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Culture of Transparency Will Be Critical to Surgical Home Hospital Development. Ann Surg 2024; 279:734-735. [PMID: 38318696 DOI: 10.1097/sla.0000000000006224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
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Interprofessional Trauma Team Training: Leveraging Each Specialties' Expertise to Teach Procedural-Based Skills. JOURNAL OF SURGICAL EDUCATION 2022; 79:e273-e284. [PMID: 36283921 DOI: 10.1016/j.jsurg.2022.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 07/16/2022] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The goal of this study was to utilize interprofessional trauma team training to teach procedural-based skills, teamwork, and assess the impact on the procedural comfort and interprofessional collaboration. DESIGN Interdisciplinary skills sessions were created to focus on chest tube placement and advanced ultrasound techniques. Chest tube sessions were taught by senior general surgery (GS) residents and faculty. Ultrasound sessions were taught by emergency medicine (EM) fellows and faculty. Mock trauma simulations for EM and GS residents and EM nurses, were developed to also focus on improving interprofessional trauma-bay collaboration. Sessions were held throughout the year for 2 consecutive academic years. After completing skills sessions and trauma scenarios, participants were surveyed on skill comfort, session utility, and willingness to collaborate with the other specialty. Likert scale responses were analyzed by specialty cohort and in aggregate. Free-text feedback responses were analyzed for common themes. SETTING Large, tertiary, urban academic medical center PARTICIPANTS: Forty seven EM residents and 32 GS residents completed instructional chest tube and ultrasound simulations, respectively. Twenty two EM residents, 24 GS residents, and 29 EM nurses participated in interprofessional trauma simulations. RESULTS For chest tube placement: 71% of EM residents reported feeling uncomfortable with the procedure prior to the session, with 100% reporting improved confidence afterwards. Seventy percent stated the model was realistic. One hundred percent thought it improved their procedural skills. All participants thought it was worthwhile, should be offered again in future years, and planned to incorporate what they learned in their future practice. For the ultrasound sessions: 61% of GS residents felt uncomfortable with the Focused Assessment with Sonography in Trauma prior to the simulation. Ninety four percent reported the improved skill and confidence, and felt the model was realistic. All participants felt sessions were worthwhile, should be offered again, and planned to incorporate what they learned in their future practice. For trauma simulations: 97% of participants felt scenarios were realistic and clinically relevant and planned to incorporate lessons learned in their future clinical practice. All participants thought participation was worthwhile. Ninety seven percent thought it improved their confidence with trauma clinical management and 56% reported it improved their skills. Many participants reported they appreciated learning from the other specialty's perspective, with greater than 95% of all participants reporting improved comfort and willingness to collaborate across disciplines when caring for future trauma patients. All participants requested the simulation sessions continue in future academic years. CONCLUSION Interprofessional trauma simulation sessions can harness the unique skill sets of different disciplines to teach procedural-based skills and improve interprofessional collaboration within the trauma bay.
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Impact of Rater Training on Residents Technical Skill Assessments: A Randomized Trial. JOURNAL OF SURGICAL EDUCATION 2022; 79:e225-e234. [PMID: 36333174 DOI: 10.1016/j.jsurg.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/28/2022] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The ACS/APDS Resident Skills Curriculum's Objective Structured Assessment of Technical Skills (OSATS) consists of task-specific checklists and a global rating scale (GRS) completed by raters. Prior work demonstrated a need for rater training. This study evaluates the impact of a rater-training curriculum on scoring discrimination, consistency, and validity for handsewn bowel anastomosis (HBA) and vascular anastomosis (VA). DESIGN/ METHODS A rater training video model was developed, which included a GRS orientation and anchoring performances representing the range of potential scores. Faculty raters were randomized to rater training or no rater training and were asked to score videos of resident HBA/VA. Consensus scores were assigned to each video using a modified Delphi process (Gold Score). Trained and untrained scores were analyzed for discrimination and score spread and compared to the Gold Score for relative agreement. RESULTS Eight general and eight vascular surgery faculty were randomized to score 24 HBA/VA videos. Rater training increased rater discrimination and decreased rating scale shrinkage for both VA (mean trained score: 2.83, variance 1.88; mean untrained score: 3.1, variance 1.14, p = 0.007) and HBA (mean trained score: 3.52, variance 1.44; mean untrained score: 3.42, variance 0.96, p = 0.033). On validity analyses, a comparison between each rater group vs Gold Score revealed a moderate training impact for VA, trained κ=0.65 vs untrained κ=0.57 and no impact for HBA, R1 κ = 0.71 vs R2 κ = 0.73. CONCLUSION A rater-training curriculum improved raters' ability to differentiate performance levels and use a wider range of the scoring scale. However, despite rater training, there was persistent disagreement between faculty GRS scores with no groups reaching the agreement threshold for formative assessment. If technical skill exams are incorporated into high stakes assessments, consensus ratings via a standard setting process are likely a more valid option than individual faculty ratings.
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Simulation versus reality: what can interprofessional simulation teach us about team dynamics in the trauma bay? GLOBAL SURGICAL EDUCATION : JOURNAL OF THE ASSOCIATION FOR SURGICAL EDUCATION 2022; 1:56. [PMID: 38013715 PMCID: PMC9614190 DOI: 10.1007/s44186-022-00063-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 10/06/2022] [Accepted: 10/11/2022] [Indexed: 11/08/2022]
Abstract
Purpose Surgical consultation and the joint management of trauma patients is a common scenario in the emergency department. The goal of this study was to utilize interprofessional trauma team training to understand the role of simulation and its impact on the overall culture of trauma-related care. Methods Interdisciplinary trauma simulation scenarios were completed by 12 groups of emergency medicine residents, general surgery residents, and emergency medicine nurses across two academic years. Following each simulation, a debriefing session was held to reflect on the scenario, focusing on team interactions. Debriefing sessions were audio-recorded, transcribed, deidentified, and independently, inductively coded by two members of the research team. Using the constant comparative method, a codebook was developed and refined until interrater reliability was confirmed with a kappa of > 0.9. Codes were organized into higher level themes. Results There were 72 participants, including 23 general surgery residents, 19 emergency medicine residents, and 30 emergency medicine nurses. 214 primary codes were collapsed into 29 coding categories, with 6 emerging themes. Pre-trauma bay impact describes how interactions prior to the trauma scenario can impact how team members communicate, trust one another, and ultimately care for the patient. Role and team identity explores the importance of one knowing their individual role in the trauma bay and how it impacts overall team identity. Resource allocation describes the balance of having appropriate resources to efficiently care for patients while not negatively impacting crowd control or role identity. Impact of the simulation experience highlights the impact of the lower stakes simulation scenario on learning and reflection as well as concerns with simulation fidelity. Trauma leader traits and actions outlines inherent traits and learned actions of trauma leaders that impact how the trauma scenario unfolds. Interprofessional team performance describes the overall performance of the trauma team, including but not limited to the type of communication used, teamwork behaviors, and transition of care of the patient. Conclusions Interdisciplinary trauma simulations and structured debriefing sessions provide insights into team dynamics and interprofessional relationships. Simulations and debriefing sessions can promote understanding, respect, and familiarity of team members' roles; recognition of key characteristics of high functioning leaders and teams; and discovery of conflict mitigating strategies for future interdisciplinary team improvement. Simulation sessions allow implementation of quality improvement measures and communication and leadership strategy practice in a safe, collaborative learning environment. The lessons learned from these sessions can encourage participants to reexamine how they interact and function as a team within the real-life trauma bay.
