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Taylor JC, Burke D, Iversen LH, Birch RJ, Finan PJ, Iles MM, Quirke P, Morris EJA. Minimally Invasive Surgery for Colorectal Cancer: Benchmarking Uptake for a Regional Improvement Programme. Clin Colorectal Cancer 2024:S1533-0028(24)00061-6. [PMID: 39004595 DOI: 10.1016/j.clcc.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 05/15/2024] [Accepted: 05/28/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND The uptake of minimally invasive surgery (MIS) for patients with colorectal cancer has progressed at differing rates, both across countries, and within countries. This study aimed to investigate uptake for a regional colorectal cancer improvement programme in England. METHOD We calculated the proportion of patients receiving elective laparoscopic and robot-assisted surgery amongst those diagnosed with colorectal cancer over 3 time periods (2007-2011, 2012-2016 and 2017-2021) in hospitals participating in the Yorkshire Cancer Research Bowel Cancer Improvement Programme (YCR BCIP). These were benchmarked against national rates. Regression analysis and funnel plots were used to develop a data driven approach for analysing trends in the use of MIS at hospitals in the programme. RESULTS In England, resections performed by MIS increased from 34.9% to 72.9% for colon cancer and from 28.8% to 72.5% for rectal cancer. Robot-assisted surgery increased from 0.1% to 2.7% for colon cancer and from 0.2% to 7.9% for rectal cancer. Wide variation in the uptake of MIS was observed at a hospital level. Detailed analysis of the YCR BCIP region identified a decreasing number of surgical departments, since the start of the programme, as potential outliers for MIS when compared to the English national average. CONCLUSION Wide variation in use of MIS for colorectal cancer exists within the English National Health Service and a data-driven approach can help identify outlying hospitals. Addressing some of the challenges behind the uptake of MIS, such as ensuring adequate provision of surgical training and equipment, could help increase its use.
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Affiliation(s)
- John C Taylor
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom; Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom.
| | - Dermot Burke
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | - Lene H Iversen
- Department of Surgery, Aarhus University Hospital, and Danish Colorectal Cancer Group, Aarhus, Denmark
| | - Rebecca J Birch
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom; Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom
| | - Paul J Finan
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom; Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom
| | - Mark M Iles
- Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom; NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Philip Quirke
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | - Eva J A Morris
- Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, United Kingdom
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Sachdeva AK, Tekian A, Park YS, Cheung JJH. Surgical skills training for practicing surgeons founded on established educational theories and frameworks. MEDICAL TEACHER 2024; 46:556-563. [PMID: 37813106 DOI: 10.1080/0142159x.2023.2262101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Following completion of structured training in residency or fellowship programs, surgeons need to acquire new skills throughout their careers to address changes in their surgical practices, and to perform new procedures and use new technologies as these are developed. The opportunities available to surgeons to acquire the new skills, safely introduce these skills into surgical practice, and then maintain the skills, vary greatly and may not fully support a surgeon's needs. The article shares background information relating to the vexing problems, and describes established educational theories and frameworks as well as specific frameworks relating to surgical skills training and verification that may be used in designing and implementing comprehensive and impactful surgical skills training programs aimed at practicing surgeons. A number of practical strategies based on these theories and frameworks are highlighted. National professional organizations and academic medical centers need to play a critical role in pursuing such efforts, which will remain pivotal in supporting the professional work of surgeons and in providing optimal surgical care well into the future.
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Affiliation(s)
- Ajit K Sachdeva
- Division of Education, American College of Surgeons, Chicago, IL, USA
| | - Ara Tekian
- Department of Medical Education, University of Illinois College of Medicine, Chicago, IL, USA
| | - Yoon Soo Park
- Department of Medical Education, University of Illinois College of Medicine, Chicago, IL, USA
| | - Jeffrey J H Cheung
- Department of Medical Education, University of Illinois College of Medicine, Chicago, IL, USA
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Tou S, Au S, Clancy C, Clarke S, Collins D, Dixon F, Dreher E, Fleming C, Gallagher AG, Gomez-Ruiz M, Kleijnen J, Maeda Y, Rollins K, Matzel KE. European Society of Coloproctology guideline on training in robotic colorectal surgery (2024). Colorectal Dis 2024; 26:776-801. [PMID: 38429251 DOI: 10.1111/codi.16904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 01/14/2024] [Indexed: 03/03/2024]
Affiliation(s)
- Samson Tou
- Department of Colorectal Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
- School of Medicine, University of Nottingham, Derby, UK
| | | | - Cillian Clancy
- Department of Colorectal Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Steven Clarke
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Danielle Collins
- Department of Colorectal Surgery, Western General Hospital, NHS Lothian, Edinburgh, Scotland
| | - Frances Dixon
- Department of Colorectal Surgery, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Elizabeth Dreher
- Department of Urology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Christina Fleming
- Department of Colorectal Surgery, University Hospital Limerick, Limerick, Ireland
| | | | - Marcos Gomez-Ruiz
- Colorectal Surgery Unit, General Surgery Department, Marqués de Valdecilla University Hospital, Santander, Spain
- Valdecilla Biomedical Research Institute (IDIVAL), Santander, Spain
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Yasuko Maeda
- Department of Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Katie Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham, UK
| | - Klaus E Matzel
- Section of Coloproctology, Department of Surgery, University of Erlangen-Nürnberg, FAU, Erlangen, Germany
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Adachi T, Kitaguchi D, Teramura K, Hasegawa H, Ikeda K, Tsukada Y, Nishizawa Y, Sasaki T, Ito M. Single-center comparative study of short-term outcomes of transanal and laparoscopic total mesorectal excisions for low and middle rectal cancers. Surg Endosc 2023:10.1007/s00464-023-09948-1. [PMID: 36890411 DOI: 10.1007/s00464-023-09948-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 02/12/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Transanal total mesorectal excision is a promising surgical treatment for rectal cancer. However, evidence regarding the differences in outcomes between the transanal and laparoscopic total mesorectal excisions is scarce. We compared the short-term outcomes of transanal and laparoscopic total mesorectal excisions for low and middle rectal cancers. METHODS This retrospective study included patients who underwent low anterior or intersphincteric resection for middle (5-10 cm) or low (< 5 cm) rectal cancer at the National Cancer Center Hospital East, Japan, from May 2013 to March 2020. Primary rectal adenocarcinoma was confirmed histologically. Circumferential resection margins (CRMs) of resected specimens were measured; margins ≤ 1 mm were considered positive. The operative time, blood loss, hospitalization length, postoperative readmission rate, and short-term treatment results were compared. RESULTS Four hundred twenty-nine patients were divided into two mesorectal excision groups: transanal (n = 295) and laparoscopic (n = 134). Operative times were significantly shorter in the transanal group than in the laparoscopic group (p < 0.001). The pathological T stage and N status were not significantly different. The transanal group had significantly lower positive CRM rates (p = 0.04), and significantly lower incidence of the Clavien-Dindo grade III (p = 0.02) and IV (p = 0.03) complications. Both groups had distal margin positivity rates of 0%. CONCLUSIONS Compared to laparoscopic, transanal total mesorectal excision for low and middle rectal cancers has lower incident postoperative complication and CRM-positivity rates, demonstrating the safety and usefulness of local curability for middle and low rectal cancers.
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Affiliation(s)
- Toshiyuki Adachi
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Daichi Kitaguchi
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Koichi Teramura
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hiro Hasegawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Koji Ikeda
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuji Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Takeshi Sasaki
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
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Shada AL, Sanchez J, Choi Y, Schwarz E, Paige JT, Dort J, Moudgill L, Bernier G. Better than the real thing? Success of a virtual platform for an established “Train the Trainer” course. Surg Endosc 2022; 37:2673-2681. [PMID: 36401104 PMCID: PMC9676712 DOI: 10.1007/s00464-022-09750-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 09/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) uses the Laparoscopic colectomy Train the Trainer (Lapco TT) framework for standardization of instructor training for Hands-On surgical skills courses. The curriculum focuses on teaching structure, skills deconstruction, trainer intervention framework, and performance enhancing feedback. A halt in the in-person Lapco TT courses due to the Coronavirus Disease 2019 (COVID-19) pandemic necessitated creation of a virtual alternative. We investigated the effectiveness of this virtual course. METHODS Adaptation of the in-person Lapco TT course to the virtual format retained the majority of content as well as the 4:6 instructor-to-participant ratio. The virtual platform and simulators chosen allowed maximal interactivity and ease of use. After participating in the day and one half course, participants completed an 8-item post-course survey using a 5-point Likert scale related to the training experience. In addition, they had the opportunity to provide answers to several open-ended questions regarding the course. For the survey, frequency counts provided an assessment of each item. For the open questions, qualitative analysis included determination of themes for each question. Frequency counts of each theme provided quantitative analysis. RESULTS Thirty-six total participants completed a Lapco TT virtual course (six sessions of six participants). Of this number, 32 participants completed post-course surveys and questions. All the participants completing the survey would very likely or definitely (Likert scale 4, 5) recommend the course to a colleague and incorporate the teaching in their practice. The majority of participants completing open-ended questions felt the virtual course format was effective; half thought that post-course follow-up would be useful. Technical concerns were an issue using the virtual format. CONCLUSION A virtual Lapco TT course is feasible and well received by participants. It presents a potentially more cost effective option to faculty development.
