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

Impact of surgeon and hospital factors on length of stay after colorectal surgery systematic review

Background

Although length of stay (LOS) after colorectal surgery (CRS) is associated with worse patient and system level outcomes, the impact of surgeon and hospital-level factors on LOS after CRS has not been well investigated. The aim of this study was to synthesize the evidence for the impact of surgeon and hospital-level factors on LOS after CRS.

Methods

A comprehensive database search was conducted using terms related to LOS and CRS. Studies were included if they reported the effect of surgeon or hospital factors on LOS after elective CRS. The evidence for the effect of each surgeon and hospital factor on LOS was synthesized using vote counting by direction of effect, taking risk of bias into consideration.

Results

A total of 13 946 unique titles and abstracts were screened, and 69 studies met the inclusion criteria. All studies were retrospective and assessed a total of eight factors. Surgeon factors such as increasing surgeon volume, colorectal surgical specialty, and progression along a learning curve were significantly associated with decreased LOS (effect seen in 87.5 per cent, 100 per cent, and 93.3 per cent of studies respectively). In contrast, hospital factors such as hospital volume and teaching hospital status were not significantly associated with LOS.

Conclusion

Provider-related factors were found to be significantly associated with LOS after elective CRS. In particular, surgeon-related factors related to experience specifically impacted LOS, whereas hospital-related factors did not. Understanding the mechanisms underlying these relationships may allow for tailoring of interventions to reduce LOS.

Does the Endoscopic Surgical Skill Qualification System improve patients' outcome following laparoscopic surgery for colon cancer? A multicentre, retrospective analysis with propensity score matching

BACKGROUND

This study aimed to investigate the short-term and oncological impact of the Endoscopic Surgical Skill Qualification System (ESSQS) by the Japan Society for Endoscopic Surgery on the operator performing laparoscopic surgery for colon cancer.

METHODS

This retrospective cohort study was based on medical records from a multicentre database. A total of 417 patients diagnosed with stage II/III colon and rectosigmoid cancer treated with curative resection were divided into two groups according to whether they were operated on by qualified surgeons (Q group, n=352) or not (NQ group, n=65). Through strict propensity score matching, 98 cases (49 in each group) were assessed.

RESULTS

Operative time was significantly longer in the NQ group than in the Q group (199 vs. 168 min, p=0.029). The amount of blood loss, post-operative complications, and duration of hospitalisation were similar between both groups. No mortality was observed. One conversion case was seen in the NQ group. The 3-year recurrence-free survival rate was 86.6% in the NQ group and 88.2% in the Q group, which was not statistically significant (log-rank p=0.966).

CONCLUSION

Direct operation by ESSQS-qualified surgeons contributed to a shortened operation time. Under an organised educational environment, almost equivalent safety and oncological outcomes are expected regardless of the surgeon's qualifications.

Short-term clinical outcomes of a European training programme for robotic colorectal surgery

BACKGROUND

Despite there being a considerable amount of published studies on robotic colorectal surgery (RCS) over the last few years, there is a lack of evidence regarding RCS training pathways. This study examines the short-term clinical outcomes of an international RCS training programme (the European Academy of Robotic Colorectal Surgery-EARCS).

METHODS

Consecutive cases from 26 European colorectal units who conducted RCS between 2014 and 2018 were included in this study. The baseline characteristics and short-term outcomes of cases performed by EARCS delegates during training were analysed and compared with cases performed by EARCS graduates and proctors.

RESULTS

Data from 1130 RCS procedures were collected and classified into three cohort groups (323 training, 626 graduates and 181 proctors). The training cases conversion rate was 2.2% and R1 resection rate was 1.5%. The three groups were similar in terms of baseline characteristics with the exception of malignant cases and rectal resections performed. With the exception of operative time, blood loss and hospital stay (training vs. graduate vs. proctor: operative time 302, 265, 255 min, p < 0.001; blood loss 50, 50, 30 ml, p < 0.001; hospital stay 7, 6, 6 days, p = 0.003), all remaining short-term outcomes (conversion, 30-day reoperation, 30-day readmission, 30-day mortality, clinical anastomotic leak, complications, R1 resection and lymph node yield) were comparable between the three groups.