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Transfer of virtual reality endoscopy training to live animal colonoscopy: a randomized control trial of proficiency vs. repetition-based training. Surg Endosc 2022; 36:6767-6776. [PMID: 35146554 PMCID: PMC8831003 DOI: 10.1007/s00464-021-08958-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/09/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Low first-time pass rates of the Fundamentals of Endoscopic Surgery (FES) exam stimulated development of virtual reality (VR) simulation curricula for test preparation. This study evaluates the transfer of VR endoscopy training to live porcine endoscopy performance and compares the relative effectiveness of a proficiency-based vs repetition-based VR training curriculum. METHODS Novice endoscopists completed pretesting including the FES manual skills examination and Global Assessment of GI Endoscopic Skills (GAGES) assessment of porcine upper and lower endoscopy. Participants were randomly assigned one of two curricula: proficiency-based or repetition-based. Following curriculum completion, participants post-tested via repeat FES examination and GAGES porcine endoscopy assessments. The two cohorts pre-to-post-test differences were compared using ANCOVA. RESULTS Twenty-two residents completed the curricula. There were no differences in demographics or clinical endoscopy experience between the groups. The repetition group spent significantly more time on the simulator (repetition: 242.2 min, SD 48.6) compared to the proficiency group (proficiency: 170.0 min, SD 66.3; p = 0.013). There was a significant improvement in porcine endoscopy (pre: 10.6, SD 2.8, post: 16.6, SD 3.4; p < 0.001) and colonoscopy (pre: 10.4, SD 2.7, post: 16.4, SD 4.2; p < 0.001) GAGES scores as well as FES manual skills performance (pre: 270.9, SD 105.5, post: 477.4, SD 68.9; p < 0.001) for the total cohort. There was no difference in post-test GAGES performance or FES manual skills exam performance between the two groups. Both the proficiency and repetition group had a 100% pass rate on the FES skills exam following VR curriculum completion. CONCLUSION A VR endoscopy curriculum translates to improved performance in upper and lower endoscopy in a live animal model. VR curricula type did not affect FES manual skills examination or live colonoscopy outcomes; however, a proficiency curriculum is less time-consuming and can provide a structured approach to prepare for both the FES exam and clinical endoscopy.
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Expression of IGF-1 receptor and GH receptor in hepatic tissue of patients with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. Growth Horm IGF Res 2022; 65:101482. [PMID: 35780715 PMCID: PMC9885486 DOI: 10.1016/j.ghir.2022.101482] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 06/02/2022] [Accepted: 06/12/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The GH and IGF-1 axis is a candidate disease-modifying target in nonalcoholic fatty liver disease (NAFLD) given its lipolytic, anti-inflammatory and anti-fibrotic properties. IGF-1 receptor (IGF-1R) and GH receptor (GHR) expression in adult, human hepatic tissue is not well understood across the spectrum of NAFLD severity. Therefore, we sought to investigate hepatic IGF-1R and GHR expression in subjects with NAFLD utilizing gene expression analysis (GEA) and immunohistochemistry (IHC). DESIGN GEA (n = 318) and IHC (n = 30) cohorts were identified from the Massachusetts General Hospital NAFLD Tissue Repository. GEA subjects were categorized based on histopathology as normal liver histology (NLH), steatosis only (Steatosis), nonalcoholic steatohepatitis (NASH) without fibrosis (NASH F0), and NASH with fibrosis (NASH F1-4) with GEA by the Nanostring nCounter assay. IHC subjects were matched for age, body mass index (BMI), sex, and diabetic status across three groups (n = 10 each): NLH, Steatosis, and NASH with fibrosis (NASH F1-3). IHC for IGF-1R, IGF-1 and GHR was performed on formalin-fixed, paraffin-embedded hepatic tissue samples. RESULTS IGF-1R gene expression did not differ across NAFLD severity while IGF-1 gene expression decreased with increasing NAFLD severity, including when controlled for BMI and age. GHR expression did not differ by severity of NAFLD based on GEA or IHC. CONCLUSIONS IGF-1R and GHR expression levels were not significantly different across NAFLD disease severity. However, expression of IGF-1 was lower with increasing severity of NAFLD. Additional research is needed regarding the contribution of the GH/IGF-1 axis to the pathophysiology of NAFLD and NASH.
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Surgeons' Coaching Techniques in the Surgical Coaching for Operative Performance Enhancement (SCOPE) Program. Ann Surg 2022; 275:e91-e98. [PMID: 32740233 DOI: 10.1097/sla.0000000000004323] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate coaching techniques used by practicing surgeons who underwent dedicated coach training in a peer surgical coaching program. BACKGROUND Surgical coaching is a developing strategy for improving surgeons' intraoperative performance. How to cultivate effective coaching skills among practicing surgeons is uncertain. METHODS Through the Surgical Coaching for Operative Performance Enhancement (SCOPE) program, 46 surgeons within 4 US academic medical centers were assigned 1:1 into coach/coachee pairs. All attended a 3-hour Surgical Coaching Workshop-developed using evidence from the fields of surgery and education-then received weekly reminders. We analyzed workshop evaluations and audio transcripts of postoperative debriefs between coach/coachee pairs, co-coding themes based on established principles of effective coaching: (i) self-identified goals, (ii) collaborative analysis, (iii) constructive feedback, and (iv) action planning. Coaching principles were cross-referenced with intraoperative performance topics: technical, nontechnical, and teaching skills. RESULTS For the 8 postoperative debriefs analyzed, mean duration was 24.4 min (range 7-47 minutes). Overall, 326 coaching examples were identified, demonstrating application of all 4 core principles of coaching. Constructive feedback (17.6 examples per debrief) and collaborative analysis (16.3) were utilized more frequently than goal-setting (3.9) and action planning (3.0). Debriefs focused more often on nontechnical skills (60%) than technical skills (32%) or teaching-specific skills (8%). Among surgeons who completed the workshop evaluation (82% completion rate), 90% rated the Surgical Coaching Workshop "good" or "excellent." CONCLUSIONS Short-course coach trainings can help practicing surgeons use effective coaching techniques to guide their peers' performance improvement in a way that aligns with surgical culture.
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ADAMTSL2 protein and a soluble biomarker signature identify at-risk non-alcoholic steatohepatitis and fibrosis in adults with NAFLD. J Hepatol 2022; 76:25-33. [PMID: 34600973 PMCID: PMC8688231 DOI: 10.1016/j.jhep.2021.09.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND & AIMS Identifying fibrosis in non-alcoholic fatty liver disease (NAFLD) is essential to predict liver-related outcomes and guide treatment decisions. A protein-based signature of fibrosis could serve as a valuable, non-invasive diagnostic tool. This study sought to identify circulating proteins associated with fibrosis in NAFLD. METHODS We used aptamer-based proteomics to measure 4,783 proteins in 2 cohorts (Cohort A and B). Targeted, quantitative assays coupling aptamer-based protein pull down and mass spectrometry (SPMS) validated the profiling results in a bariatric and NAFLD cohort (Cohort C and D, respectively). Generalized linear modeling-logistic regression assessed the ability of candidate proteins to classify fibrosis. RESULTS From the multiplex profiling, 16 proteins differed significantly by fibrosis in cohorts A (n = 62) and B (n = 98). Quantitative and robust SPMS assays were developed for 8 proteins and validated in Cohorts C (n = 71) and D (n = 84). The A disintegrin and metalloproteinase with thrombospondin motifs like 2 (ADAMTSL2) protein accurately distinguished non-alcoholic fatty liver (NAFL)/non-alcoholic steatohepatitis (NASH) with fibrosis stage 0-1 (F0-1) from at-risk NASH with fibrosis stage 2-4, with AUROCs of 0.83 and 0.86 in Cohorts C and D, respectively, and from NASH with significant fibrosis (F2-3), with AUROCs of 0.80 and 0.83 in Cohorts C and D, respectively. An 8-protein panel distinguished NAFL/NASH F0-1 from at-risk NASH (AUROCs 0.90 and 0.87 in Cohort C and D, respectively) and NASH F2-3 (AUROCs 0.89 and 0.83 in Cohorts C and D, respectively). The 8-protein panel and ADAMTSL2 protein had superior performance to the NAFLD fibrosis score and fibrosis-4 score. CONCLUSION The ADAMTSL2 protein and an 8-protein soluble biomarker panel are highly associated with at-risk NASH and significant fibrosis; they exhibited superior diagnostic performance compared to standard of care fibrosis scores. LAY SUMMARY Non-alcoholic fatty liver disease (NAFLD) is one of the most common causes of liver disease worldwide. Diagnosing NAFLD and identifying fibrosis (scarring of the liver) currently requires a liver biopsy. Our study identified novel proteins found in the blood which may identify fibrosis without the need for a liver biopsy.