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Affiliation(s)
- Amber L Shada
- University of Wisconsin School of Medicine and Public Health, 4602 Eastpark Blvd, Madison, WI, 53718, USA.
| | - Jaime Sanchez
- University of Wisconsin School of Medicine and Public Health, 4602 Eastpark Blvd, Madison, WI, 53718, USA
- University of South Florida, Tampa, USA
| | - Yong Choi
- University of Wisconsin School of Medicine and Public Health, 4602 Eastpark Blvd, Madison, WI, 53718, USA
- Baylor St. Luke's, The Woodlands, USA
| | - Erin Schwarz
- University of Wisconsin School of Medicine and Public Health, 4602 Eastpark Blvd, Madison, WI, 53718, USA
- Society of American Gastrointestinal and Endoscopic Surgeons, Los Angeles, USA
| | - John T Paige
- University of Wisconsin School of Medicine and Public Health, 4602 Eastpark Blvd, Madison, WI, 53718, USA
- Louisiana State University Health, New Orleans, USA
| | - Jonathan Dort
- University of Wisconsin School of Medicine and Public Health, 4602 Eastpark Blvd, Madison, WI, 53718, USA
- Inova Medical Group, Fairfax, USA
| | - Lisa Moudgill
- University of Wisconsin School of Medicine and Public Health, 4602 Eastpark Blvd, Madison, WI, 53718, USA
- University of South Florida, Tampa, USA
| | - Greta Bernier
- University of Wisconsin School of Medicine and Public Health, 4602 Eastpark Blvd, Madison, WI, 53718, USA
- Valley Medical Center, Renton, USA
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Consensus statements on complete mesocolic excision for right-sided colon cancer-technical steps and training implications. Surg Endosc 2022; 36:5595-5601. [PMID: 35790593 PMCID: PMC9283340 DOI: 10.1007/s00464-021-08395-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 02/09/2021] [Indexed: 11/16/2022]
Abstract
Background CME is a radical resection for colon cancer, but the procedure is technically demanding with significant variation in its practice. A standardised approach to the optimal technique and training is, therefore, desirable to minimise technical hazards and facilitate safe dissemination. The aim is to develop an expert consensus on the optimal technique for Complete Mesocolic Excision (CME) for right-sided and transverse colon cancer to guide safe implementation and training pathways. Methods Guidance was developed following a modified Delphi process to draw consensus from 55 international experts in CME and surgical education representing 18 countries. Domain topics were formulated and subdivided into questions pertinent to different aspects of CME practice. A three-round Delphi voting on 25 statements based on the specific questions and 70% agreement was considered as consensus. Results Twenty-three recommendations for CME procedure were agreed on, describing the technique and optimal training pathway. CME is recommended as the standard of care resection for locally advanced colon cancer. The essential components are central vascular ligation, exposure of the superior mesenteric vein and excision of an intact mesocolon. Key anatomical landmarks to perform a safe CME dissection include identification of the ileocolic pedicle, superior mesenteric vein and root of the mesocolon. A proficiency-based multimodal training curriculum for CME was proposed including a formal proctorship programme. Conclusions Consensus on standardisation of technique and training framework for complete mesocolic excision was agreed upon by a panel of experts to guide current practice and provide a quality control framework for future studies. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08395-0.
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Micha JP, Rettenmaier MA, Bohart RD, Goldstein BH. Robotic-Assisted Surgery for the Treatment of Breast and Cervical Cancers. JSLS 2022; 26:JSLS.2022.00014. [PMID: 35815331 PMCID: PMC9215693 DOI: 10.4293/jsls.2022.00014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Robotic-assisted surgery facilitates the performance of numerous, complex procedures, namely conferring precision, flexibility, and control that is otherwise unavailable with conventional laparoscopy; and compared to open surgery, robotic-assisted surgery is ostensibly associated with fewer complications, reduced intraoperative complications, and shorter hospital stay duration. Nevertheless, the American College of Obstetricians and Gynecologists and the Food and Drug Administration have criticized the pervasive acceptance of robotic-assisted surgery, given the absence of randomized clinical trial data compared to traditional laparoscopy and open procedures, not to mention the increased surgical cost. Conclusions: While the research data continue to be borne out, surgeons should exercise considerable discretion in selecting the surgical approach from which their patients would derive the greatest clinical benefit.
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Affiliation(s)
- John P Micha
- Women's Cancer Research Foundation, Newport Beach, CA
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Odermatt M, Khan J, Parvaiz A. Supervised training of laparoscopic colorectal cancer resections does not adversely affect short- and long-term outcomes: a Propensity-score-matched cohort study. World J Surg Oncol 2022; 20:98. [PMID: 35351126 PMCID: PMC8962584 DOI: 10.1186/s12957-022-02560-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 03/10/2022] [Indexed: 11/12/2022] Open
Abstract
Background Supervised training of laparoscopic colorectal cancer surgery to fellows and consultants (trainees) may raise doubts regarding safety and oncological adequacy. This study investigated these concerns by comparing the short- and long-term outcomes of matched supervised training cases to cases performed by the trainer himself. Methods A prospective database was analysed retrospectively. All elective laparoscopic colorectal cancer resections in curative intent of adult patients (≥ 18 years) which were performed (non-training cases) or supervised to trainees (training cases) by a single laparoscopic expert surgeon (trainer) were identified. All trainees were specialist surgeons in training for laparoscopic colorectal surgery. Supervised training was standardised. Training cases were 1:1 propensity-score matched to non-training cases using age, American Society of Anesthesiologists (ASA) grade, tumour site (rectum, left and right colon) and American Joint Committee on Cancer (AJCC) tumour stage. The resulting groups were analysed for both short- (operative, oncological, complications) and long-term (time to recurrence, overall and disease-free survival) outcomes. Results From 10/2006 to 2/2016, a total of 675 resections met the inclusion criteria, of which 95 were training cases. These resections were matched to 95 non-training cases. None of the matched covariates exhibited an imbalance greater than 0.25 (│d│>0.25). There were no significant differences in short- (length of procedure, conversion rate, blood loss, postoperative complications, R0 resections, lymph node harvest) and long-term outcomes. When comparing training cases to non-training cases, 5-year overall and disease-free survival rates were 71.6% (62.4–82.2) versus 81.9% (74.2–90.4) and 70.0% (60.8–80.6) versus 73.6% (64.9–83.3), respectively (not significant). The corresponding hazard ratios (95% confidence intervals, p) were 0.57 (0.32–1.02, p = 0.057) and 0.87 (0.51–1.48, p = 0.61), respectively (univariate Cox proportional hazard model). Conclusions Standardised supervised training of laparoscopic colorectal cancer procedures to specialist surgeons may not adversely impact short- and long-term outcomes. This result may also apply to newer surgical techniques as long as standardised teaching methods are followed.
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Measurement and Accreditation of Minimal Access Surgical Skills: Challenges and Solutions. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03319-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Vlachou F, Zhang Y, Lee S, Mavroveli S, Patel B, Francis N. The development and evaluation of "Training the trainer" curriculum for surgical residents: Feasibility study. Int J Surg 2022; 98:106209. [PMID: 35007774 DOI: 10.1016/j.ijsu.2021.106209] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/13/2021] [Accepted: 12/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Over the last decades, there has been greater emphasis on enhancing teaching skills and concepts of Train-The-Trainer (TTT) have been widely adopted across surgical training programs. Current TTT curricula, however, mostly address teaching generic principles without specific guidance on how to teach technical skills among residents. The aim of this proof-of-concept study was to design a bespoke TTT curriculum for surgical technical skills and evaluate its impact. MATERIAL AND METHODS A bespoke TTT curriculum was developed to address key teaching surgical skills including a training framework, and performance enhancing feedback. The curriculum was delivered to 41 junior surgical residents in this feasibility study and focused on promoting a training framework including three domains; "set" involving pre-operative preparation, "dialogue" referring to teaching techniques and "closure" covering structured feedback. It was evaluated using Kirkpatrick's model: (i) course feedback; (ii) training quality assessment on a suturing simulated scenario using (a) Competency Assessment Tool (CAT) and a (b) Structured Training Trainer Assessment Report (STTAR) tool; (iii-iv) follow-up survey after one year. RESULTS The TTT curriculum was well-perceived, with a median score of 4/5 ("agree") across all components of evaluation forms. The simulated training scenario demonstrated a significant reduction in suturing errors following delivery of training (pre-TTT [4.25; IQR:4.42]; post-TTT [2.34; IQR:2.38], p-value = 0.014). Improvement in teaching was also noted and reflected in 'Set' (pre-TTT [3.50; IQR: 3.00] and post-TTT [5.00; IQR: 0.00], p-value = 0.019) and 'Closure' (pre-TTT [4.75; IQR: 1.88] and post-TTT [5.00; IQR: 0.00], p value = 0.007). 25% of participants contributed to the long-term survey highlighting that most practiced skills within 6 months of the curriculum with positive feedback from their learners. CONCLUSION This proof-of-concept study confirms the feasibility and acceptability of delivering a bespoke Train-The-Trainer curriculum to surgical residents. It provides a structured training framework that can enhance teaching technical skills.
