Minimally invasive surgery fellows would perform a wider variety of cases in their "ideal" fellowship

Training in endocrine surgery

BACKGROUND/PURPOSE

In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe.

METHODS

A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate.

RESULTS

For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs.

CONCLUSIONS

Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.

Single-session laparoscopic cholecystectomy and ERCP: a valid option for the management of choledocholithiasis

BACKGROUND AND AIMS

The option for performing ERCP and laparoscopic cholecystectomy (LC) for the management of choledocholithiasis in the same operative session is often overlooked. We compared the success, safety, and cost of ERCP and LC when performed in either a single session or in separate sessions.

METHODS

We conducted a retrospective cohort study at a U.S. tertiary care hospital. We identified patients undergoing ERCP and LC between April 2011 and August 2014 in either a single operative session (n = 33) or in 2 separate sessions within a 30-day period (n = 80). Technical success, total anesthesia duration, operative time, length of hospitalization, cost of care, and morbidity and mortality were evaluated.

RESULTS

Bile duct clearance was achieved in all patients at ERCP in the same-session cohort. The separate versus single-session groups, respectively, did not differ in terms of total procedure times (mean ± SD = 142 ± 64 vs 142 ± 58 min; t test, P =.98), anesthesia duration (251 ± 64 vs 225 ± 69 min; P =.06), or overall cost (49.3 ± 24.5 vs 42.3 ± 23.2 ×1000 USD; P =.167), but hospitalization was longer in the separate-sessions group (6.2 ± 3.3 vs 4.8 ± 2.6 days; P =.03). The rates of adverse events were similarly low (7% vs 2%, P =.70).

CONCLUSIONS

Performing single-session ERCP and LC is safe, effective, economically viable, and reduces hospital stay compared with performing ERCP and LC during separate sessions.

Minimally invasive surgery in gastrointestinal cancer: benefits, challenges, and solutions for underutilization

Background and Objectives:

After the widespread application of minimally invasive surgery for benign diseases and given its proven safety and efficacy, minimally invasive surgery for gastrointestinal cancer has gained substantial attention in the past several years. Despite the large number of publications on the topic and level I evidence to support its use in colon cancer, minimally invasive surgery for most gastrointestinal malignancies is still underused.

Methods:

We explore some of the challenges that face the fusion of minimally invasive surgery technology in the management of gastrointestinal malignancies and propose solutions that may help increase the utilization in the future. These solutions are based on extensive literature review, observation of current trends and practices in this field, and discussion made with experts in the field.

Results:

We propose 4 different solutions to increase the use of minimally invasive surgery in the treatment of gastrointestinal malignancies: collaboration between surgical oncologists/hepatopancreatobiliary surgeons and minimally invasive surgeons at the same institution; a single surgeon performing 2 fellowships in surgical oncology/hepatopancreatobiliary surgery and minimally invasive surgery; establishing centers of excellence in minimally invasive gastrointestinal cancer management; and finally, using robotic technology to help with complex laparoscopic skills.

Conclusions:

Multiple studies have confirmed the utility of minimally invasive surgery techniques in dealing with patients with gastrointestinal malignancies. However, training continues to be the most important challenge that faces the use of minimally invasive surgery in the management of gastrointestinal malignancy; implementation of our proposed solutions may help increase the rate of adoption in the future.

Clinical fellowships in surgical training: analysis of a national pan-specialty workforce survey

Background

Fellowship posts are increasingly common and offer targeted opportunities for training and personal development. Despite international demand, there is little objective information quantifying this effect or the motivations behind undertaking such a post. The present study investigated surgical trainees’ fellowship aims and intentions.

Methods

An electronic, 38-item, self-administered questionnaire survey was distributed in the United Kingdom via national and regional surgical mailing lists and websites via the Association of Surgeons in Training, Royal Surgical Colleges, and Specialty Associations.

Results

In all, 1,581 fully completed surveys were received, and 1,365 were included in the analysis. These represented trainees in core or higher training programs or research from all specialties and training regions: 66 % were male; the mean age was 32 years; 77.6 % intended to or had already completed a fellowship. Plastic surgery (95.2 %) and cardiothoracic (88.6 %) trainees were most likely to undertake a fellowship, with pediatrics (51.2 %), and urology (54.3 %) the least likely. Fellowship uptake increased with seniority (p < 0.01) and was positively correlated (p = 0.016, r = 0.767) with increasing belief that fellowships are necessary to the attainment of clinical competence, agreed by 73.1 %. Fellowship aims were ranked in descending order of importance as attaining competence, increasing confidence, and attaining subspecialist skills.