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Challenges of virtual interviewing for surgical fellowships: a qualitative analysis of applicant experiences. Surg Endosc 2022; 36:3763-3771. [PMID: 34448935 PMCID: PMC8393782 DOI: 10.1007/s00464-021-08691-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/24/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The COVID-19 pandemic forced surgical fellowship programs to transition from in-person to remote applicant interviews; the virtual interviewing format presented new and unique challenges. We sought to understand applicants' perceived challenges to virtual interviewing for a surgical fellowship program. METHOD A grounded theory-based qualitative study was performed utilizing semi-structured interviews with fellowship applicants from the 2020 fellowship match. All Fellowship Council-registered applicants were eligible. We purposefully sampled participants to balance across gender, specialty-choice, and academic versus community-program affiliation. Interviews were inductively analyzed by two researchers for prominent themes. RESULTS Fifteen interviews were conducted. Participants were 60% male (n = 9), with 33% (n = 5) from non-academic institutions. They applied for the following fellowships: Advanced Gastrointestinal/Minimal Invasive (55%), Bariatric (30%), Hepatopancreatobiliary (10%) and Surgical Oncology (5%). Four main themes emerged to describe virtual interview process challenges: (1) perceived data deficiency, (2) superficial personal connections, (3) magnification of non-professionalism, and (4) logistical frustrations. Applicants recommend program directors provide more information about the fellowship prior to interview day and offer informal independent interactions with current and previous fellows. CONCLUSIONS According to fellowship applicants, virtual interviews resulted in a lack of information for rank-list decision making ultimately requiring them to rely on other information avenues to base their decisions. These applicants have offered advice to fellowship program directors and future applicants to better optimize this process.
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Distinct Hepatic Gene-Expression Patterns of NAFLD in Patients With Obesity. Hepatol Commun 2021; 6:77-89. [PMID: 34558849 PMCID: PMC8710788 DOI: 10.1002/hep4.1789] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/13/2021] [Indexed: 02/06/2023] Open
Abstract
Approaches to manage nonalcoholic fatty liver disease (NAFLD) are limited by an incomplete understanding of disease pathogenesis. The aim of this study was to identify hepatic gene‐expression patterns associated with different patterns of liver injury in a high‐risk cohort of adults with obesity. Using the NanoString Technologies (Seattle, WA) nCounter assay, we quantified expression of 795 genes, hypothesized to be involved in hepatic fibrosis, inflammation, and steatosis, in liver tissue from 318 adults with obesity. Liver specimens were categorized into four distinct NAFLD phenotypes: normal liver histology (NLH), steatosis only (steatosis), nonalcoholic steatohepatitis without fibrosis (NASH F0), and NASH with fibrosis stage 1‐4 (NASH F1‐F4). One hundred twenty‐five genes were significantly increasing or decreasing as NAFLD pathology progressed. Compared with NLH, NASH F0 was characterized by increased inflammatory gene expression, such as gamma‐interferon‐inducible lysosomal thiol reductase (IFI30) and chemokine (C‐X‐C motif) ligand 9 (CXCL9), while complement and coagulation related genes, such as C9 and complement component 4 binding protein beta (C4BPB), were reduced. In the presence of NASH F1‐F4, extracellular matrix degrading proteinases and profibrotic/scar deposition genes, such as collagens and transforming growth factor beta 1 (TGFB1), were simultaneously increased, suggesting a dynamic state of tissue remodeling. Conclusion: In adults with obesity, distinct states of NAFLD are associated with intrahepatic perturbations in genes related to inflammation, complement and coagulation pathways, and tissue remodeling. These data provide insights into the dynamic pathogenesis of NAFLD in high‐risk individuals.
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Standard laparoscopy remains the routine approach to cholecystectomy. Surgery 2021; 170:1004-1005. [PMID: 34332781 DOI: 10.1016/j.surg.2021.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/25/2021] [Indexed: 10/20/2022]
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Adaptation to Open-Book Online Examination During the COVID-19 Pandemic. JOURNAL OF SURGICAL EDUCATION 2021; 78:737-739. [PMID: 33011103 PMCID: PMC7467022 DOI: 10.1016/j.jsurg.2020.08.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/23/2020] [Accepted: 08/29/2020] [Indexed: 05/09/2023]
Abstract
INTRODUCTION COVID-19 altered medical education systems worldwide as many medical schools quickly changed to online assessment systems. However, the feasibility of online assessment and how it compares to traditional examinations is unclear. METHODS We compared 4th year medical students' online surgery clerkship assessment scores to the traditional written examinations. The percent of correct scores using online open-book examination was compared to the results of the traditional closed-book examination in the previous three rotations. Additional correlation between grade point average(GPA) and examination performance were reviewed. RESULTS Compared with the traditional groups, medical students who took the online, open-book examination had a significantly higher mean score in both MCQ(85.21 vs. 77.36, 72.43, 83.00, p<0.001) and essay examinations (187.36 vs. 158.77, 152.17, 152.29, p<0.001), but a significantly lower mean score in short answer examination (60.09 vs. 66.79, 67.73, 64.82, p<0.001). The online open-book examination group had a significantly lower correlation between the essay score and their GPA than the previous traditional groups (z=2.81 p=0.005, z=2.23 p=0.026, z=2.19 p=0.029). CONCLUSION Although an online, open-book examination was feasible during the COVID-19 pandemic, this study indicates that mean scores are significantly different which has important implications regarding grading and standard setting. More research is required to assess other effects of this new assessment on long-term knowledge retention and application.
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A Needs Assessment of Video-based Education Resources Among General Surgery Residents. J Surg Res 2021; 263:116-123. [PMID: 33652173 DOI: 10.1016/j.jss.2021.01.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 01/10/2021] [Accepted: 01/31/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Video-based education (VBE) is an effective tool for knowledge and skill acquisition for medical students, but its utility is less clear for resident physicians. We sought to determine how to incorporate VBE into a general surgery resident operative curriculum. METHODS We conducted a single-institution, survey-based needs assessment of general surgery residents to determine desired content and format of an operative VBE module. RESULTS The response rate was 84% (53/63), with 66% senior (postgraduate year ≥3) resident respondents. VBE was the most commonly cited resource that residents used to prepare for an operation (93%) compared with surgical textbooks (89%) and text-based website content (57%). Junior residents were more likely to utilize text-based website content than senior residents (P < 0.01). The three most important operative video components were accuracy, length, and cost. Senior residents significantly preferred videos that were peer-reviewed (P < 0.05) and featured attending surgeons whom they knew (P = 0.03). A majority of residents (59%) believed 5-10 min is the ideal length of an operative video. Across all postgraduate year levels, residents indicated that detailed instruction of each operative step was the most important content of a VBE module. Senior residents believed that the overall indications and details of each step of the operation were the most important contents of VBE for a junior resident. CONCLUSIONS At this institution, general surgery residents preferentially use VBE resources for operative preparation. A centralized, standardized operative resource would likely improve resident studying efficiency, but would require personalized learning options to work for both junior and senior surgery residents.
