and may be a safe alternative in the treatment of GERD.
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Affiliation(s)
| | - Georg O Spaun
- Department of Surgery, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | | | - Kai Witzel
- Department of Surgery, Paracelsus Medical University, 5020, Salzburg, Austria.,Minimal Invasiv Center, Hersfelder Strasse 1, 36088, Huenfeld, Germany
| | - Klaus Emmanuel
- Department of Surgery, Paracelsus Medical University, 5020, Salzburg, Austria
| | - Oliver O Koch
- Department of Surgery, Paracelsus Medical University, 5020, Salzburg, Austria
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Abstract
Gastroesophageal reflux (GER) affects ∼10-20% of American adults. Although symptoms are equally common in men and women, we hypothesized that sex influences diagnostic and therapeutic approaches in patients with GER. PubMed database between 1997 and October 2011 was searched for English language studies describing symptoms, consultative visits, endoscopic findings, use and results of ambulatory pH study, and surgical therapy for GER. Using data from Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, we determined the sex distribution for admissions and reflux surgery between 1997 and 2008. Studies on symptoms or consultative visits did not show sex-specific differences. Even though women are less likely to have esophagitis or Barrett's esophagus, endoscopic studies enrolled as many women as men, and women were more likely to undergo ambulatory pH studies with a female predominance in studies from the US. Surgical GER treatment is more commonly performed in men. However, studies from the US showed an equal sex distribution, with Nationwide Inpatient Sample data demonstrating an increase in women who accounted for 63% of the annual fundoplications in 2008. Despite less common or severe mucosal disease, women are more likely to undergo invasive diagnostic testing. In the US, women are also more likely to undergo antireflux surgery. These results suggest that healthcare-seeking behavior and socioeconomic factors rather than the biology of disease influence the clinical approaches to reflux disease.
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Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 2010; 24:2647-69. [PMID: 20725747 DOI: 10.1007/s00464-010-1267-8] [Citation(s) in RCA: 238] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 05/27/2010] [Indexed: 02/06/2023]
Affiliation(s)
- Dimitrios Stefanidis
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Training for laparoscopic Nissen fundoplication with a newly designed model: a replacement for animal tissue models? Surg Endosc 2010; 24:3134-40. [PMID: 20526629 PMCID: PMC2982997 DOI: 10.1007/s00464-010-1104-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2009] [Accepted: 08/14/2009] [Indexed: 12/18/2022]
Abstract
BACKGROUND To bridge the early learning curve for laparoscopic Nissen fundoplication from the clinical setting to a safe environment, training models can be used. This study aimed to develop a reusable, low-cost model to be used for training in laparoscopic Nissen fundoplication procedure as an alternative to the use of animal tissue models. METHODS From artificial organs and tissue, an anatomic model of the human upper abdomen was developed for training in performing laparoscopic Nissen fundoplication. The 20 participants and tutors in the European Association for Endoscopic Surgery (EAES) upper gastrointestinal surgery course completed four complementary tasks of laparoscopic Nissen fundoplication with the artificial model, then compared the realism, haptic feedback, and training properties of the model with those of animal tissue models. RESULTS The main difference between the two training models was seen in the properties of the stomach. The wrapping of the stomach in the artificial model was rated significantly lower than that in the animal tissue model (mean, 3.6 vs. 4.2; p = 0.010). The main criticism of the stomach of the artificial model was that it was too rigid for making a proper wrap. The suturing of the stomach wall, however, was regarded as fairly realistic (mean, 3.6). The crura on the artificial model were rated better (mean, 4.3) than those on the animal tissue (mean, 4.0), although the difference was not significant. The participants regarded the model as a good to excellent (mean, 4.3) training tool. CONCLUSION The newly developed model is regarded as a good tool for training in laparoscopic Nissen fundoplication procedure. It is cheaper, more durable, and more readily available for training and can therefore be used in every training center. The stomach of this model, however, still needs improvement because it is too rigid for making the wrap.
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Walter SD, Ismaila AS, Devereaux PJ. Statistical issues in the design and analysis of expertise-based randomized clinical trials. Stat Med 2009; 27:6583-96. [PMID: 18837074 DOI: 10.1002/sim.3448] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In order to avoid certain difficulties with the conventional randomized clinical trial design, the expertise-based design has been proposed as an alternative. In the expertise-based design, patients are randomized to clinicians (e.g. surgeons), who then treat all their patients with their preferred intervention. This design recognizes individual clinical preferences and so may reduce the rates of procedural crossovers compared with the conventional design. It may also facilitate recruitment of clinicians, because they are always allowed to deliver their therapy of choice, a feature that may also be attractive to patients.The expertise-based design avoids the possibility of so-called differential expertise bias. If a standard treatment is generally more familiar to clinicians than a new experimental treatment, then in the conventional design, more patients randomized to the standard treatment will have an expert clinician, compared with patients randomized to the experimental treatment. If expertise affects the study outcome, then a biased comparison of the treatment groups will occur.We examined the relative efficiency of estimating the treatment effect in the expertise-based and conventional designs. We recognize that expected patient outcomes may be better in the expertise-based design, which in turn may modify the estimated treatment effect. In particular, a larger treatment effect in the expertise-based design can sometimes offset a higher standard error arising from the confounding of clinician effects with treatments.These concepts are illustrated with data taken from a randomized trial of two alternative surgical techniques for tibial fractures.