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Affiliation(s)
- Florentia Vlachou
- Barts Cancer Institute, Queen Mary University of London, Charterhouse Square, London, EC1M 6AS, UK Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Garrod Building, Turner St, Whitechapel, London, E1 2AD, UK Princess Royal University Hospital, Farnborough Common, Orpington, BR6 8ND, United Kingdom St George's University Hospitals NHS Foundation Trust, Blackshaw Rd, London, SW17 0QT, United Kingdom Faculty of Medicine, Imperial Collage London St. Mary's Hospital, Paterson Centre, South Wharf Road, Paddington, London, W2 1BL, UK Department of Upper GI & Laparoscopic Surgery, Royal London Hospital, Whitechapel Rd, Whitechapel, London, E1 1FR, UK Department of Upper GI & Laparoscopic Surgery, University College London, 235 Euston Rd, Bloomsbury, London, NW1 2BU, UK Department of Colorectal Surgery, Yeovil District Hospital Foundation Trust, Yeovil, BA21 4AT, Somerset, UK The Griffin Institute, Northwick Park and St Mark's Hospital, Y Block, Watford Rd, Harrow, HA1 3UJ, UK Division of Surgery and Interventional Science, University College London, UK
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Locally Advanced Rectal Cancer: What We Learned in the Last Two Decades and the Future Perspectives. J Gastrointest Cancer 2022; 54:188-203. [PMID: 34981341 DOI: 10.1007/s12029-021-00794-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2021] [Indexed: 12/13/2022]
Abstract
The advancement in surgical techniques, optimization of systemic chemoradiotherapy, and development of refined diagnostic and imaging modalities have brought a phenomenal shift in the treatment of the locally advanced rectal cancer. Although each therapeutic option has shown substantial progress in their field, it is finding their ideal amalgamation which has baffled the clinician and researchers alike. In the effort to identifying the perfect salutary treatment plan, we have even shifted our attention from the trimodal approach to non-operative "watchful waiting" to more recent individualized care. In this article, we acknowledge the scientific progress in the management of locally advanced rectal cancer and compare the opportunities as well as the obstacles while implementing them clinically. We also explore the current challenges and controversies surrounding the multidisciplinary approach and highlight the new trends and recent advances with an ultimate goal to improve the patients' quality of life.
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12
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Concepts and prospects of minimally invasive colorectal cancer surgery. Clin Radiol 2021; 76:889-895. [PMID: 34654544 DOI: 10.1016/j.crad.2021.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/15/2021] [Indexed: 01/18/2023]
Abstract
It is important that clinical radiologists understand and appreciate the minimally invasive surgery (MIS) options available to surgeons. Operative technologies are constantly evolving, and accurate, informed interpretation of clinical imaging is essential for optimum surgical management. Concurrent advancements in both MIS and radiological staging have certainly improved treatment decisions and outcomes. This article outlines the history, current concepts, evolving techniques, and future prospects of MIS as it pertains to colorectal cancer surgery.
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Rückbeil O, Sebestyen U, Schlick T, Krüger CM. [Structured Implementation and Modular In-house Training as Key Success Factors in Robotically Assisted Surgery - Evaluation Using the Example of Colorectal Surgery]. Zentralbl Chir 2021; 147:35-41. [PMID: 34607387 DOI: 10.1055/a-1552-4236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To demonstrate the applicability of structured implementation of robotic assisted surgery (RAS) and to evaluate a modular training procedure during the implementation phase in in-house mentoring. METHOD Execution of a self-defined PDCA (PDCA: Plan-Do-Check-Act) implementation cycle accompanied by prospective data collection of patient characteristics, operation times, complications, conversion rates and postoperative length of stay of a modularly defined training operation (robotic assisted rectosigmoid resection - RARSR). RESULTS Evaluation of 100 consecutive cases distributed among 3 trainees and an in-house mentor as internal control group. Presentation of qualitatively safe and successful implementation with a short learning curve of the training operation with balanced patient characteristics. CONCLUSIONS Structured implementation enables the safe introduction of RAS in visceral surgery. In this context, modular training operations can facilitate the adoption of RAS by users under everyday conditions. For the first time, we demonstrate this within an in-house mentoring approach.
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Affiliation(s)
- Oskar Rückbeil
- Chirurgie/Zentrum für Robotik, Immanuel Klinik Rüdersdorf, Rüdersdorf bei Berlin, Germany
| | - Uwe Sebestyen
- Chirurgie/Zentrum für Robotik, Immanuel Klinik Rüdersdorf, Rüdersdorf bei Berlin, Germany
| | - Tilman Schlick
- Chirurgie/Zentrum für Robotik, Immanuel Klinik Rüdersdorf, Rüdersdorf bei Berlin, Germany
| | - Colin M Krüger
- Chirurgie/Zentrum für Robotik, Immanuel Klinik Rüdersdorf, Rüdersdorf bei Berlin, Germany
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Tilney HS, Huddy JR, Nizar AS, Smith R, Gudgeon AM. Minimal access rectal cancer surgery: an observational study of patient outcomes from a district general hospital with over a decade of experience with robotic rectal cancer surgery. Colorectal Dis 2021; 23:1961-1970. [PMID: 34157214 DOI: 10.1111/codi.15776] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 12/12/2022]
Abstract
AIM Robotic surgery for colorectal cancer has become established more slowly than in other specialities. The aim of this study was to assess the risks and benefits of the use of robotic rectal cancer surgery in comparison with laparoscopic surgery within the confines of a subspecialist rectal cancer service in a district general hospital. METHOD Outcomes from consecutive patients undergoing minimal access rectal cancer surgery between July 2008 and January 2020 were analysed. Comparisons were made between short-term outcomes including conversion rates, anastomotic leakage and pathological outcomes as well as long-term survival and cancer recurrence. RESULTS A total of 337 patients were included in the analysis, 204 (60.5%) of whom underwent robotic surgery. Demographic characteristics and use of neoadjuvant chemoradiotherapy were similar between groups. However, patients having robotic surgery had significantly lower tumours than in the laparoscopic group (7.6 cm vs. 9.8 cm, p = 0.003). Conversion to open surgery in the robotic group was significantly less likely (9.8% vs. 22.6%, p = 0.001). Operative mortality, clinical leakage and major complications were similar between groups. While asymptomatic 'radiological' leaks were significantly more common following robotic surgery (13.7% vs. 5.3%, p = 0.017) this did not affect the long-term stoma closure rate. Pathological outcomes were similar with the exception of shorter mean distal resection margins (25.9 mm vs. 32.8 mm, p = 0.001) for the robotic group of patients. There was no statistical difference in 5-year survival between groups (78.7% robotic vs. 85.4% laparoscopic, p = 0.263) nor local recurrence (2.0% robotic vs. 3.8% laparoscopic, p = 0.253). CONCLUSIONS These results illustrate how the selective use of robotic surgery by a dedicated rectal cancer team can achieve low rates of cancer recurrence and low permanent stoma rates.
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Affiliation(s)
- Henry S Tilney
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
| | - Jeremy R Huddy
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
| | - A Shiyam Nizar
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
| | - Ralph Smith
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
| | - A Mark Gudgeon
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
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Abstract
OBJECTIVE To investigate the frequency, nature, and severity of intraoperative adverse near miss events within advanced laparoscopic surgery and report any associated clinical impact. BACKGROUND Despite implementation of surgical safety initiatives, the intraoperative period is poorly documented with evidence of underreporting. Near miss analyses are undertaken in high-risk industries but not in surgical practice. METHODS Case video and data from 2 laparoscopic total mesorectal excision randomized controlled trials were analyzed (ALaCaRT ACTRN12609000663257, 2D3D ISRCTN59485808). Intraoperative adverse events were identified and categorized using the observational clinical human reliability analysis technique. The EAES classification was applied by 2 blinded assessors. EAES grade 1 events (nonconsequential error, no damage, or need for correction) were considered near misses. Associated clinical impact was assessed with early morbidity and histopathology outcomes. RESULTS One hundred seventy-five cases contained 1113 error events. Six hundred ninety-eight (62.7%) were near misses (median 3, IQR 2-5, range 0-15) with excellent inter-rater and test-retest reliability (κ=0.86, 95% CI 0.83-0.89, P < 0.001 and κ=0.88, 95% CI 0.85-0.9, P < 0.001 respectively). Significantly more near misses were seen in patients who developed early complications (4 (3-6) vs. 3 (2-4), P < 0.001). Higher numbers of near misses were seen in patients with more numerous (P = 0.002) and more serious early complications (P = 0.003). Cases containing major intraoperative adverse events contained significantly more near misses (5 (3-7) vs. 3 (2-5), P < 0.001) with a major event observed for every 19.4 near misses. CONCLUSION Intraoperative adverse events and near misses can be reliably and objectively captured in advanced laparoscopic surgery. Near misses are commonplace and closely associated with morbidity outcomes.