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Implementation of the ACS/ APDS Resident Skills Curriculum reveals a need for rater training: An analysis using generalizability theory. Am J Surg 2021; 222:541-548. [PMID: 33516415 DOI: 10.1016/j.amjsurg.2021.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/16/2020] [Accepted: 01/11/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) Resident Skills Curriculum includes validated task-specific checklists and global rating scales (GRS) for Objective Structured Assessment of Technical Skills (OSATS). However, it does not include instructions on use of these assessment tools. Since consistency of ratings is a key feature of assessment, we explored rater reliability for two skills. METHODS Surgical faculty assessed hand-sewn bowel and vascular anastomoses in real-time using the OSATS GRS. OSATS were video-taped and independently evaluated by a research resident and surgical attending. Rating consistency was estimated using intraclass correlation coefficients (ICC) and generalizability analysis. RESULTS Three-rater ICC coefficients across 24 videos ranged from 0.12 to 0.75. Generalizability reliability coefficients ranged from 0.55 to 0.8. Percent variance attributable to raters ranged from 2.7% to 32.1%. Pairwise agreement showed considerable inconsistency for both tasks. CONCLUSIONS Variability of ratings for these two skills indicate the need for rater training to increase scoring agreement and decrease rater variability for technical skill assessments.
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#SurgEdVidz: Using Social Media to Create a Supplemental Video-Based Surgery Didactic Curriculum. J Surg Res 2020; 256:680-686. [DOI: 10.1016/j.jss.2020.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 11/30/2022]
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Trainee Autonomy in Minimally Invasive General Surgery in the United States: Establishing a National Benchmark. JOURNAL OF SURGICAL EDUCATION 2020; 77:e52-e62. [PMID: 33250116 DOI: 10.1016/j.jsurg.2020.07.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/14/2020] [Accepted: 07/19/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Minimally invasive surgery (MIS) is an integral component of General Surgery training and practice. Yet, little is known about how much autonomy General Surgery residents achieve in MIS procedures, and whether that amount is sufficient. This study aims to establish a contemporary benchmark for trainee autonomy in MIS procedures. We hypothesize that trainees achieve progressive autonomy, but fail to achieve meaningful autonomy in a substantial percentage of MIS procedures prior to graduation. SETTING/PARTICIPANTS Fifty General Surgery residency programs in the United States, from September 1, 2015 to March 19, 2020. All Categorical General Surgery Residents and Attending Surgeons within these programs were eligible. DESIGN Data were collected prospectively from attending surgeons and categorical General Surgery residents. Trainee autonomy was assessed using the 4-level Zwisch scale (Show and Tell, Active Help, Passive Help, and Supervision Only) on a smartphone application (SIMPL). MIS procedures included all laparoscopic, thoracoscopic, endoscopic, and endovascular/percutaneous procedures performed by residents during the study. Primary outcomes of interest were "meaningful autonomy" rates (i.e., scores in the top 2 categories of the Zwisch scale) by postgraduate year (PGY), and "progressive autonomy" (i.e., differences in autonomy between PGYs) in MIS procedures, as rated by attending surgeons. Primary outcomes were determined with descriptive statistics, one-way analysis of variance (ANOVA) and Z-tests. Secondary analyses compared (i) progressive autonomy between common MIS procedures, and (ii) progressive autonomy in MIS vs. non-MIS procedures. RESULTS A total of 106,054 evaluations were performed across 50 General Surgery residency programs, of which 38,985 (37%) were for MIS procedures. Attendings performed 44,842 (42%) of all evaluations, including 16,840 (43%) of MIS evaluations, while residents performed the rest. Overall, meaningful autonomy in MIS procedures increased from 14.1% (PGY1s) to 75.9% (PGY5s), with significant (p < 0.001) increases between each PGY level. Meaningful autonomy rates were higher in the MIS vs. non-MIS group [57.2% vs. 48.0%, p < 0.001], and progressed more rapidly in MIS vs. non-MIS, (p < 0.05). The 7 most common MIS procedures accounted for 83.5% (n = 14,058) of all MIS evaluations. Among PGY5s performing these procedures, meaningful autonomy rates (%) were: laparoscopic appendectomy (95%); laparoscopic cholecystectomy (93%); diagnostic laparoscopy (87%); upper/lower endoscopy (85%); laparoscopic hernia repair (72%); laparoscopic partial colectomy (58%); and laparoscopic sleeve gastrectomy (45%). CONCLUSIONS US General Surgery residents receive progressive autonomy in MIS procedures, and appear to progress more rapidly in MIS versus non-MIS procedures. However, residents fail to achieve meaningful autonomy in nearly 25% of MIS cases in their final year of residency, with higher rates of meaningful autonomy only achieved in a small subset of basic MIS procedures.
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Optimizing the Implementation of Surgical Coaching Through Feedback From Practicing Surgeons. JAMA Surg 2020; 156:42-49. [PMID: 33052407 DOI: 10.1001/jamasurg.2020.4581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Importance Surgical coaching is maturing as a tangible strategy for surgeons' continuing professional development. Resources to spread this innovation are not yet widely available. Objective To identify surgeon-derived implementation recommendations for surgical coaching programs from participants' exit interviews and ratings of their coaching interactions. Design, Setting, and Participants This qualitative analysis of the Surgical Coaching for Operative Performance Enhancement (SCOPE) program, a quality improvement intervention, was conducted at 4 US academic medical centers. Participants included 46 practicing surgeons. The SCOPE program ran from December 7, 2018, to October 31, 2019. Data were analyzed from November 1, 2019, to January 31, 2020. Interventions Surgeons were assigned as either a coach or a coachee, and each coach was paired with 1 coachee by a local champion who knew the surgeons professionally. Coaching pairs underwent training and were instructed to complete 3 coaching sessions-consisting of preoperative goal setting, intraoperative observation, and postoperative debriefing-focused on intraoperative performance. Main Outcomes and Measures Themes from the participants' exit interviews covering 3 major domains: (1) describing the experience, (2) coach-coachee relationship, and (3) facilitators and barriers to implementing surgical coaching. Surgeons' responses were stratified by the net promoter score (NPS), a scale ranging from 0 to 10 points, indicating how likely they were to recommend their coaching session to others, with 9 to 10 indicating promoters; 7 to 8, passives; and 0 to 6, detractors. Results Among the 46 participants (36 men [78.3%]), 23 were interviewed (50.0%); thematic saturation was reached with 5 coach-coachee pairs (10 interviews). Overall, coaches and coachees agreed on key implementation recommendations for surgical coaching, including how to optimize coach-coachee relationships and facilitate productive coaching sessions. The NPS categories were associated with how participants experienced their own coaching sessions. Specifically, participants who reported excellent first sessions, had a coaching partner in the same clinical specialty, and were transparent about each other's intentions in the program tended to be promoters. Participants who described suboptimal first sessions, less clinical overlap, and unclear goals with their partner were more likely detractors. Conclusions and Relevance These exit interviews with practicing surgeons offer critical insights for addressing cultural barriers and practical challenges for successful implementation of peer coaching programs focused on surgical performance improvement. With empirical evidence on optimizing coach-coachee relationships and facilitating participants' experience, organizations can establish effective coaching programs that enable meaningful continuous professional development for surgeons and ultimately enhance patient care.
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Implementation of the ACS/APDS Technical Skills Curriculum Reveals a Need for Rater Training. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Development and Evaluation of a Novel Instrument to Measure Severity of Intraoperative Events Using Video Data. Ann Surg 2020; 272:220-226. [PMID: 32675485 DOI: 10.1097/sla.0000000000003897] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To develop and evaluate a novel instrument to measure SEVERE processes using video data. BACKGROUND Surgical video data can serve an important role in understanding the relationship between intraoperative events and postoperative outcomes. However, a standard tool to measure severity of intraoperative events is not yet available. METHODS Items to be included in the instrument were identified through literature and video reviews. A committee of experts guided item reduction, including pilot tests and revisions, and determined weighted scores. Content validity was evaluated using a validated sensibility questionnaire. Inter-rater reliability was assessed by calculating intraclass correlation coefficient. Construct validity was evaluated on a sample of 120 patients who underwent laparoscopic Roux-en-Y gastric bypass procedure, in which comprehensive video data was obtained. RESULTS SEVERE index measures severity of 5 event types using ordinal scales. Each intraoperative event is given a weighted score out of 10. Inter-rater reliability was excellent [0.87 (95%-confidence interval, 0.77-0.92)]. In a sample of consecutive 120 patients undergoing gastric bypass procedures, a median of 12 events [interquartile range (IQR) 9-18] occurred per patient and bleeding was the most frequent type (median 10, IQR 7-14). The median SEVERE score per case was 11.3 (IQR 8.3-16.9). In risk-adjusted multivariable regression models, history of previous abdominal surgery (P = 0.02) and body mass index (P = 0.005) were associated with SEVERE scores, demonstrating construct validity evidence. CONCLUSION The SEVERE index may prove to be a useful instrument in identifying patients with high risk of developing postoperative complications.