CONCLUSIONS

Colorectal surgeons learning how to perform RCS under the EARCS-structured training pathway can safely achieve short-term clinical outcomes comparable to their trainers and overcome the learning process in a way that minimises patient harm.

Acquiring Advanced Laparoscopic Colectomy Skills - The Issues

Colorectal surgery has been revolutionised towards minimally invasive surgery with the emergence of enhanced recovery protocol after surgery initiatives. However, laparoscopic colectomy has yet to be widely adopted, due mainly to the steep learning curve. We aim to review and discuss the methods of overcoming these learning curves by accelerating the competency level of the trainees without compromising patient safety. To provide this mini review, we assessed 70 articles in PubMed that were found through a search comprised the keywords laparoscopic colectomy, minimal invasive colectomy, learning curve and surgical education. We found England's Laparoscopic Colorectal National Training Programme (LAPCO-NTP) England to be by far the most structured programme established for colorectal surgeons, which involves pre-clinical and clinical phases that end with an assessment. For budding colorectal trainees, learning may be accelerated by simulator-based training to achieve laparoscopic dexterity coupled with an in-theatre proctorship by field experts. Task-specific checklists and video recordings are essential adjuncts to gauge progress and performance. As competency is established, careful case selections with the proctor are essential to maintain motivation and ensure safe performances. A structured programme to establish competency is vital to help both the proctor and trainee gauge real-time progress and performance. However, training systems both inside and outside the operating theatre (OT) are equally useful to achieve the desired performance.

Mentored Trainees have Similar Short-Term Outcomes to a Consultant Trainer Following Laparoscopic Colorectal Resection

BACKGROUND

Laparoscopic colorectal surgery has a long learning curve. Using a modular-based training programme may shorten this. Concerns with laparoscopic surgery have been oncological compromise and poor surgical outcomes when training more junior surgeons. This study aimed to compare operative and oncological outcomes between trainees undergoing a mentored training programme and a consultant trainer.

METHODS

A prospective study of all elective laparoscopic colorectal resections was undertaken in a single institution. Operative and oncological outcomes were recorded. All trainees were mentored by a National Laparoscopic Trainer (Lapco), and results between trainer and trainees compared.

RESULTS

Three hundred cases were included, with 198 (66%) performed for cancer. The trainer undertook 199 (66%) of operations, whilst trainees performed 101 (34%). Anterior resection was the commonest operation (n = 124, 41%). There were no differences between trainer and trainees for the majority of surgical outcomes, including blood loss (p = 0.598), conversion to open (p = 0.113), anastomotic leak (p = 0.263), readmission (p = 1.000) and death rates (p = 0.549). Only length of stay (p = 0.034), stoma formation (p < 0.01) and operative duration (p = 0.007) were higher in the trainer cohort, reflecting the more complex cases undertaken. Overall, there were no significant differences in both short- and longer-term oncology outcomes according to the grade of operating surgeon, including lymph nodes in specimen, circumferential resection margin and 1- and 2-year radiological recurrence.

CONCLUSION

When a modular-based training system was combined with case selection, both clinical and histopathological outcomes following resectional laparoscopic colorectal surgery were similar between trainees and trainer. This should encourage the use of more training opportunities in laparoscopic colorectal surgery.

Conversions in laparoscopic surgery for rectal cancer

BACKGROUND

Laparoscopic surgery offers patients with rectal cancer short-term benefits and similar survival rates as open surgery. However, selecting patients who are suitable candidates for laparoscopic surgery is essential to prevent intra-operative conversion from laparoscopic to open surgery. Clinical and pathological variables were studied among patients who had converted laparoscopic surgeries within the COLOR II trial to improve patient selection for laparoscopic rectal cancer surgery.

METHODS

Between January 20, 2004, and May 4, 2010, 1044 patients with rectal cancer enrolled in the COLOR II trial and were randomized to either laparoscopic or open surgery. Of 693 patients who had laparoscopic surgery, 114 (16 %) were converted to open surgery. Predictive factors were studied using multivariate analyses, and morbidity and mortality rates were determined.