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Zahid A, Miskovic D. Proctorship in Minimally Invasive Colorectal Surgery. Clin Colon Rectal Surg 2021; 34:186-193. [PMID: 33815001 DOI: 10.1055/s-0040-1722765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Teaching an established surgeon in a novel technique by a colleague who has acquired a level of expertise is often referred to as "proctoring" or "precepting." Surgical preceptorships can be defined as supervised teaching programs, whereby individual or groups of surgeons (proctors) experienced in a certain technique support a colleague who wants to adopt this technique (sometimes referred to as "delegates" or "preceptees"). Preceptorship programs really focus on a specific technique, technology, or skill which is required to broaden, complement, or transform an established surgeon's practice. Within colorectal surgery, in the past 30 years, there is been an evolution of interventional options including open, laparoscopic, robotic, and endoscopic procedures. With each new emerging technology and technique, safe and effective uptake by established surgeons is best been attained by a period of proctorship by an experienced colleague. Formalizing this has been facilitated largely through industry support. There, however, remains a considerable chasm when it comes to standardization, quality control, and jurisprudence. This article aims to describe the requirements for a contemporary proctorship program, to examine instruments of quality control, and how to improve effectiveness.
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Affiliation(s)
- Assad Zahid
- St Mark's Hospital, London, United Kingdom.,University of Sydney, Australia
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17
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Humm G, Harries RL, Stoyanov D, Lovat LB. Supporting laparoscopic general surgery training with digital technology: The United Kingdom and Ireland paradigm. BMC Surg 2021; 21:123. [PMID: 33685437 PMCID: PMC7941971 DOI: 10.1186/s12893-021-01123-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/25/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical training in the UK and Ireland has faced challenges following the implementation of the European Working Time Directive and postgraduate training reform. The health services are undergoing a digital transformation; digital technology is remodelling the delivery of surgical care and surgical training. This review aims to critically evaluate key issues in laparoscopic general surgical training and the digital technology such as virtual and augmented reality, telementoring and automated workflow analysis and surgical skills assessment. We include pre-clinical, proof of concept research and commercial systems that are being developed to provide solutions. Digital surgical technology is evolving through interdisciplinary collaboration to provide widespread access to high-quality laparoscopic general surgery training and assessment. In the future this could lead to integrated, context-aware systems that support surgical teams in providing safer surgical care.
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Affiliation(s)
- Gemma Humm
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK.
- Division of Surgery and Interventional Science, University College London, London, UK.
| | | | - Danail Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
- Department of Computer Science, University College London, London, UK
| | - Laurence B Lovat
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
- Division of Surgery and Interventional Science, University College London, London, UK
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Heywood N, Parmar KL, Stott M, Sodde P, Doherty DT, Lim J, Sharma A. The laparoscopy in emergency general surgery (LEGS) study: a questionnaire survey of UK practice. Ann R Coll Surg Engl 2021; 103:120-129. [PMID: 33559556 PMCID: PMC9773896 DOI: 10.1308/rcsann.2020.7005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Recent consensus guidelines suggest that the laparoscopic approach may be a useful, safe and feasible approach in emergency general surgery. Despite this, the UK National Emergency Laparotomy Audit (NELA) suggests the rate of laparoscopy is low (9% fully laparoscopic) and slow to increase over time. A European survey found uptake to be variable. This UK survey was therefore undertaken to establish current UK practice and to determine factors affecting implementation. MATERIALS AND METHODS A questionnaire survey of currently practising UK consultant general surgeons was carried out by the North West Surgical Research Collaborative, using a secure web-based database maintained by the North West Surgical Trials Centre. RESULTS A total of 151 completed questionnaires were returned from 22 UK centres; 18% of respondents were unaware that laparoscopic cases should be reported to NELA. Appendicectomy (97%) and cholecystectomy (87%) were routinely performed laparoscopically. Laparoscopy was infrequently used in perforation, ischaemia or obstructed hernias. There appears to be equipoise regarding laparoscopic compared with open surgery in small-bowel obstruction among all subspecialty emergency general surgeons, in perforated peptic ulcer among upper gastrointestinal surgeons and in Hinchey III diverticulitis among colorectal surgeons. CONCLUSION Uptake of laparoscopy in UK emergency general surgery is influenced by surgeon preference, subspecialty, patient and operative factors. Further research into outcomes may help to identify areas of greatest potential benefit. The rate of laparoscopy reported by NELA may be an underestimate due to the 18% of surgeons unaware that laparoscopic cases should be reported, which may affect the validity of analyses performed from this dataset.
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Affiliation(s)
- N Heywood
- General Surgery Training Programme, Health Education North West England, Manchester, UK
| | | | - M Stott
- General Surgery Training Programme, Health Education North West England, Manchester, UK
| | - P Sodde
- General Surgery Training Programme, Health Education North West England, Manchester, UK
| | - DT Doherty
- General Surgery Training Programme, Health Education North West England, Manchester, UK
| | - J Lim
- General Surgery Training Programme, Health Education North West England, Manchester, UK
| | - A Sharma
- Manchester University NHS Foundation Trust, Manchester, UK
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Panteleimonitis S, Miskovic D, Bissett-Amess R, Figueiredo N, Turina M, Spinoglio G, Heald RJ, Parvaiz A. Short-term clinical outcomes of a European training programme for robotic colorectal surgery. Surg Endosc 2020; 35:6796-6806. [PMID: 33289055 PMCID: PMC8599412 DOI: 10.1007/s00464-020-08184-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 11/17/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Sofoklis Panteleimonitis
- School of Health and Care Professions, University of Portsmouth, St Andrews Court, St Michael's Road, Portsmouth, PO1 2PR, UK
| | | | | | - Nuno Figueiredo
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| | - Matthias Turina
- Division of Colorectal Surgery and Proctology, University of Zurich Hospital, Moussonstrasse 2, 8044, Zurich, Switzerland
| | | | - Richard J Heald
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal.,Pelican Cancer Foundation, Dinwoodie Dr, Basingstoke, RG24 9NN, UK
| | - Amjad Parvaiz
- School of Health and Care Professions, University of Portsmouth, St Andrews Court, St Michael's Road, Portsmouth, PO1 2PR, UK. .,Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal. .,Poole Hospital NHS Trust, Longfleet road, Poole, BH15 2JB, UK.
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20
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Tou S, Gómez Ruiz M, Gallagher AG, Matzel KE. European expert consensus on a structured approach to training robotic-assisted low anterior resection using performance metrics. Colorectal Dis 2020; 22:2232-2242. [PMID: 32663361 PMCID: PMC7818231 DOI: 10.1111/codi.15269] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 01/22/2023]
Abstract
AIM The aim was to develop and operationally define 'performance metrics' that characterize a reference approach to robotic-assisted low anterior resection (RA-LAR) and to obtain face and content validity through a consensus meeting. METHOD Three senior colorectal surgeons with robotic experience and a senior behavioural scientist formed the Metrics Group. We used published guidelines, training materials, manufacturers' instructions and unedited videos of RA-LAR to deconstruct the operation into defined, measurable components - performance metrics (i.e. procedure phases, steps, errors and critical errors). The performance metrics were then subjected to detailed critique by 18 expert colorectal surgeons in a modified Delphi process. RESULTS Performance metrics for RA-LAR had 15 procedure phases, 128 steps, 89 errors and 117 critical errors in women, 88 errors and 118 critical errors in men. After the modified Delphi process the final performance metrics consisted of 14 procedure phases, 129 steps, 88 errors and 115 critical errors in women, 87 errors and 116 critical errors in men. After discussion by the Delphi panel, all procedure phases received unanimous consensus apart from phase I (patient positioning and preparation, 83%) and phase IV (docking, 94%). CONCLUSION A robotic rectal operation can be broken down into procedure phases, steps, with errors and critical errors, known as performance metrics. The face and content of these metrics have been validated by a large group of expert robotic colorectal surgeons from Europe. We consider the metrics essential for the development of a structured training curriculum and standardized procedural assessment for RA-LAR.
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Affiliation(s)
- S. Tou
- Department of Colorectal SurgeryRoyal Derby HospitalUniversity Hospitals of Derby and Burton NHS Foundation TrustDerbyUK
| | - M. Gómez Ruiz
- Cirugía Colorrectal – Cirugía General y del Aparato DigestivoHospital Universitario Marqués de ValdecillaSantanderSpain
| | | | - K. E. Matzel
- Section of ColoproctologyDepartment of SurgeryUniversity of Erlangen‐Nürnberg, FAUErlangenGermany
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Amin-Tai H, Elnaim ALK, Wong MPK, Sagap I. Acquiring Advanced Laparoscopic Colectomy Skills - The Issues. Malays J Med Sci 2020; 27:24-35. [PMID: 33154699 PMCID: PMC7605826 DOI: 10.21315/mjms2020.27.5.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/14/2020] [Indexed: 10/28/2022] Open
Abstract
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.