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Surgical Coaching for Operative Performance Enhancement (SCOPE): skill ratings and impact on surgeons’ practice. Surg Endosc 2020; 35:3829-3839. [DOI: 10.1007/s00464-020-07776-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/01/2020] [Indexed: 01/03/2023]
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Comparison of Short and Long-Term Outcomes of Metabolic and Bariatric Surgery in Adolescents and Adults. Front Endocrinol (Lausanne) 2020; 11:157. [PMID: 32265846 PMCID: PMC7105703 DOI: 10.3389/fendo.2020.00157] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/06/2020] [Indexed: 12/30/2022] Open
Abstract
Objective: We sought to compare the short and long-term outcomes of MBS in adolescents vs. adults who have undergone a Roux-en-Y gastric bypass (RYGB) or Sleeve gastrectomy (SG). Design: Retrospective cohort study. Setting: Single tertiary care academic referral center. Participants: One hundred fifty adolescent (≤ 21-years) and adult (>21-years) subjects with severe obesity between 15 and 70 years of age who underwent RYGB or SG. Outcomes: Metabolic parameters, weight and height measures were obtained pre-and post-surgery (at 3 and 6 months, and then annually for 4 years). Results: Median pre-surgical body mass index (BMI) was higher in adolescents (n = 76) vs. adults (n = 74): 50 (45-57) vs. 44 (40-51) kg/m2 (p < 0.0001). However, obesity related complications were greater in adults vs. adolescents: 66 vs. 21% had hypertension, 68 vs. 28% had dyslipidemia, and 42 vs. 21% had type 2 diabetes mellitus (all p < 0.010). % BMI reduction and % weight loss (WL) were greater in adolescents vs. adults at all time points (p < 0.050). %WL was higher in adolescents who underwent SG at each time point (p < 0.050), and trended higher among adolescents who underwent RYGB (p = 0.060), compared to adults with the respective procedure. Follow-up data showed greater resolution of type 2 diabetes and hypertension in adolescents than adults (87.5 vs. 54.8%; p = 0.04, and 68.7 vs. 35.4%; p = 0.040). Conclusion: Adolescents compared to adults had greater reductions in BMI and weight, even at 4 years, and greater resolution of type 2 diabetes and hypertension. Earlier intervention in the treatment of severe obesity with MBS may lead to better outcomes.
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Does Clinical Exposure Matter? An Analysis of General Surgery Categorical Intern Schedules and the Impact of Rotation Timing on ABSITE Performance. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Risk factors and prevalence of liver disease in review of 2557 routine liver biopsies performed during bariatric surgery. Surg Obes Relat Dis 2019; 15:843-849. [PMID: 31014948 DOI: 10.1016/j.soard.2019.01.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/21/2019] [Accepted: 01/30/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Obesity is a known risk factor for nonalcoholic fatty liver disease (NAFLD). However, among individuals undergoing bariatric surgery, the prevalence and risk factors for NAFLD, as well as distinct phenotypes of steatosis, nonalcoholic steatohepatitis (NASH), and fibrosis remain incompletely understood. OBJECTIVES To determine the prevalence and risk factors for steatosis, NASH, and fibrosis in individuals undergoing routine bariatric surgery. SETTING Academic medical center in the United States. METHODS Liver wedge biopsies were performed at the time of surgery between 2001 and 2017. Pathology reports were reviewed, and individuals were grouped by NAFLD phenotype. Covariates including demographic characteristics, co-morbidities, and preoperative laboratory values were compared between groups using Student's t test, Pearson's χ2, and logistic regression. RESULTS Liver biopsies were obtained in 97.7% of first-time bariatric procedures, representing 2557 patients. Mean age was 45.6 years, mean body mass index was 46.7, and most were non-Hispanic white (76.1%) and female (71.6%). On histologic review 61.2% had steatosis and 30.9% NASH. Fibrosis was identified in 29.3% of individuals, and 7.8% had stage ≥2 fibrosis. On logistic regression, elevated aspartate aminotransferase (odds ratio [OR] 1.87; P < .001) and elevated alanine aminotransferase (OR 1.62; P < .001) were independently associated with fibrosis. Elevated hemoglobin A1C of 5.7% to 6.5% (OR 1.29; P < .01) and >6.5% (OR 3.23; P < .001) were also associated with fibrosis. A similar trend was seen for NASH. CONCLUSIONS NASH and/or fibrosis is present in nearly one third of patients undergoing routine bariatric surgery. Risk factors include diabetes, elevated liver enzymes, and diabetes. Risk assessment and aggressive screening should be considered in patients undergoing bariatric surgery.
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Feasibility and Perceived Usefulness of Using Head-Mounted Cameras for Resident Video Portfolios. J Surg Res 2019; 239:233-241. [PMID: 30856516 DOI: 10.1016/j.jss.2019.01.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/21/2018] [Accepted: 01/11/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND There is limited guidance on how to longitudinally administer simulation materials or to incorporate video recordings into assessment portfolios of simulated surgical skills. MATERIALS AND METHODS We launched a longitudinal weekly simulation curriculum for PGY1-PGY3 surgical residents based on the ACS/APDS Curriculum. Residents underwent monthly objective structured assessment of technical skills (OSATS) while wearing head-mounted cameras. Videos of OSATS performance accrued into individual online video portfolios. Residents were surveyed about their attitudes toward video recording. RESULTS Twenty-seven general surgical residents participated, completing 161 OSATS encompassing 11 distinct skills and generating 258 videos of simulated skills performance. The overall survey response rate was 88%. Residents viewed the curriculum favorably overall, and 36.4% of residents accessed their videos. Of those who did not watch their videos, 78.6% cited not having enough time, whereas 28.6% did not think the videos would be useful. Over 95% of surveyed residents expressed interest in having a video library of attending-performed procedures, 59.1% were interested in having their own operations recorded, and 45.5% were interested in video-based coaching. CONCLUSIONS Residents viewed longitudinal administration of the ACS/APDS Curriculum positively. Although video recording in simulation is feasible, resident interest may be higher for intraoperative recordings than for simulated skills.
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Assessing bimanual motor skills with optical neuroimaging. SCIENCE ADVANCES 2018; 4:eaat3807. [PMID: 30306130 PMCID: PMC6170034 DOI: 10.1126/sciadv.aat3807] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 08/29/2018] [Indexed: 05/12/2023]
Abstract
Measuring motor skill proficiency is critical for the certification of highly skilled individuals in numerous fields. However, conventional measures use subjective metrics that often cannot distinguish between expertise levels. We present an advanced optical neuroimaging methodology that can objectively and successfully classify subjects with different expertise levels associated with bimanual motor dexterity. The methodology was tested by assessing laparoscopic surgery skills within the framework of the fundamentals of a laparoscopic surgery program, which is a prerequisite for certification in general surgery. We demonstrate that optical-based metrics outperformed current metrics for surgical certification in classifying subjects with varying surgical expertise. Moreover, we report that optical neuroimaging allows for the successful classification of subjects during the acquisition of these skills.