Conclusions

Over three-quarters of trainees have or will undertake a clinical fellowship, varying with gender, specialty, and seniority. Competence, confidence, and subspecialty skills development are the main aims. The findings will influence workforce planning, and perceptions that current training does not deliver sufficient levels of competence and confidence merit further investigation.

The Fellowship Council: a decade of impact on surgical training

BACKGROUND

The objective of this project is to document the history of the Fellowship Council (FC) and report its current impact on surgical training. The need for advanced training in laparoscopic surgery resulted in the rapid development of fellowships for which there was no oversight. Fellowship program directors began meeting in the 1990s and formally created the FC in 2004 to provide that oversight.

METHODS

To obtain information with which to create a narrative of the history of the FC, the authors performed a detailed review of all available minutes from the meetings of the various iterations of the council and its committees between 2001 and 2012. Information about fellowships and meetings of the directors of fellowships prior to 2001 are based on information included in minutes of meetings after 2001.

RESULTS

Minimally invasive surgery fellowship program directors in collaboration with surgical societies created the FC to bring order to the application process for residents and program directors. It has evolved into an organization with mature, reliable processes for application, matching, curriculum development, accreditation, and reporting. It now receives applications from more than 30 % of graduating chief residents in general surgery. It has 223 accredited fellowship positions in the following disciplines: Minimally invasive surgery, bariatric/metabolic surgery, Flexible endoscopy, hepato-pancreato-biliary Surgery, colorectal surgery, and Thoracic surgery.

CONCLUSIONS

The FC provides a reliable, fair process for matching residents with fellowship programs and has successfully expanded its oversight of such programs with mature processes for accreditation, curriculum development, and reporting.

Surgical fellowship training in Canada: what is its current status and is improvement required?

This paper examines current issues concerning surgical fellowship training in Canada. Other than information from a few studies of fellowship training in North America, there are scant data on this subject in the literature. Little is known about the demographic characteristics of those who pursue fellowship training in Canada, what the experiences and expectations are of fellows and their supervisors with respect to the strengths and weaknesses of this level of training, or how this level of education fits in with Canadian undergraduate and postgraduate medical training. We summarize current knowledge about fellowship training in Canada as it pertains to demographic characteristics, finances, work hours, residency training, preparation for clinical and research work and satisfaction with training. Most information on surgical fellowship training comes from the United States. As such, we used information from American studies to supplement the Canadian data. Because a surgical fellowship experience in Canada may be different from that in the United States, we propose that Canadian surgical fellows and their supervisors should be surveyed to gain an understanding of such information. This knowledge could be used to improve surgical fellowship training in Canada.

Extracorporeal shock wave lithotripsy for pancreatic and large common bile duct stones

Extraction of large pancreatic and common bile duct (CBD) calculi has always challenged the therapeutic endoscopist. Extracorporeal shockwave lithotripsy (ESWL) is an excellent tool for patients with large pancreatic and CBD calculi that are not amenable to routine endotherapy. Pancreatic calculi in the head and body are targeted by ESWL, with an aim to fragment them to < 3 mm diameter so that they can be extracted by subsequent endoscopic retrograde cholangiopancreatography (ERCP). In our experience, complete clearance of the pancreatic duct was achieved in 76% and partial clearance in 17% of 1006 patients. Short-term pain relief with reduction in the number of analgesics ingested was seen in 84% of these patients. For large CBD calculi, a nasobiliary tube is placed to help target the calculi, as well as bathe the calculi in saline - a simple maneuver which helps to facilitate fragmentation. The aim is to fragment calculi to < 5 mm size and clear the same during ERCP. Complete clearance of the CBD was achieved in 84.4% of and partial clearance in 12.3% of 283 patients. More than 90% of the patients with pancreatic and biliary calculi needed three or fewer sessions of ESWL with 5000 shocks being delivered at each session. The use of epidural anesthesia helped in reducing patient movement. This, together with the better focus achieved with newer third-generation lithotripters, prevents collateral tissue damage and minimizes the complications. Complications in our experience with nearly 1300 patients were minimal, and no extension of hospital stay was required. Similar rates of clearance of pancreatic and biliary calculi with minimal adverse effects have been reported from the centers where ESWL is performed regularly. In view of its high efficiency, non-invasive nature and low complication rates, ESWL can be offered as the first-line therapy for selected patients with large pancreatic and CBD calculi.