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Affiliation(s)
- Hizami Amin-Tai
- Department of Surgery, Universiti Putra Malaysia, Kuala Lumpur, Malaysia
| | | | - Michael Pak Kai Wong
- School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Ismail Sagap
- Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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A Paradigm Shift in Physician Reimbursement: A Model to Align Reimbursement to Value in Laparoscopic Colorectal Surgery in the United States. Dis Colon Rectum 2020; 63:1446-1454. [PMID: 32969888 DOI: 10.1097/dcr.0000000000001738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Despite common beliefs, underuse of laparoscopic colorectal surgery remains an issue. A paradigm shift to increase laparoscopy and align payment with effort is needed, with pressures to improve value. OBJECTIVE The purpose of this study was to compare reimbursement across surgical approach and payer for common colorectal procedures and to propose a novel way to increase use in the United States. DATA SOURCES Centers for Medicare & Medicaid Services (Medicare) reimbursement and commercial claims data from 2012 to 2015 were used. STUDY SELECTION Reimbursement across payers was mapped for the 10 most common colorectal procedures using the open and laparoscopic approaches. MAIN OUTCOME MEASURES The reimbursement difference across approaches by payer and potential value proposition from a cost-shifting model increasing reimbursement with corresponding increases in laparoscopic use was measured. RESULTS For Medicare, reimbursement was lower laparoscopically than open for the majority. With commercial, laparoscopy was reimbursed less for 3 procedures. When laparoscopic reimbursement was higher, the amount was not substantial. Medicare payments were consistently lower than commercial, with corresponding lower reimbursement for laparoscopy. Increasing reimbursement by 10%, 20%, and 30% resulted in significant cost savings with laparoscopy. Savings were amplified with increasing use, with additional savings over baseline at all levels, except 30% reimbursement/10% increased use. LIMITATIONS The study was limited by the use of claims data, which could have coding errors and confounding in the case mix across approaches. CONCLUSIONS Reimbursement for laparoscopic colorectal surgery is comparatively lower than open. Reimbursement can be increased with significant overall cost savings, as the reimbursement/case is still less than total cost savings with laparoscopy compared with open cases. Incentivizing surgeons toward laparoscopy could drive use and improve outcomes, cost, and quality as we shift to value-based payment. See Video Abstract at http://links.lww.com/DCR/B290. CAMBIOS EN LOS PARADIGMAS DE REEMBOLSOS MÉDICOS: UN MODELO PARA ALINEAR EL REEMBOLSO AL VALOR REAL DE LA CIRUGÍA COLORRECTAL LAPAROSCÓPICA EN LOS ESTADOS UNIDOS: A pesar de las creencias comunes, la subutilización de la cirugía colorrectal laparoscópica sigue siendo un problema. Se necesita un cambio en los paradigmas para aumentar y alinear el rembolso de la laparoscopia aplicando mucho esfuerzo para obtener una mejoría en su valor real.Comparar los reembolsos del abordaje quirúrgico y los de la administración para procedimientos colorrectales comunes y proponer una nueva forma de aumentar su uso en los Estados Unidos.Reembolsos en los Centros de Servicios de Medicare y Medicaid (Medicare) y los datos de reclamos comerciales encontrados de 2012-2015.El reembolso administrativo se mapeó para los diez procedimientos colorrectales más comunes utilizando los enfoques abiertos y laparoscópicos.Diferencias de reembolso entre los enfoques por parte de la administración y la propuesta de valor real de un modelo de cambio de costos que aumentan el reembolso con los aumentos correspondientes si se utiliza la laparoscopía.Para Medicare, el reembolso fue menor para una mayoría por vía laparoscópica que abierta. Comercialmente, la laparoscopia se reembolsó menos por 3 procedimientos. Cuando el reembolso laparoscópico fue mayor, la cantidad no fue sustancial. Los pagos de Medicare fueron consistentemente más bajos que los pagos comerciales, con el correspondiente reembolso más bajo por laparoscopia. El aumento del reembolso en un 10%, 20% y 30% resultó en ahorros de costos significativos con la laparoscopía. Los ahorros se amplificaron con el aumento de la utilización, con ahorros adicionales sobre la línea de base en todos los niveles, excepto el 30% de reembolso / 10% de mayor uso.Uso de datos de reclamos, que podrían tener errores de codificación y confusión en la combinación de casos entre enfoques.El reembolso por la cirugía colorrectal laparoscópica es comparativamente más bajo que el abordaje abierto. El reembolso se puede aumentar con ahorros significativos en los costos generales, ya que el reembolso / caso es aún menor que el ahorro total en los costos de la laparoscopia en comparación con los casos abiertos. Incentivar a los cirujanos hacia la laparoscopía podría impulsar la utilización y mejorar los resultados, el costo y la calidad a medida que se pasa al pago basado en el valor real. Consulte Video Resumen en http://links.lww.com/DCR/B290. (Traducción-Dr Xavier Delgadillo).
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Markar SR, Ni M, Gisbertz SS, van der Werf L, Straatman J, van der Peet D, Cuesta MA, Hanna GB, van Berge Henegouwen MI. Implementation of Minimally Invasive Esophagectomy From a Randomized Controlled Trial Setting to National Practice. J Clin Oncol 2020; 38:2130-2139. [PMID: 32421440 DOI: 10.1200/jco.19.02483] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE The aim of this study was to examine the external validity of the randomized TIME trial, when minimally invasive esophagectomy (MIE) was implemented nationally in the Netherlands, using data from the Dutch Upper GI Cancer Audit (DUCA) for transthoracic esophagectomy. METHODS Original patient data from the TIME trial were extracted along with data from the DUCA dataset (2011-2017). Multivariate analysis, with adjustment for patient factors, tumor factors, and year of surgery, was performed for the effect of MIE versus open esophagectomy on clinical outcomes. RESULTS One hundred fifteen patients from the TIME trial (59 MIE v 56 open) and 4,605 patients from the DUCA dataset (2,652 MIE v 1,953 open) were included. In the TIME trial, univariate analysis showed that MIE reduced pulmonary complications and length of hospital stay. On the contrary, in the DUCA dataset, MIE was associated with increased total and pulmonary complications and reoperations; however, benefits included increased proportion of R0 margin and lymph nodes harvested, and reduced 30-day mortality. Multivariate analysis from the TIME trial showed that MIE reduced pulmonary complications (odds ratio [OR], 0.19; 95% CI, 0.06 to 0.61). In the DUCA dataset, MIE was associated with increased total complications (OR, 1.36; 95% CI, 1.19 to 1.57), pulmonary complications (OR, 1.50; 95% CI, 1.29 to 1.74), reoperations (OR, 1.74; 95% CI, 1.42 to 2.14), and length of hospital stay. Multivariate analysis of the combined and MIE datasets showed that inclusion in the TIME trial was associated with a reduction in reoperations, Clavien-Dindo grade > 1 complications, and length of hospital stay. CONCLUSION When adopted nationally outside the TIME trial, MIE was associated with an increase in total and pulmonary complications and reoperation rate. This may reflect nonexpert surgeons outside of high-volume centers performing this minimally invasive technique in a nonstandardized fashion outside of a controlled environment.
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Affiliation(s)
- Sheraz R Markar
- Department Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Melody Ni
- Department Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Leonie van der Werf
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Jennifer Straatman
- Department of Surgery, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Donald van der Peet
- Department of Surgery, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Miguel A Cuesta
- Department of Surgery, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - George B Hanna
- Department Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
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Tejedor P, Francis N. Can complete mesocolon excision be considered the treatment of choice in right hemicolectomy for cancer? Cir Esp 2020; 99:255-257. [PMID: 32345441 DOI: 10.1016/j.ciresp.2020.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/16/2020] [Indexed: 10/24/2022]
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Urethral Injury and Other Urologic Injuries During Transanal Total Mesorectal Excision: An International Collaborative Study. Ann Surg 2019; 274:e115-e125. [PMID: 31567502 DOI: 10.1097/sla.0000000000003597] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To identify risk factors for urethral and urologic injuries during transanal total mesorectal excision (taTME) and evaluate outcomes. BACKGROUND Urethral injury is a rare complication of abdominoperineal resection (APR) that has not been reported during abdominal proctectomy. The Low Rectal Cancer Development Program international taTME registry recently reported a 0.8% incidence, but actual incidence and mechanisms of injury remain largely unknown. METHODS A retrospective analysis of taTME cases complicated by urologic injury was conducted. Patient demographics, tumor characteristics, intraoperative details, and outcomes were analyzed, along with surgeons' experience and training in taTME. Surgeons' opinion of contributing factors and best approaches to avoid injuries were evaluated. RESULTS Thirty-four urethral, 2 ureteral, and 3 bladder injuries were reported during taTME operations performed over 7 years by 32 surgical teams. Twenty injuries occurred during the teams' first 8 taTME cases ("early experience"), whereas the remainder occurred between the 12th to 101st case. Injuries resulted in a 22% conversion rate and 8% rate of unplanned APR or Hartmann procedure. At median follow-up of 27.6 months (range, 3-85), the urethral repair complication rate was 26% with a 9% rate of failed urethral repair requiring permanent urinary diversion. In patients with successful repair, 18% reported persistent urinary dysfunction. CONCLUSIONS Urologic injuries result in substantial morbidity. Our survey indicated that those occurring in surgeons' early experience might best be reduced by implementation of structured taTME training and proctoring, whereas those occurring later relate to case complexity and may be avoided by more stringent case selection.