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A Pilot Study to Gauge Effectiveness of Standardized Patient Scenarios in Assessing General Surgery Milestones. JOURNAL OF SURGICAL EDUCATION 2016; 73:e1-e8. [PMID: 27886969 DOI: 10.1016/j.jsurg.2016.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 08/18/2016] [Accepted: 08/22/2016] [Indexed: 06/06/2023]
Abstract
PURPOSE Some General Surgery Milestones can be difficult to assess in traditional clinical settings and especially difficult to assess in junior residents. The purpose of this pilot study was to METHODS: A total of 9 categorical interns participated in a comprehensive, 4-module, SP scenario designed to evaluate and manage right upper quadrant pain. SP checklist scores (SP%) were converted to Milestone-equivalent scores for direct comparison (SP-C). Milestone scores were analyzed from 3 different sources: SP, faculty (FAC), and CCC. Interns completed course evaluations at the end of each session. Spearman's rho was used to determine correlations. Wilcoxon signed rank tests were used to test for differences between scores from different sources. RESULTS Individual intern Milestone scores from the 3 sources (SP-C, FAC, and CCC) did not correlate. All 7 mean Milestone scores from SPs were significantly higher than from FAC and CCC. FAC and CCC scores were statistically equivalent except for Systems-Based Practice 1 (SBP1) and Patient Care 3 (PC3) where CCC scores were significantly higher than FAC. Mean SP% scores for PC1 were significantly lower than for PROF1, MK1, MK2, and ICS1 (p < 0.05). Interns felt the modules were moderately to very useful. CONCLUSIONS Developing an SP scenario for Milestones evaluation is feasible. SPs, faculty observers, and CCC each use different data to provide a unique source of Milestone assessment. SP scenarios may be ideally suited to assess specific resident strengths and weaknesses and provide individualized feedback, thus augmenting traditional evaluations. Additional SP scenarios, assessing a broader range of skills and Milestones, are advisable for more reliable estimates of resident performance.
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Abstract
BACKGROUND Simulation has been shown to improve trainee performance at the bedside and in the operating room. As the use of simulation-based training is expanded to address a host of health care challenges, its added value needs to be clearly demonstrated. Demonstrable improvements will support the expansion of infrastructure, staff, and programs within existing simulation facilities as well as the establishment of new facilities to meet growing needs and demands. Thus, organizational and institutional leaders, faculty members, and other stakeholders can be assured of the best use of existing resources and can be persuaded to make greater investments in simulation-based training for the future. METHODS A multidisciplinary panel was convened during the 8th Annual Meeting of the Consortium of the American College of Surgeons-Accredited Education Institutes (Simulation Centers) in March 2015 to discuss the added value of simulation-based training. Panelists shared the ways in which the value of simulation was demonstrated at their institutions. CONCLUSION The value of simulation-based training was considered and described in terms of educational impact, patient care outcomes, and costs.
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Laparoscopic Roux-en-Y gastric bypass patients have an increased lifetime risk of repeat operations when compared to laparoscopic sleeve gastrectomy patients. Surg Endosc 2015; 30:1833-8. [DOI: 10.1007/s00464-015-4466-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/22/2015] [Indexed: 01/07/2023]
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Endoscopic simulator curriculum improves colonoscopy performance in novice surgical interns as demonstrated in a swine model. Surg Endosc 2013; 28:1494-9. [DOI: 10.1007/s00464-013-3339-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 11/11/2013] [Indexed: 12/01/2022]
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A prospective, randomized trial of esophageal submucosal tunnel closure with a stent versus no closure to secure a transesophageal natural orifice transluminal endoscopic surgery access site. Gastrointest Endosc 2011; 73:785-90. [PMID: 21288511 DOI: 10.1016/j.gie.2010.11.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Accepted: 11/11/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Secure esophagotomy closure methods are a critical element in the advancement of transesophageal natural orifice transluminal endoscopic surgery (NOTES) procedures. OBJECTIVE To compare the clinical outcomes in swine receiving an esophageal stent or no stent after a submucosal tunnel NOTES access procedure. DESIGN Prospective, randomized, controlled trial in 10 Yorkshire swine. SETTING Academic center. INTERVENTION An endoscopic mucosectomy device was used to create an esophageal mucosal defect. An endoscope was advanced through a submucosal tunnel into the mediastinum and thorax, and diagnostic mediastinoscopy and thoracoscopy were performed. Ten animals were randomized to no stenting (n = 5) or stenting (n = 5) with a prototype small-intestine submucosa-covered stent. MAIN OUTCOME MEASUREMENTS Gross and histologic appearance of the mucosectomy and esophagotomy sites as well as clinical outcomes. RESULTS There was a significant difference in the overall procedure time between the animals that received a stent (35.0 min, range 27-46.0 min) and those with no closure (19.0 min, range 17-32 min) (P value = .018). The unstented group achieved endoscopic and histologic evidence of complete re-epithelialization and healing (100%) at the mucosectomy site compared with the stented group (20%, P = .048). Stent migration into the stomach occurred in two swine. Both groups had complete closure of the submucosal tunnel and well-healed esophagotomy sites. LIMITATIONS Animal study, small number of subjects. CONCLUSION The placement of a covered esophageal stent significantly interferes with mucosectomy site healing.
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Endoscopic transesophageal mediastinal lymph node dissection and en bloc resection by using mediastinal and thoracic approaches (with video). Gastrointest Endosc 2010; 72:831-5. [PMID: 20573345 PMCID: PMC3863608 DOI: 10.1016/j.gie.2010.04.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Accepted: 04/08/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND The criterion standard for sampling mediastinal lymph nodes is cervical mediastinoscopy. Current methods that require transthoracic or cervical incisions can result in significant postoperative pain. OBJECTIVE To determine the feasibility of a novel, transesophageal endoscopic technique for mediastinal lymph node dissection and en bloc resection. DESIGN Nonsurvival and survival animal study. SETTING Animal trial at a tertiary-care academic center. SUBJECTS This study involved 12 Yorkshire swine. INTERVENTION An endoscopic cap band mucosectomy device was used to create an esophageal mucosal defect. By using the tip of the endoscope and biopsy forceps, a submucosal tunnel was fashioned, and, within the submucosal space, a hook-knife incised the muscular esophageal wall. The endoscope was then advanced into the mediastinum and chest. Mediastinoscopy and thoracoscopy were performed to identify lymph node stations. Prototype endoscopic devices permitted lymph node dissection prior to removal with an electrocautery snare. A covered prototype stent was placed over the mucosectomy site. MAIN OUTCOME MEASUREMENTS Feasibility of endoscopic transesophageal lymphadenectomy. RESULTS Three lymph nodes (1 para-aortic and 2 right paratracheal) were removed in the 3 nonsurvival swine. Nine swine were survived for 14 days (range 13-14 days) and had a total of 7 lymph nodes (2 para-aortic and 5 paratracheal) removed. Two swine had no endoscopically visible lymph nodes in the mediastinum or chest. Lymph node dissection and resection was successful in all cases where lymph nodes were identified. Lymphadenectomy was completed in a median time of 20.0 minutes (range 8-60 minutes); median total procedure time was 70.0 minutes (range 28-105 minutes). Median lymph node size was 1.1 cm (range 0.6-1.4 cm). LIMITATIONS Animal study. CONCLUSION An endoscopic transesophageal approach can accomplish mediastinal lymph node dissection and en bloc resection and provides architecturally intact lymph node specimens for histologic examination.