RESULTS

Factors correlating with conversion were as follows: age above 65 years (OR 1.9; 95 % CI 1.2-3.0: p = 0.003), BMI greater than 25 (OR 2.7; 95 % CI 1.7-4.3: p < 0.001), and tumor location more than 5 cm from the anal verge (OR 0.5; CI 0.3-0.9). Gender was not significantly related to conversion (p = 0.14). In the converted group, blood loss was greater (p < 0.001) and operating time was longer (p = 0.028) compared with the non-converted laparoscopies. Hospital stay did not differ (p = 0.06). Converted procedures were followed by more postoperative complications compared with laparoscopic or open surgery (p = 0.041 and p = 0.042, respectively). Mortality was similar in the laparoscopic and converted groups.

CONCLUSIONS

Age above 65 years, BMI greater than 25, and tumor location between 5 and 15 cm from the anal verge were risk factors for conversion of laparoscopic to open surgery in patients with rectal cancer.

Aortic valve reimplantation for aortic root aneurysms: trainer and trainee differences on long-term results

PURPOSE

The advantages of aortic valve-preserving surgery are still hampered by a higher rate of reoperations compared to root replacement with valved conduits. This study evaluates whether valve deterioration rate is related to the method or depends on stringent adherence to technical concepts, which might be lost once trainees perform this complex surgery on their own.

METHODS

From 1991 to 2011, the David procedure was performed in 209 consecutive patients. Mean age was 57 ± 14 years. The patients were operated either by the senior author or trainees under his supervision (group 1, n = 130) or by surgeons on their own after training by the senior author (group 2, n = 79). Clinical and echocardiography data were evaluated pre- and postoperatively and at follow-up (mean 6.0 ± 4 years).

RESULTS

In-hospital mortality was 1.5 % in group 1 and 5 % in group 2 (p = 0.29), and late mortality was 12 % (n = 12 in group 1 and n = 14 in group 2, p = 0.11), three were cardiac related. Nine patients (4.3 %) had to be reoperated; three for endocarditis in group 1, six for structural valve deterioration in group 2 (p = 0.14). The 9-year freedom from reoperation or aortic valve insufficiency (AI) ≥2° was 93 % in group 1 and 78 % in group 2 (p < 0.01). As groups showed differences in preoperative variables, results were compared also in a propensity matched subgroup. Despite no difference in perioperative results, long-term valve competence remained inferior in group 2.

CONCLUSIONS

With stringent adherence to technical concepts, structural valve deterioration may virtually be considerably reduced in aortic valve reimplantation. Once performing this operation on their own, trainees-after training by the senior-achieved results as independent surgeons well comparable to published series. As long-term performance seems to depend more on judgment of the geometry achieved intraoperatively than on technical steps, a means of measurement of effective coaptation height with a caliper might facilitate evaluation of perfect repair.

Systematic review and meta-analysis of trainee- versus expert surgeon-performed colorectal resection

BACKGROUND

The aim of this meta-analysis was to compare short-term and oncological outcomes following colorectal resection performed by surgical trainees and expert surgeons.

METHODS

Systematic literature searches were made to identify articles on colorectal resection for benign or malignant disease published until April 2013. The primary outcome was the rate of anastomotic leak. Secondary outcomes were intraoperative variables, postoperative adverse event rates, and early and late oncological outcomes. Odds ratios (ORs), weighted mean differences (WMDs) and hazard ratios (HRs) for outcomes were calculated using meta-analytical techniques.

RESULTS

The final analysis included 19 non-randomized, observational studies of 14,344 colorectal resections, of which 8845 (61.7 per cent) were performed by experts and 5499 (38.3 per cent) by trainees. The overall rate of anastomotic leak was 2.6 per cent. Compared with experts, trainees had a lower leak rate (3.0 versus 2.0 per cent; OR 0.72, P = 0.010), but there was no difference between experts and expert-supervised trainees (3.2 versus 2.5 per cent; OR 0.77, P = 0.080). A subgroup of expert-supervised trainees had a significantly longer operating time for laparoscopic procedures (WMD 10.00 min, P < 0.001), lower 30-day mortality (OR 0.70, P = 0.001) and lower wound infection rate (OR 0.67, P = 0.040) than experts. No difference was observed in laparoscopic conversion, R0 resection or local recurrence rates. For oncological resection, there was no significant difference in cancer-specific survival between trainees and consultants (3 studies, 533 patients; hazard ratio 0.76, P = 0.130).

CONCLUSION

In selected patients, it is appropriate for supervised trainees to perform colorectal resection.