Systematic review on mentoring and simulation in laparoscopic colorectal surgery

OBJECTIVE

To identify and evaluate the influence of mentoring and simulated training in laparoscopic colorectal surgery (LCS) and define the key components for learning advanced technical skills.

BACKGROUND

Laparoscopic colorectal surgery is a complex procedure, often being self-taught by senior surgeons. Educational issues such as inadequate training facilities or a shortfall of training fellowships may result in a slow uptake of LCS. The effectiveness of mentored and simulated training, however, remains unclear.

METHODS

We conducted a systematic search, using Ovid databases. Four study categories were identified: mentored versus nonmentored cases, training case selection, simulation, and assessment. We performed a meta-analysis and a mixed model regression on the difference of the main outcome measures (conversion rates, morbidity, and mortality) for mentored trainees and expert surgeons. We also compared conversion rates of mentored and nonmentored. Meta-analysis of risk factors for conversion was performed using published and unpublished data sets requested from various investigators. For studies on simulation, we compared scores of surveys on the perception of different training courses.

RESULTS

Thirty-seven studies were included. Pooled weighted outcomes of mentored cases (n = 751) showed a lower conversion rate (13.3% vs 20.5%, P = 0.0332) compared with nonmentored cases (n = 695). Compared to expert case series (n = 5313), there was no difference in conversion (P = 0.2835), anastomotic leak (P = 0.8342), or mortality (P = 0.5680). A meta-analysis of training case selection data (n = 4444) revealed male sex (P < 0.0001), previous abdominal surgery (P = 0.0200), a BMI greater than 30 (P = 0.0050), an ASA of less than 2 (P < 0.0001), colorectal cancer (P < 0.0001) and intra-abdominal fistula (P < 0.0001), but not older than 64 years (P = 0.4800), to significantly increase conversion risk. Participants on cadaveric courses were highly satisfied with the teaching value yet trainees on an animal course gave less positive feedback. Structured assessment for LCS has been partially implemented.

CONCLUSION

This review and meta-analysis supports evidence that trainees can obtain similar clinical results like expert surgeons in laparoscopic colorectal surgery if supervised by an experienced trainer. Cadaveric models currently provide the best value for training in a simulated environment. There remains a need for further research into technical skills assessment and the educational value of simulated training.

Analysis of laboratory-based laparoscopic colorectal surgery workshops within the English National Training Programme

BACKGROUND

This study aimed to determine and compare the opinions of trainees and trainers attending courses using two simulation models (fresh frozen cadavers or anaesthetized pigs) and to assess trainees' degree of insight into both the difficulty of different procedures and their operative performance in the simulated environment.

METHODS

Trainers and trainees attending the training courses completed questionnaires. Performance was evaluated using the Global Assessment Score (GAS).

RESULTS

Data were collected over a 12-month period from 26 trainers and 77 trainees. The overall satisfaction was high after attendance at either course (4.50 vs. 4.49; p=0.83). When the opinions of the trainees and trainers in cadaveric and animal courses were compared, the findings rated the animal model as superior in terms of tissue quality (3.97 vs. 3.55; p=0.02), persistence of air leak (1.43 vs. 2.40; p<0.001), and lack of disturbance by odor (4.24 vs. 3.41; p<0.001). The cadaveric model provided more realistic simulation for port placement (4.02 vs. 3.11; p<0.001) and anatomy (4.25 vs. 3.00; p<0.001) and was perceived to be superior as a training model (4.53 vs. 3.61; p=0.001). The trainees demonstrated good insight into procedure difficulty and their operative performance. The trainees and trainers were shown to have a good concordance of scores. The trainees were more inclined to underrate and the peers to overrate their performance.

CONCLUSIONS

Trainees appear to have a good insight into procedure difficulty and their ability. Both training models have advantages and disadvantages, but overall, the cadaveric model is perceived to have a higher fidelity and greater educational value.