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Stent placement provides safe esophageal closure in thoracic NOTES(TM) procedures. Surg Endosc 2010; 25:913-8. [PMID: 20820811 DOI: 10.1007/s00464-010-1297-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 07/26/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Safe esophageal closure remains a challenge in transesophageal Natural Orifice Transluminal Endoscopic Surgery (NOTES). Previously described methods, such as suturing devices, clips, or submucosal tunneling, all have weaknesses. In this survival animal series, we demonstrate safe esophageal closure with a prototype retrievable, antimigration stent. METHODS Nine Yorkshire swine underwent thoracic NOTES procedures. A double-channel gastroscope equipped with a mucosectomy device was used to create an esophageal mucosal defect. A 5-cm submucosal tunnel was created and the muscular esophageal wall was incised with a needle-knife. Mediastinoscopy and thoracoscopy were performed in all swine; lymphadenectomy was performed in seven swine. A prototype small intestinal submucosal (SurgiSIS(®)) covered stent was deployed over the mucosectomy site and tunnel. Three versions of the prototype stent were developed. Prenecropsy endoscopy confirmed stent location and permitted stent retrieval. Explanted esophagi were sent to pathology. RESULTS Esophageal stenting was successful in all animals. Stent placement took 15.8 ± 4.8 minuted and no stent migration occurred. Prenecropsy endoscopy revealed proximal ingrowth of esophageal mucosa and erosion with Stent A. Mucosal inflammation and erosion was observed proximally with Stent B. No esophageal erosion or pressure damage from proximal radial forces was seen with Stent C. On necropsy, swine 5 had a 0.5-cm periesophageal abscess. Histology revealed a localized inflammatory lesion at the esophageal exit site in swine 1, 3, and 9. The mucosectomy site was partially healed in three swine and poorly healed in six. All swine thrived clinically, except for a brief period of mild lethargy in swine 9 who improved with short-term antibiotic therapy. The submucosal tunnels were completely healed and no esophageal bleeding or stricture formation was observed. All swine survived 13.8 ± 0.4 days and gained weight in the postoperative period. CONCLUSIONS Esophageal stenting provides safe closure for NOTES thoracic procedures but may impede healing of the mucosectomy site.
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Leaks and endoscopic assessment of break of integrity after NOTES gastrotomy: the LEAKING study, a prospective, randomized, controlled trial. Gastrointest Endosc 2010; 71:1018-24. [PMID: 20185125 DOI: 10.1016/j.gie.2009.10.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Accepted: 10/20/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastric leak testing after natural orifice transluminal endoscopic surgery (NOTES) gastrotomy closure may help reduce the risk of leaks after transgastric procedures. OBJECTIVE To develop a novel endoscopy-based system to determine the presence of a leak after NOTES gastrotomy and to compare this system prospectively with radiographic leak testing. DESIGN Prospective, randomized, controlled trial. SETTING Academic Medical Center laboratory. SUBJECTS Fifty swine. INTERVENTION During the pretrial phase, an endoscopic system for the measurement of intragastric pressure was developed. In the trial phase, swine with a NOTES gastrotomy were randomized to endoscopic versus radiographic leak testing. If a leak was demonstrated, the gastrotomy was reclosed by using a second-generation prototype T-anchor system. The primary outcome was leak detection after gastrotomy closure. The secondary outcome variables included necropsy findings, peritoneal fluid analysis, histologic examination, and clinical outcome. RESULTS Fourteen swine were included in the pretrial phase and 36 in the randomized trial. Swine were survived for a mean of 9 days postoperatively. Endoscopic pressure monitoring demonstrated a reproducible change in intragastric pressure with insufflation; r = 0.735, P = .001 and r = 0.769, P < or = .000 for the total and maximum pressures, respectively. Post-peritoneoscopy, there was a detectable and significant decrease in the mean total and mean maximum pressures versus baseline (P = .006 and P = .009). There was no significant difference between the radiologic and endoscopic arms in leak detection rate (4/18 vs 3/18, respectively, P = .500). Clinical outcomes and mean weight gain were equivalent. There was 1 operative abdominal wall injury and no deaths. LIMITATIONS Animal study. CONCLUSION Endoscopic pressure monitoring was reproducible, demonstrated the presence of gastric leak, and was as reliable as contrast-based radiographic leak testing.
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Survival study of natural orifice translumenal endoscopic surgery for rectosigmoid resection using transanal endoscopic microsurgery with or without transgastric endoscopic assistance in a swine model. Surg Endosc 2010; 24:2022-30. [PMID: 20174948 DOI: 10.1007/s00464-010-0898-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 01/03/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND The feasibility of transanal rectosigmoid resection with transanal endoscopic microsurgery (TEM) was previously demonstrated in a swine nonsurvival model in which transgastric endoscopic assistance also was shown to extend the length of colon mobilized transanally. METHODS A 2-week survival study evaluating transanal endoscopic rectosigmoid resection with stapled colorectal anastomosis was conducted with swine using the transanal approach alone (TEM group, n = 10) or a transanal approach combined with transgastric endoscopic assistance (TEM + TG group, n = 10). Gastrotomies were created using a needleknife and balloon dilation, then closed using prototype T-tags. Outcomes were evaluated and compared between the groups using Student's t-test and Fisher's exact test. RESULTS Relative to the TEM group, the average length of rectosigmoid mobilized in the TEM + TG group was 15.6 versus 10.5 cm (p < 0.0005), the length of the resected specimen was 9 versus 6.2 cm (p < 0.0005), and the mean operative time was 254.5 versus 97.5 min (p < 0.0005). Intraoperatively, no organ injury or major bleeding was noted. Two T-tag misfires occurred during gastrotomy closure and four small staple line defects requiring transanal repair including one in the TEM group and three in the TEM + TG group (p = 0.2). Postoperatively, there was no mortality, and the animals gained an average of 3.4 lb. Two major complications (10%) were identified at necropsy in the TEM + TG group including an intraabdominal abscess and an abdominal wall hematoma related to T-tag misfire. Gastrotomy closure sites and colorectal anastomoses were all grossly healed, with adhesions noted in 60 and 70% and microabscesses in 50 and 20% of the gastrotomy sites and colorectal anastomoses, respectively. CONCLUSIONS Natural orifice translumenal endoscopic surgery (NOTES) for rectosigmoid resection using TEM with or without transgastric endoscopic assistance is feasible and associated with low morbidity in a porcine survival model. Transgastric assistance significantly prolongs the operative time but extends the length of the rectosigmoid mobilized transanally, with a nonsignificant increase in complication rates related to gastrotomy creation.
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Natural orifice transesophageal thoracoscopic surgery: A review of the current state. World J Gastrointest Endosc 2010; 2:3-9. [PMID: 21160671 PMCID: PMC2998863 DOI: 10.4253/wjge.v2.i1.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 10/07/2009] [Accepted: 10/14/2009] [Indexed: 02/05/2023] Open
Abstract
Since the concept of Natural Orifice Translumenal Endoscopic Surgery (NOTES) was introduced, it has continued to gain significantly in popularity and enthusiasm for its potential clinical applications. The ability to perform conventional laparoscopic and thoracoscopic procedures without the creation of scars and perhaps faster and less painful recovery has prompted a worldwide devotion to further this field. While intra-abdominal NOTES has rapidly transitioned from animal models to human trials, applying the NOTES concept to perform thoracic procedures has been slower to gain momentum. The goal of this review is to summarize the current state of transesophageal NOTES thoracoscopy by looking at its potential for diagnostic and therapeutic interventions as well as the challenges in transitioning to human trials.
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Feasibility of endoscopic transesophageal thoracic sympathectomy (with video). Gastrointest Endosc 2010; 71:171-5. [PMID: 19879572 DOI: 10.1016/j.gie.2009.07.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Accepted: 07/09/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Thoracoscopic sympathectomy is the preferred surgical treatment for patients with disabling palmar hyperhidrosis. Current methods require a transthoracic approach to permit ablation of the thoracic sympathetic chain. OBJECTIVE To develop a minimally invasive, transesophageal endoscopic technique for a sympathectomy in a swine model. DESIGN Nonsurvival animal study. SETTING Animal trial at a tertiary care academic center. SUBJECTS This study involved 8 healthy Yorkshire swine. INTERVENTIONS After insertion of a double-channel gastroscope, a Duette Band mucosectomy device was used to create a small esophageal mucosal defect. A short, 5-cm submucosal tunnel was created by using the tip of the endoscope and biopsy forceps. Within the submucosal space, a needle-knife was used to incise the muscular esophageal wall and permit entry into the mediastinum and chest. The sympathetic chain was identified at the desired thoracic level and was ablated or transected. The animals were killed at the completion of the procedure. MAIN OUTCOME MEASUREMENTS Feasibility of endoscopic transesophageal thoracic sympathectomy. RESULTS The sympathetic chain was successfully ablated in 7 of 8 swine, as confirmed by gross surgical pathology and histology. In 1 swine, muscle fibers were inadvertently transected. On average, the procedure took 61.4+/-24.5 minutes to gain access to the chest, whereas the sympathectomy was performed in less than 3 minutes in all cases. One animal was killed immediately after sympathectomy, before the completion of the observation period, because of hemodynamic instability. LIMITATIONS Nonsurvival series, animal study. CONCLUSIONS Endoscopic transesophageal thoracic sympathectomy is technically feasible, simple, and can be performed in a porcine model.