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Randell R, Honey S, Alvarado N, Greenhalgh J, Hindmarsh J, Pearman A, Jayne D, Gardner P, Gill A, Kotze A, Dowding D. Factors supporting and constraining the implementation of robot-assisted surgery: a realist interview study. BMJ Open 2019; 9:e028635. [PMID: 31203248 PMCID: PMC6589012 DOI: 10.1136/bmjopen-2018-028635] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/09/2019] [Accepted: 05/23/2019] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To capture stakeholders' theories concerning how and in what contexts robot-assisted surgery becomes integrated into routine practice. DESIGN A literature review provided tentative theories that were revised through a realist interview study. Literature-based theories were presented to the interviewees, who were asked to describe to what extent and in what ways those theories reflected their experience. Analysis focused on identifying mechanisms through which robot-assisted surgery becomes integrated into practice and contexts in which those mechanisms are triggered. SETTING Nine hospitals in England where robot-assisted surgery is used for colorectal operations. PARTICIPANTS Forty-four theatre staff with experience of robot-assisted colorectal surgery, including surgeons, surgical trainees, theatre nurses, operating department practitioners and anaesthetists. RESULTS Interviewees emphasised the importance of support from hospital management, team leaders and surgical colleagues. Training together as a team was seen as beneficial, increasing trust in each other's knowledge and supporting team bonding, in turn leading to improved teamwork. When first introducing robot-assisted surgery, it is beneficial to have a handpicked dedicated robotic team who are able to quickly gain experience and confidence. A suitably sized operating theatre can reduce operation duration and the risk of de-sterilisation. Motivation among team members to persist with robot-assisted surgery can be achieved without involvement in the initial decision to purchase a robot, but training that enables team members to feel confident as they take on the new tasks is essential. CONCLUSIONS We captured accounts of how robot-assisted surgery has been introduced into a range of hospitals. Using a realist approach, we were also able to capture perceptions of the factors that support and constrain the integration of robot-assisted surgery into routine practice. We have translated these into recommendations that can inform future implementations of robot-assisted surgery.
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Affiliation(s)
| | - Stephanie Honey
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Joanne Greenhalgh
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Jon Hindmarsh
- School of Management and Business, Kings College London, London, UK
| | - Alan Pearman
- Centre for Decision Research, University of Leeds, Leeds, UK
| | - David Jayne
- School of Medicine, University of Leeds, Leeds, UK
| | - Peter Gardner
- School of Psychology, University of Leeds, Leeds, UK
| | - Arron Gill
- Geoffrey Giles Theatres, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alwyn Kotze
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Dawn Dowding
- School of Health Sciences, University of Manchester, Manchester, UK
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Obermair A, Armfield NR, Graves N, Gebski V, Hanna GB, Coleman MG, Hughes A, Janda M. How to train practising gynaecologists in total laparoscopic hysterectomy: protocol for the stepped-wedge IMAGINE trial. BMJ Open 2019; 9:e027155. [PMID: 31072858 PMCID: PMC6528001 DOI: 10.1136/bmjopen-2018-027155] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Hysterectomy is the most common major gynaecological procedure in women and minimally invasive approaches should be used wherever possible; total laparoscopic hysterectomy (TLH) is one such surgical approach which allows removal of the uterus entirely laparoscopically. However, lack of surgical training opportunities is impeding its increased adoption. This study will formally test a surgical outreach training model to equip surgeons with the skills to provide TLH as an alternative to total abdominal hysterectomy (TAH). METHODS AND ANALYSIS Stepped wedge implementation trial of a surgical training programme for practising obstetrician gynaecologist specialists in four hospitals. PRIMARY OUTCOMES Change in the proportion of hysterectomies performed by TAH, measured between preintervention and postintervention; we aim to reduce TAH by at least 30% in 75% of the trainees. SECONDARY OUTCOMES (1) Number of hospitals screened, eligible, agree to training and complete the training; (2) number of surgeons screened for eligibility, eligible, agree to training, who complete training and achieve proficiency; (3) proportion of trainees achieving proficiency in correct theatre setup, vascular exposure, mobilisation and surgery closure; change in proportion proficient over time; (4) adverse events (conversion from TLH to TAH, anaesthetic incident, intraoperative visceral injury, red cell transfusions, hospital stay >7 days, incidental finding of malignancy, unplanned readmission, admission to intensive care, return to theatre, postoperative pulmonary embolism or deep vein thrombosis, development of a fistula, vault haematoma, vaginal vault dehiscence or pelvic infection); (5) hospital length-of-stay; (6) cost-effectiveness and (7) trainee surgeon proficiency with TLH. ETHICS AND DISSEMINATION The study has been approved by the Royal Brisbane and Women's Hospital Human Research Ethics Committee and has received site-specific approval from all participating hospitals. Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT03617354; Pre-results.
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Affiliation(s)
- Andreas Obermair
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- Queensland Centre for Gynaecological Cancer, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
| | - Nigel R Armfield
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | | | - Val Gebski
- CTC, University of Sydney, Sydney, New South Wales, Australia
| | - George B Hanna
- Department of Surgery & Cancer, Faculty of Medicine, Imperial College, London, UK
| | - Mark G Coleman
- Department of Surgery, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Anne Hughes
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - Monika Janda
- Centre of Health Services Research, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- School of Public Health and Social Work, Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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Veltcamp Helbach M, van Oostendorp SE, Koedam TWA, Knol JJ, Stockmann HBAC, Oosterling SJ, Vuylsteke RCLM, de Graaf EJR, Doornebosch PG, Hompes R, Bonjer HJ, Sietses C, Tuynman JB. Structured training pathway and proctoring; multicenter results of the implementation of transanal total mesorectal excision (TaTME) in the Netherlands. Surg Endosc 2019; 34:192-201. [PMID: 30888498 PMCID: PMC6946716 DOI: 10.1007/s00464-019-06750-w] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 03/06/2019] [Indexed: 12/17/2022]
Abstract
Background Transanal total mesorectal excision (TaTME) is a new complex technique with potential to improve the quality of surgical mesorectal excision for patients with mid and low rectal cancer. The procedure is technically challenging and has shown to be associated with a relative long learning curve which might hamper widespread adoption. Therefore, a national structured training pathway for TaTME has been set up in the Netherlands to allow safe implementation. The aim of this study was to monitor safety and efficacy of the training program with 12 centers. Methods Short-term outcomes of the first ten TaTME procedures were evaluated in 12 participating centers in the Netherlands within the national structured training pathway. Consecutive patients operated during and after the proctoring program for rectal carcinoma with curative intent were included. Primary outcome was the incidence of intraoperative complications, secondary outcomes included postoperative complications and pathological outcomes. Results In October 2018, 12 hospitals completed the training program and from each center the first 10 patients were included for evaluation. Intraoperative complications occurred in 4.9% of the cases. The clinicopathological outcome reported 100% for complete or nearly complete specimen, 100% negative distal resection margin, and the circumferential resection margin was positive in 5.0% of patients. Overall postoperative complication rate was 45.0%, with 19.2% Clavien–Dindo ≥ III and an anastomotic leak rate of 17.3%. Conclusions This study shows that the nationwide structured training program for TaTME delivers safe implementation of TaTME in terms of intraoperative and pathology outcomes within the first ten consecutive cases in each center. However, postoperative morbidity is substantial even within a structured training pathway and surgeons should be aware of the learning curve of this new technique.
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Affiliation(s)
- M Veltcamp Helbach
- Department of Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - S E van Oostendorp
- Department of Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - T W A Koedam
- Department of Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - J J Knol
- Department of Surgery, Jessa Hospital, Hasselt and Herk-de-Stad, Belgium
| | - H B A C Stockmann
- Department of Surgery, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
| | - S J Oosterling
- Department of Surgery, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
| | - R C L M Vuylsteke
- Department of Surgery, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
| | - E J R de Graaf
- Department of Surgery, IJsselland Hospital, Cappelle a/d Ijssel, The Netherlands
| | - P G Doornebosch
- Department of Surgery, IJsselland Hospital, Cappelle a/d Ijssel, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - H J Bonjer
- Department of Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - C Sietses
- Department of Surgery, Gelderse Vallei Hospital, Ede, The Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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Stenstra MHBC, van Workum F, van den Wildenberg FJH, Polat F, Rosman C. Evolution of the surgical technique of minimally invasive Ivor-Lewis esophagectomy: description according to the IDEAL framework. Dis Esophagus 2019; 32:5105841. [PMID: 30247660 DOI: 10.1093/dote/doy079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Totally minimally invasive Ivor-Lewis esophagectomy (Ivor Lewis TMIE) is a technically challenging procedure and is associated with a learning curve. Refinement of surgical technique is an important part of this learning curve. However, detailed descriptions of these refinements according to the idea, development, exploration, assessment, and long-term follow-up (IDEAL) framework are lacking and this study was undertaken to fill this knowledge gap. From 2010 until 2016, all consecutive patients (n = 164) were included from the first patient undergoing Ivor Lewis TMIE. Surgical reports were analyzed and surgeons were interviewed to determine surgical refinements. These data were used to describe the transition of the surgical technique from IDEAL stage IIB to stage III. The main findings were that four refinements were made to the surgical procedure in IDEAL stage IIB: (1) At case 9, the use of the 25 mm OrVil was abandoned, exchanged for a 28 mm EEA stapler and a large omental wrap around the anastomosis was introduced; (2) at case 27, the omental wrap was reduced in volume; (3) at case 60, the omental wrap was refined to cover the full 360° of the anastomosis and (4) at case 77, the fixation of the anvil with the Endostitch was replaced by fixation with two Endoloops®. During the transition from IDEAL stage IIB to stage III, the incidence of anastomotic leakage decreased from 26.0% to 4.6% (P < 0.001) and the incidence of textbook outcome increased from 31.2% to 47.1% (P = 0.039). In conclusion, this study describes the surgical refinements that were made during the progression of Ivor Lewis TMIE from IDEAL stage IIB to IDEAL stage III. During IDEAL stage IIB, postoperative outcome improved as surgical proficiency was gained and the technique was refined.