Competency in laparoscopic colorectal surgery is achievable with appropriate training but takes time: a comparison of 300 elective resections with anastomosis

AIM

The aim of this retrospective cohort study was to compare outcomes in patients who underwent elective laparoscopic colorectal resection with anastomosis performed by a single surgeon or his training fellow.

METHOD

A prospective electronic database of all laparoscopic procedures between January 2005 and September 2008 was used. Two groups were compared; those patients operated upon by the Consultant trainer (C) and those by seven supervised Fellows (F). Fellows were either post CCT or in their last year of training. Three hundred consecutive patients undergoing laparoscopic colorectal resection with anastomosis were examined, 150 in each group. Groups were matched for indication, age, American Society of Anesthesiology (ASA) grade, cancer T stage and resection performed. Preoperative work-up, operative surgery and anaesthesia were identical between groups.

RESULTS

No significant difference was demonstrated in age, mean 67 (26-91) or ASA grade. Indications for surgery were; cancer (C) 120, (F) 126, diverticular disease (C) 22, (F) 20, Crohn's disease (C) 8, (F) 7. Fellow's mean operative time was significantly longer at 123 min (95%CI 117-134) compared to the consultant trainer -105 min. (95%CI 98-111): P < 0.01). No significant differences in the complication or conversion rates were demonstrated. Length of stay and the 30-day readmission rates were similar.

CONCLUSION

In this retrospective cohort study we have demonstrate that when matched patients are compared, supervised trainee operating time is significantly longer than that of the consultant trainer but without any significant increase in length of stay, complication or readmission rates. Training to a level of competency takes time but not at the expense of patient care.

Trends towards increased use of the laparoscopic approach in colorectal surgery

AIM

The aim of the study was to identify the trend towards laparoscopic resection in the practice of one surgeon and to determine whether the default approach to all colorectal procedures could be by means of minimally invasive techniques with an associated low rate of conversion.

METHOD

A prospective database of primary colorectal resections under the care of one colorectal surgeon collected between July 2003 and December 2008 was analysed to determine the trend in the use of the laparoscopic approach and the rate of conversion of an intention-to-treat policy for laparoscopic procedures. Patients with recurrent rectal or colonic malignancy were excluded from the study.

RESULTS

A total of 598 patients underwent elective colorectal resection of which 371 (62%) were carried out laparoscopically with a rate of conversion of 3.2%. The proportion of all colorectal resections that were undertaken laparoscopically in the first 1 year was 26% (22/85) (no conversions). This proportion rose to 100% (127/127) in the fifth year of the study of which 4.0% were converted. The introduction of more complex procedures did not have an adverse effect on the trend towards more laparoscopic resections The commencement of a laparoscopic colorectal fellowship in 2006 was associated with a marked increase in the number of laparoscopic cases.

CONCLUSION

A conscious decision to make the laparoscopic approach the default for all colorectal resections can be achieved safely with a low conversion rate. This can be achieved within the context of training a 'novice' laparoscopic colorectal surgeon.

Impact of minimally invasive surgery on the pediatric surgical profession

We conducted a survey among pediatric surgeons to examine the impact of the advent of minimally invasive surgery (MIS) on the pediatric surgical profession with respect to job satisfaction and training challenges. An invitation to participate in a web-based questionnaire was sent out to 306 pediatric surgeons. Apart from demographic details and training recommendations, parameters relevant to job satisfaction, including patient interaction, peer pressure, ethical considerations, academic progress, ability to train residents, and financial remuneration, were studied. The response rate was 38.2%. Working in a unit performing MIS was identified by 71% of respondents as the most effective and feasible modality of training in MIS. Inability to get away from a busy practice was the most common reason cited for inability to acquire MIS training. The overall responses to the job satisfaction parameters showed a positive trend in the current MIS era for patient interaction, ethical considerations, academic progress, and training residents, with a negative trend for peer pressure and financial remuneration. The enthusiastic minimally invasive surgeons (EMIS) were defined as those having more than 5 years of MIS experience and also performing more than 10% of their work using MIS. Of the 113 responses analyzed, 67 belonged to the EMIS category. Those belonging to the EMIS group were less likely to feel inadequate in training their residents, in meeting the felt needs of the patients, or to complain about peer pressure. They were more likely to consider MIS to be as relevant and beneficial in children as in adults. Embracing MIS, as represented by the EMIS group, correlated with an overall greater job satisfaction.