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Natural orifice versus conventional laparoscopic distal pancreatectomy in a porcine model: a randomized, controlled trial. Gastrointest Endosc 2009; 70:740-7. [PMID: 19560766 DOI: 10.1016/j.gie.2009.03.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Accepted: 03/11/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) research has primarily involved case series reports of low-risk procedures. Distal pancreatectomy has significant postoperative morbidity and would permit rigorous examination in a controlled trial setting. OBJECTIVE To compare endoscopic transgastric distal pancreatectomy (ETDP) and laparoscopic distal pancreatectomy (LDP). DESIGN Prospective, randomized, controlled trial. SETTING Academic hospital. SUBJECTS Forty-one swine, 28 block randomized. INTERVENTIONS LDP was performed with 3 trocars and stapled transection of the pancreas. ETDP was performed via a gastrotomy, with 1 trocar for visualization, by using endoloop placement, snare transection, and purse-string gastrotomy closure. MAIN OUTCOME MEASUREMENTS Clinical examination, CT, serum chemistries, necropsy, peritoneal fluid analysis, and histologic examination. RESULTS Swine were survived for 8 days. The procedure time for ETDP was significantly greater than for LDP (1:52 vs 0:33 [hours:minutes]; P = .00). Pancreatic specimen weight was similar (4.1 g vs 5.5 g; P = .108). Postoperatively, 26 of 28 animals thrived. In the LDP group, 1 death caused by pancreatic leak and renal failure occurred on day 1. In the ETDP group, 1 death caused by pneumothorax occurred intraoperatively. The necropsy, CT, and histologic examinations revealed focal resection-margin necrosis in 3 to 7 swine in the ETDP group with no proximal necrosis or pancreatitis. The groups were equivalent clinically, by survival, and by serum and peritoneal fluid analysis. The gastrotomy closure was associated with small serosal adhesions, but no gross abscess or necrosis. LIMITATION Animal study. CONCLUSIONS In the largest controlled trial of NOTES orifice surgery to date, there was no clinical or survival difference between NOTES and laparoscopic approaches.
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Reducing the unexpectedly high rate of injuries caused by NOTES gastrotomy creation. Surg Endosc 2009; 24:277-82. [PMID: 19533234 DOI: 10.1007/s00464-009-0570-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Revised: 04/29/2009] [Accepted: 05/14/2009] [Indexed: 11/26/2022]
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En bloc esophageal mucosectomy for concentric circumferential mucosal resection (with video). Gastrointest Endosc 2009; 69:147-51. [PMID: 19111695 DOI: 10.1016/j.gie.2008.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Accepted: 09/05/2008] [Indexed: 12/10/2022]
Abstract
BACKGROUND With conventional EMR, specimens are fragmented, metaplasia may be left behind, and invasive lesions could be missed because of incomplete sampling. Concentric subtotal esophageal mucosectomy would address these limitations. OBJECTIVE To examine en bloc esophageal mucosectomy (EEM). DESIGN A prospective case series. SETTING An academic hospital. SUBJECTS Nine swine. INTERVENTIONS Conventional EMR was performed in the proximal esophagus. The submucosal space was entered, and the distal two thirds of the esophageal mucosa was freed with blunt dissection. A snare was threaded over the column of mucosa to the gastroesophageal junction. The column was resected, and the mucosa was retrieved. MAIN OUTCOME AND MEASUREMENTS Clinical examination, follow-up endoscopy, necropsy, and gross and histopathologic examination. RESULTS EEM permitted subtotal esophageal mucosectomy in 9 of 9 swine (tissue specimens removed ranged 9-15 cm in length). The mean procedure duration was 110 minutes. In the survival series, 4 of 4 swine thrived after surgery, for 9 to 13 days. At 9 days, there was no evidence of a perforation, stricture, or leak. At 13 days, 2 swine had a mild proximal stricture, which was easily traversed with a 9.8-mm gastroscope. On necropsy, the mediastinal and thoracic cavities were unremarkable in 3 of 4 swine. One swine was found to have a contained abscess containing cellulose, presumably secondary to ingestion of wood-chip bedding material postoperatively. Reepithelialization was present on histologic examination. LIMITATIONS An animal study. CONCLUSIONS EEM is feasible and enabled concentric subtotal esophageal mucosal resection. The technique could completely and circumferentially excise intramucosal lesions. Longer follow-up and larger studies are needed to evaluate infection, stricture, and safety.
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Measuring the effectiveness of laparoscopic antireflux surgery: long-term results. ACTA ACUST UNITED AC 2008; 143:482-7. [PMID: 18490558 DOI: 10.1001/archsurg.143.5.482] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To evaluate long-term results and quality of life of patients undergoing laparoscopic antireflux surgery. DESIGN A validated survey instrument, the Gastroesophageal Reflux Disease-Health-Related Quality-of-Life Scale (GERD-HRQL) was mailed to all patients who underwent laparoscopic fundoplications (LFs) from 1997 to 2006. Additional information was obtained regarding reintervention, satisfaction, and medication use. SETTING Tertiary care referral center. PATIENTS Four hundred five consecutive patients who underwent primary or redo LF from 1997 to 2006. MAIN OUTCOME MEASURES GERD-HRQL score, reoperation rate, and antireflux medication use. RESULTS A 54% response rate was obtained. Median follow-up was 60 months (range, 4-75 months). In patients who underwent primary LF, the mean (SD) GERD-HRQL score was 5.71 (7.99) (range, 0-45, with 0 representing no symptoms). Seventy-one percent of patients were satisfied with long-term results. Forty-three percent of patients took antireflux medications at some point following surgery; half of these patients had no diagnostic testing to document GERD recurrence. Only 3 patients (1.2%) required reoperation. Patients undergoing redo LF had higher GERD-HRQL scores (mean [SD], 14.25 [10.33]), lower satisfaction (35%), and greater probability of requiring antireflux medication (78%). Patients with body mass indexes (BMIs) (calculated as weight in kilograms divided by height in meters squared) between 25 and 35 had lower GERD-HRQL scores than thin (BMI < 25) and morbidly obese (BMI >/= 35) patients. CONCLUSIONS Contrary to the medical literature, our results demonstrate that patients undergoing primary LF by an experienced surgical team have near-normal GERD-HRQL scores at long-term follow-up and low reoperation rates and are satisfied with their decision to undergo surgery. Results following redo LF are not as good, highlighting the importance of proper patient selection and surgical technique when performing primary LF.
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Abstract
The incidence of adenocarcinomas of the gastroesophageal junction has increased in recent years. These tumors possess distinct pathophysiologic characteristics. Although the consensus is that an R0 resection (complete microscopic and macroscopic resection) is the goal when operating for curative intent, much controversy remains regarding other aspects of patient management. There is lack of consensus regarding the type of surgery to perform, the role and extent of lymphadenectomy, and the role of neoadjuvant therapy. Utilizing an evidence-based approach, this review article provides an overview of the management of gastroesophageal junction carcinomas with particular emphasis on current areas of controversy.
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