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Affiliation(s)
| | - F van Workum
- Department of Surgery, Radboud University Medical Centre
| | | | - F Polat
- Department of surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - C Rosman
- Department of Surgery, Radboud University Medical Centre
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Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, de Boer HD, Urman RD, Chang GJ, Fichera A, Kessler H, Grass F, Whang EE, Fawcett WJ, Carli F, Lobo DN, Rollins KE, Balfour A, Baldini G, Riedel B, Ljungqvist O. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS ®) Society Recommendations: 2018. World J Surg 2019; 43:659-695. [PMID: 30426190 DOI: 10.1007/s00268-018-4844-y] [Citation(s) in RCA: 1061] [Impact Index Per Article: 212.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Danderyd Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - M J Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, VA, USA
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, USA
| | - M Hubner
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - J Nygren
- Department of Surgery, Ersta Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - N Demartines
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - N Francis
- Colorectal Unit, Yeovil District Hospital, Higher Kingston, Yeovil, BA21 4AT, UK
- University of Bath, Wessex House Bath, BA2 7JU, UK
| | - T A Rockall
- Department of Surgery, Royal Surrey County Hospital NHS Trust, and Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - T M Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - A G Hill
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland Middlemore Hospital, Auckland, New Zealand
| | - M Soop
- Irving National Intestinal Failure Unit, The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - H D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital, Groningen, The Netherlands
| | - R D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G J Chang
- Department of Surgical Oncology and Department of Health Services Research, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - A Fichera
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, USA
| | - F Grass
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - E E Whang
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - W J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust and University of Surrey, Guildford, UK
| | - F Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - K E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - A Balfour
- Department of Colorectal Surgery, Surgical Services, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - G Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - B Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - O Ljungqvist
- Department of Surgery, Örebro University and University Hospital, Örebro & Institute of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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2D versus 3D laparoscopic total mesorectal excision: a developmental multicentre randomised controlled trial. Surg Endosc 2019; 33:3370-3383. [PMID: 30656453 PMCID: PMC6722156 DOI: 10.1007/s00464-018-06630-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/17/2018] [Indexed: 12/21/2022]
Abstract
AIMS The role of laparoscopy in rectal cancer has been questioned. 3D laparoscopic systems are suggested to aid optimal surgical performance but have not been evaluated in advanced procedures. We hypothesised that stereoscopic imaging could improve the performance of laparoscopic total mesorectal excision (TME). METHODS A multicentre developmental randomised controlled trial comparing 2D and 3D laparoscopic TME was performed (ISRCTN59485808). Trial surgeons were colorectal consultants that had completed their TME proficiency curve and underwent stereoscopic visual testing. Patients requiring elective laparoscopic TME with curative intent were centrally randomised (1:1) to 2D or 3D using Karl Storz IMAGE1 S D3-Link™ and 10-mm TIPCAM®1S 3D passive polarising laparoscopic systems. Outcomes were enacted adverse events as assessed by the observational clinical human reliability analysis technique, intraoperative data, 30-day patient outcomes, histopathological specimen assessment and surgeon cognitive load. RESULTS 88 patients were included. There were no differences in patient or tumour demographics, surgeon stereopsis, case difficulty, cognitive load, operative time, blood loss or conversion between the trial arms. 1377 intraoperative adverse events were identified (median 18 per case, IQR 14-21, range 2-49) with no differences seen between the 2D and 3D arms (18 (95% CI 17-21) vs. 17 (95% CI 16-19), p = 0.437). 3D laparoscopy had non-significantly higher mesorectal fascial plane resections (94 vs. 77%, p = 0.059; OR 0.23 (95% CI 0.05-1.16)) but equal lymph node yield and circumferential margin distance and involvement. 30-day morbidity, anastomotic leak, re-operation, length of stay and readmission rates were equal between the 2D and 3D arms. CONCLUSION Feasibility of performing multicentre 3D laparoscopic multicentre trials of specialist performed complex procedures is shown. 3D imaging did not alter the number of intraoperative adverse events; however, a potential improvement in mesorectal specimen quality was observed and should form the focus of future 3D laparoscopic TME trials.
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Formisano G, Esposito S, Coratti F, Giuliani G, Salaj A, Bianchi PP. Structured training program in colorectal surgery: the robotic surgeon as a new paradigm. MINERVA CHIR 2018; 74:170-175. [PMID: 30484601 DOI: 10.23736/s0026-4733.18.07951-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND One major issue in general surgery is how to provide novice surgeons with a structured training program (STP). The aim of our study was to assess the efficacy of a STP in robotic colorectal surgery for young surgeons without prior experience in both open and laparoscopic colorectal surgery, who were autonomous in basic minimally-invasive surgical procedures. Right colectomy with intracorporeal anastomosis has been chosen as a model. METHODS Between May 2015 and December 2017 two junior attending surgeons were trained through a STP. Right colectomy was divided into three main learning modules (colonic mobilization, vascular control, intracorporeal anastomosis) and each one was carried out by the trainees for at least two times under direct supervision of the senior surgeon. After the initial robotic cases completely performed under formal proctoring, they were privileged to perform robotic right colectomy independently without a mentor (20 procedures). Operative time, conversion rate, intra- and postoperative complications, length of stay and pathological outcomes were the variables analyzed to assess the effectiveness of the STP. RESULTS The mean operative time was 200 minutes and no conversion was required. Neither intraoperative nor major postoperative complications were recorded and the mean length of hospital stay was 6 days. Mean nodal yield was 21. CONCLUSIONS A STP in robotic colorectal surgery is feasible and effective. Right colectomy represents a good model as first step of the program in order to develop multiple technical skills. Previous experience in open or laparoscopic colorectal surgery may not be necessary.
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Affiliation(s)
- Giampaolo Formisano
- Department of General and Minimally-Invasive Surgery, Misericordia Hospital, Grosseto, Italy -
| | - Sofia Esposito
- Department of General and Minimally-Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Francesco Coratti
- Department of General and Minimally-Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Giuseppe Giuliani
- Department of General and Minimally-Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Adelona Salaj
- Department of General and Minimally-Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Paolo P Bianchi
- Department of General and Minimally-Invasive Surgery, Misericordia Hospital, Grosseto, Italy
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Byrne BE, Vincent CA, Faiz OD. Inequalities in Implementation and Different Outcomes During the Growth of Laparoscopic Colorectal Cancer Surgery in England: A National Population-Based Study from 2002 to 2012. World J Surg 2018; 42:3422-3431. [PMID: 29633102 PMCID: PMC6132863 DOI: 10.1007/s00268-018-4615-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
AIM Laparoscopic colorectal cancer surgery has developed from unproven technique to mainstay of treatment. This study examined the application and relative outcomes of laparoscopic and open colorectal cancer surgery over time, as laparoscopic uptake and experience have grown. METHODS Adults undergoing elective laparoscopic and open colorectal cancer surgery in the English NHS during 2002-2012 were included. Age, sex, Charlson Comorbidity Index and Index of Multiple Deprivation were compared over time. Post-operative 30-day mortality, length of stay, failure to rescue reoperation and the associated mortality rate were examined. RESULTS Laparoscopy rates rose from 1.1 to 50.8%. Patients undergoing laparoscopic surgery had lower comorbidity by 0.24 points (95% confidence intervals (CI) 0.20-0.27) and lower socioeconomic deprivation by 0.16 deciles (95% CI 0.12-0.20) than those having open procedures. Overall mortality fell by 48.0% from 2002-2003 to 2011-2002 and was 37.8% lower after laparoscopic surgery. Length of stay and mortality after surgical re-intervention also fell. However, re-intervention rates were higher after laparoscopic procedures by 7.8% (95% CI 0.9-15.2%). CONCLUSIONS There was clear and persistent inequality in the application of laparoscopic colorectal cancer surgery during this study. Further work must explore and remedy inequalities to maximise patient benefit. Higher re-intervention rates after laparoscopy are unexplained and differ from randomized controlled trials. This may reflect differences in surgeons and practice between research and usual care settings and should be further investigated.
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Affiliation(s)
- B E Byrne
- Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK.