Influence of median surgeon operative duration on adverse outcomes in bariatric surgery

BACKGROUND

Evidence suggests that prolonged operative time adversely affects surgical outcomes. However, whether faster surgeons have better outcomes is unclear, as a surgeon׳s speed could reflect skill and efficiency, but may alternatively reflect haste. This study evaluates whether median surgeon operative time is associated with adverse surgical outcomes after laparoscopic Roux-en-Y gastric bypass.

METHODS

We performed a retrospective cohort study using statewide clinical registry data from the years 2006 to 2012. Surgeons were ranked by their median operative time and grouped into terciles. Multivariable logistic regression with robust standard errors was used to evaluate the influence of median surgeon operative time on 30-day surgical outcomes, adjusting for patient and surgeon characteristics, trainee involvement, concurrent procedures, and the complex interaction between these variables.

RESULTS

A total of 16,344 patients underwent surgery during the study period. Compared to surgeons in the fastest tercile, slow surgeons required 53 additional minutes to complete a gastric bypass procedure (median [interquartile range] 139 [133-150] versus 86 [69-91], P<.001). After adjustment for patient characteristic only, slow surgeons had significantly higher adjusted rates of any complication, prolonged length of stay, emergency department visits or readmissions, and venous thromboembolism (VTE). After further adjustment for surgeon characteristics, resident involvement, and the interaction between these variables, slow surgeons had higher rates of any complication (10.5% versus 7.1%, P=.039), prolonged length of stay (14.0% versus 4.4%, P=.002), and VTE (0.39% versus .22%, P<.001).

CONCLUSION

Median surgeon operative duration is independently associated with adjusted rates of certain adverse outcomes after laparoscopic Roux-en-Y gastric bypass. Improving surgeon efficiency while operating may reduce operative time and improve the safety of bariatric surgery.

Supervised surgical training and its effect on the short-term outcome in laparoscopic colorectal surgery

AIM

Laparoscopic colorectal surgery requires supervised training. In this paper we examine the short-term outcome following a component-based training in laparoscopic colorectal surgery.

METHOD

Surgical outcome following laparoscopic colorectal resection was recorded on a prospective database. Patients were divided into three groups, including those performed by the fellows, those completed by the consultant and those completed by a combination of both. Analysis of data was carried out for all colorectal resections and the subgroup with colorectal cancer.

RESULTS

511 operations were examined between June 2006 and January 2011. There was no statistically significant difference in operating time between fellows and consultants but it was significantly longer for procedures where consultants and fellows performed components. Conversion rate, postoperative morbidity, recovery and length of stay were similar for all three groups for the whole patient cohort and also the subgroup of cancer patients. In the cancer subgroup, there was no difference in the pathological stage in the three groups.

CONCLUSION

Closely supervised training in laparoscopic colorectal surgery is not associated with any adverse effect on the short-term outcome.

Learning curve and case selection in laparoscopic colorectal surgery: systematic review and international multicenter analysis of 4852 cases

BACKGROUND

The learning curve for laparoscopic colorectal surgery has not been conclusively analyzed. No reliable framework for case selection during training is available.

OBJECTIVE

The aim of this study was to analyze the length of the learning curve of laparoscopic colorectal surgeons and to recommend a case selection framework at the early stage of independent practice.

DATA SOURCES

Medline (1988-2010, October week 4) and Embase (1988-2010) were used for the literature review, databases were retrieved from the authors, and expert opinion was surveyed.

STUDY SELECTION

Studies describing the learning curve of laparoscopic or laparoscopically assisted colorectal surgery were selected.

INTERVENTION

No interventions were performed.

MAIN OUTCOME MEASURES

Learning curves were analyzed by using risk-adjusted, bootstrapped cumulative sum curves. Conversions and complications were independent variables in a multilevel random-effects regression model. Recommendations are based on analysis of ORs and a structured expert opinion gauging process.

RESULTS

Twenty-three studies were identified, showing great disparity on the length of the learning curve. Seven studies, representing 4852 cases (19 surgeons), were analyzed. Risk-adjusted cumulative sum charts demonstrated the length of the learning curves to be 152 cases for conversions, 143 for complications, 96 for operating time, 87 for blood loss, and 103 for length of stay. Body mass index and pelvic dissection (rectum), especially in male patients, independently increased the risk of complication and conversion. The expert survey revealed that increasing T stage and complicated inflammatory disease are likely to increase the complexity of the case. Based on this evidence, a framework for case selection in training was proposed.