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Affiliation(s)
- S D Walter
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont., Canada L8N 3Z5.
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Abstract
Studies from large volume centers of excellence have proven the efficacy of laparoscopic antireflux surgery. However, the majority of these operations are performed in community hospitals, where the results are more variable. Major issues potentially affecting laparoscopic antireflux surgery in community hospitals include a) the individual skills and experience of the surgeons, b) the volume of operations per surgeon and hospital, and c) the sophistication of the esophageal motility labs evaluating these patients prior to surgery. Another evolving issue is the increasing number of fundoplication failures and where best to evaluate and treat these patients.
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Tierney B, Iqbal A, Haider M, Filipi C. Effects of prior endoluminal gastroplication on subsequent laparoscopic Nissen fundoplication. Surg Endosc 2007; 21:321-3. [PMID: 17219292 DOI: 10.1007/s00464-005-0065-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2005] [Accepted: 07/19/2005] [Indexed: 01/15/2023]
Abstract
BACKGROUND The long-term results of endoluminal gastroplication (ELGP) for gastroesophageal reflux disease (GERD) are still under investigation. Laparoscopic Nissen fundoplication (LNF) has unquestionable results in the treatment of GERD and, therefore, it would be unfortunate to compromise this treatment option by performing alternative therapies such as ELGP. METHODS Six patients underwent ELGP for the treatment of GERD symptoms. After symptoms returned, these patients elected to have a LNF. RESULTS There was no sign of periesophagitis or intraperitoneal adhesion formation found at hiatal dissection that hindered or complicated the LNF procedure. Recent follow-up has shown that the patient's GERD symptom scores have decreased, as expected after a de novo LNF. CONCLUSION ELGP does not alter the surgical dissection or results of a subsequent LNF.
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Affiliation(s)
- B Tierney
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
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Ahlberg G, Kruuna O, Leijonmarck CE, Ovaska J, Rosseland A, Sandbu R, Strömberg C, Arvidsson D. Is the learning curve for laparoscopic fundoplication determined by the teacher or the pupil? Am J Surg 2005; 189:184-9. [PMID: 15720987 DOI: 10.1016/j.amjsurg.2004.06.043] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2004] [Revised: 06/13/2004] [Accepted: 06/13/2004] [Indexed: 12/23/2022]
Abstract
BACKGROUND For all surgical procedures, a surgeons' learning curve can be anticipated during which complication rates are increased. The aims of this study were to evaluate individual learning curves for a group of surgeons performing laparoscopic fundoplication and to evaluate if the Procedicus MIST-simulator (Mentice Inc., Göteborg, Sweden) accurately predicts surgical performance. METHODS Twelve Nordic centers participated, each contributing with a "master" and a "pupil" surgeon. The pupils were tested in the simulator and thereafter performed their first 20 supervised operations. All procedures were videotaped and evaluated by 3 independent reviewers. RESULTS A significant decrease in operative time (P <0.001) and a trend (P = 0.12) toward improved score were seen during the series. The master significantly affected the pupil's score (P =0.0137). The simulator-test showed no correlation with the operative score. CONCLUSIONS Individual learning curves varied, and the teacher was shown to be the most important factor influencing the pupil's performance score. The correlation between assessed performance and patient outcome will be further investigated.
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Affiliation(s)
- Gunnar Ahlberg
- Department of Surgery, Karolinska Hospital, SE-171 76 Stockholm, Sweden.
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Devereaux PJ, Bhandari M, Clarke M, Montori VM, Cook DJ, Yusuf S, Sackett DL, Cinà CS, Walter SD, Haynes B, Schünemann HJ, Norman GR, Guyatt GH. Need for expertise based randomised controlled trials. BMJ 2005; 330:88. [PMID: 15637373 PMCID: PMC543877 DOI: 10.1136/bmj.330.7482.88] [Citation(s) in RCA: 337] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Surgical procedures are less likely to be rigorously evidence based than drug treatments because of difficulties with randomisation. Expertise based trials could be the way forward
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Affiliation(s)
- P J Devereaux
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street, West Hamilton ON, Canada L8N 3Z5.
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