LIMITATIONS

The generalizability of the study results maybe reduced because of inconsistent data quality and individual variations in the length of the learning curve

CONCLUSIONS

This multicenter database suggests a length of the learning curve of 88 to 152 cases. The use of the suggested framework may prevent high conversion and complication rates during the learning curve.

Laparoscopic colorectal surgery - why would you not want to have it and, more importantly, not be trained in it? A consecutive series of 500 elective resections with anastomoses

AIM

We analysed the outcome of a consecutive series of 500 unselected patients who underwent elective laparoscopic colorectal resection with anastomosis (ELCRA) under the care of a single surgeon.

METHOD

A prospectively collected electronic database of all laparoscopic procedures conducted from April 2001 to September 2008 was analysed.

RESULTS

A total of 500 ELCRAs were performed [230 male and 270 female patients; mean age 65.6 years (range 19-93 years; American Society of Anesthesiologists grade I (103), II (246), III (145) and IV (6)]. Of these, 217 patients underwent high anterior resection. A total of 131 total mesorectal excisions (55 covering ileostomies), 152 right/extended right resections and 240 operations were performed by trainees under supervision. The indications for surgery included cancer (340), diverticular disease (96), Crohn's disease (40) and polyps (24). Mean operating time was 115 min (range 35-550 min). There were eight (1.6%) conversions. The mean length of hospital stay was 5.2 days (median 4 days). A total of 93 (18.6%) patients had an inpatient complication, including ileus (22), wound infection (14), anastomotic leakage (12), enterotomy (2), 'off-screen' enterotomy (2), abscess (3), ureteric injury (1), cardiac arrhythmia (12), myocardial infarction (5), pulmonary embolus (4), pneumonia (1), Clostridium difficile (3) and retention of urine (9). There were 20 (4%) readmissions for complications, including ileus (4), urinary retention (3), abscess formation (2) and leakage (2). The 30-day mortality was nine of 500 (1.8%) following anastomotic leakage (3), duodenal enterotomy (1), bleeding duodenal ulcer (1), C. difficile infection (1) and cardiac complications (3).

CONCLUSION

This unselected cohort of patients (the largest single surgeon series in the UK) demonstrates that in trained hands low conversion and complication rates can be consistently achieved.

Development, validation and implementation of a monitoring tool for training in laparoscopic colorectal surgery in the English National Training Program

INTRODUCTION

The National Training Program for laparoscopic colorectal surgery (LCS) provides supervised training to colorectal surgeons in England. The purpose of this study was to create, validate, and implement a method for monitoring training progression in laparoscopic colorectal surgery that met the requirements of a good assessment tool.

METHODS

A generic scale for different tasks in LCS was created under the guidance of a national expert group. The scores were defined by the extent to which the trainees were dependent on support (1 = unable to perform, 5 = unaided (benchmark), 6 = proficient). Trainers were asked to rate their trainees after each supervised case; trainees completed a similar self-assessment form. Construct validity was evaluated comparing scores of trainees at different experience levels (1-5, 6-10, 11-15, 16+) using the Wilcoxon signed-rank test and ANOVA. Internal consistency was determined by Crohnbach's alpha, interrater reliability by comparing peer- and self-assessment (interclass correlation coefficient, ICC). Proficiency gain curves were plotted using CUSUM charts.

RESULTS

Analysis included 610 assessments (333 by trainers and 277 by trainees). There was high interrater reliability (ICC = 0.867), internal consistency (α = 0.920), and construct validity [F(3,40) = 6.128, p < 0.001]. Detailed analysis of proficiency gain curves demonstrates that theater setup, exposure, and anastomosis were performed independently after 5 to 15 sessions, and the dissection of the vascular pedicle took 24 cases. Mobilization of the colon and of the splenic/hepatic flexure took more than 25 procedures. Median assessment time was 3.3 (interquartile range (IQR) 1-5) minutes and the tool was accepted as useful [median score 5 of 6 (IQR 4-5)].

DISCUSSION

A valid and reliable monitoring tool for surgical training has been implemented successfully into the National Training Program. It provides a description of an individualized proficiency gain curve in terms of both the level of support required and the competency level achieved.