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - C A Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - O D Faiz
- Surgical Epidemiology, Trials and Outcome Centre, St Mark's Hospital, Harrow, UK
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Panteleimonitis S, Pickering O, Abbas H, Harper M, Kandala N, Figueiredo N, Qureshi T, Parvaiz A. Robotic rectal cancer surgery in obese patients may lead to better short-term outcomes when compared to laparoscopy: a comparative propensity scored match study. Int J Colorectal Dis 2018; 33:1079-1086. [PMID: 29577170 PMCID: PMC6060802 DOI: 10.1007/s00384-018-3030-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Laparoscopic rectal surgery in obese patients is technically challenging. The technological advantages of robotic instruments can help overcome some of those challenges, but whether this translates to superior short-term outcomes is largely unknown. The aim of this study is to compare the short-term surgical outcomes of obese (BMI ≥ 30) robotic and laparoscopic rectal cancer surgery patients. METHODS All consecutive obese patients receiving laparoscopic and robotic rectal cancer resection surgery from three centres, two from the UK and one from Portugal, between 2006 and 2017 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for ASA grade, neoadjuvant radiotherapy and pathological T stage. Their short-term outcomes were examined. RESULTS A total of 222 patients were identified (63 robotic, 159 laparoscopic). The 63 patients who received robotic surgery were matched with 61 laparoscopic patients. Cohort characteristics were similar between the two groups. In the robotic group, operative time was longer (260 vs 215 min; p = 0.000), but length of stay was shorter (6 vs 8 days; p = 0.014), and thirty-day readmission rate was lower (6.3% vs 19.7%; p = 0.033). CONCLUSIONS In this study population, robotic rectal surgery in obese patients resulted in a shorter length of stay and lower 30-day readmission rate but longer operative time when compared to laparoscopic surgery. Robotic rectal surgery in the obese may be associated with a quicker post-operative recovery and reduced morbidity profile. Larger-scale multi-centre prospective observational studies are required to validate these results.
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Affiliation(s)
- Sofoklis Panteleimonitis
- Poole Hospital NHS Trust, Longfleet road, Poole, BH15 2JB, UK.
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st road, Portsmouth, PO1 2FR, UK.
| | | | - Hassan Abbas
- Poole Hospital NHS Trust, Longfleet road, Poole, BH15 2JB, UK
| | - Mick Harper
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st road, Portsmouth, PO1 2FR, UK
| | - Ngianga Kandala
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st road, Portsmouth, PO1 2FR, UK
| | - Nuno Figueiredo
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| | - Tahseen Qureshi
- Poole Hospital NHS Trust, Longfleet road, Poole, BH15 2JB, UK
- Bournemouth University School of Health and Social Care, Bournemouth, UK
| | - Amjad Parvaiz
- Poole Hospital NHS Trust, Longfleet road, Poole, BH15 2JB, UK
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st road, Portsmouth, PO1 2FR, UK
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
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Panteleimonitis S, Popeskou S, Aradaib M, Harper M, Ahmed J, Ahmad M, Qureshi T, Figueiredo N, Parvaiz A. Implementation of robotic rectal surgery training programme: importance of standardisation and structured training. Langenbecks Arch Surg 2018; 403:749-760. [PMID: 29926187 PMCID: PMC6153605 DOI: 10.1007/s00423-018-1690-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 06/08/2018] [Indexed: 12/20/2022]
Abstract
Purpose A structured training programme is essential for the safe adoption of robotic rectal cancer surgery. The aim of this study is to describe the training pathway and short-term surgical outcomes of three surgeons in two centres (UK and Portugal) undertaking single-docking robotic rectal surgery with the da Vinci Xi and integrated table motion (ITM). Methods Prospectively, collected data for consecutive patients who underwent robotic rectal cancer resections with the da Vinci Xi and ITM between November 2015 and September 2017 was analysed. The short-term surgical outcomes of the first ten cases of each surgeon (supervised) were compared with the subsequent cases (independent). In addition, the Global Assessment Score (GAS) forms from the supervised cases were analysed and the GAS cumulative sum (CUSUM) charts constructed to investigate the training pathway of the participating surgeons. Results Data from 82 patients was analysed. There were no conversions to open, no anastomotic leaks and no 30-day mortality. Mean operation time was 288 min (SD 63), median estimated blood loss 20 (IQR 20–20) ml and median length of stay 5 (IQR 4–8) days. Thirty-day readmission and reoperation rates were 4% (n = 3) and 6% (n = 5) respectively. When comparing the supervised cases with the subsequent solo cases, there were no statistically significant changes in any of the short-term outcomes with the exception of mean operative time, which was significantly shorter in the independent cases (311 vs 275 min, p = 0.038). GAS form analysis and GAS CUSUM charting revealed that ten proctoring cases were enough for trainee surgeons to independently perform robotic rectal resections with the da Vinci Xi. Conclusions Our results show that by applying a structured training pathway and standardising the surgical technique, the single-docking procedure with the da Vinci Xi is a valid, reproducible technique that offers good short-term outcomes in our study population.
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Affiliation(s)
- Sofoklis Panteleimonitis
- Poole Hospital NHS Trust, Longfleet Road, Poole, BH15 2JB, UK. .,School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, PO1 2FR, UK.
| | | | - Mohamed Aradaib
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, PO1 2FR, UK
| | - Mick Harper
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, PO1 2FR, UK
| | - Jamil Ahmed
- Poole Hospital NHS Trust, Longfleet Road, Poole, BH15 2JB, UK
| | - Mukhtar Ahmad
- Poole Hospital NHS Trust, Longfleet Road, Poole, BH15 2JB, UK
| | - Tahseen Qureshi
- Poole Hospital NHS Trust, Longfleet Road, Poole, BH15 2JB, UK.,Bournemouth University School of Health and Social Care, Bournemouth, UK
| | - Nuno Figueiredo
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| | - Amjad Parvaiz
- Poole Hospital NHS Trust, Longfleet Road, Poole, BH15 2JB, UK.,School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, PO1 2FR, UK.,Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
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Wynn GR, Austin RCT, Motson RW. Using cadaveric simulation to introduce the concept and skills required to start performing transanal total mesorectal excision. Colorectal Dis 2018; 20:496-501. [PMID: 29368376 DOI: 10.1111/codi.14034] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 12/08/2017] [Indexed: 02/08/2023]
Abstract
AIM The aim was to document the outcomes of surgeons attending a cadaveric simulation course designed to provide an introduction to transanal total mesorectal excision (TaTME). METHOD This was a prospective observational study documenting the outcomes from classroom and wet lab activities. Follow-up questionnaires were used to monitor clinical activity after the course. RESULTS Outcomes of 65 delegates from 12 different countries attending seven cadaveric simulation courses are described. Median time to insert and close the rectal purse-string was 15 min (range 7-50 min) and median time to complete the transanal mesorectal dissection was 105 min (range 60-260 min). Objective assessment of specimen quality showed that 42% of specimens were complete, 47% nearly complete and 11% were incomplete. Failure of the intraluminal rectal purse-string was the most common difficulty encountered. Within 6 months of attending the course, nearly half (26/55; 47%) of the surgeons who responded had performed between 1 and 13 TaTMEs. Only 8/26 (31%) of the surgeons had arranged mentoring for their first case. CONCLUSION This training model provides high levels of trainee satisfaction and the knowledge and technical skills to enable them to start performing TaTME. There is still work to do to provide adequate supervision and mentorship for surgeons early on their learning curve that is essential for the safe introduction of this new technique.
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Disbrow DE, Pannell SM, Shanker BA, Albright J, Wu J, Bastawrous A, Soliman M, Ferraro J, Cleary RK. The Effect of Formal Robotic Residency Training on the Adoption of Minimally Invasive Surgery by Young Colorectal Surgeons. JOURNAL OF SURGICAL EDUCATION 2018; 75:767-778. [PMID: 29054345 DOI: 10.1016/j.jsurg.2017.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/18/2017] [Accepted: 09/11/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE The minimally invasive approach to colorectal surgery is still underused. Only 50% to 60% of colectomies and 10% to 20% of rectal resections for cancer are performed laparoscopically. The increasing adoption of the robotic platform for colorectal surgery warrants re-evaluation of minimally invasive surgery (MIS) training techniques. Although considering lessons learned from past laparoscopic training, a standardized national robotic training program for colon and rectal surgery residents was developed and implemented in 2011. The objective of this study was to assess the effect of this program on the usage of MIS in practice following residency training. DESIGN An internet-based 18 question survey was sent to all colon and rectal surgeons who graduated from ACGME-approved colon and rectal surgery residencies from 2013 to 2016. The survey questions were designed to determine MIS practice patterns for young colon and rectal surgeons after residency training for those who participated in the standardized national robotics training course when compared to those who did not participate. Grouped bar charts with error bars are presented along with summary statistics to offer a descriptive overview of training experiences by cohort. SETTING/PARTICIPANTS This study is a survey of colon and rectal surgeons who completed colon and rectal surgery residencies to include all 52 programs across the United States. RESULTS The overall survey response rate was 37.2% (109 of 293). Most (79.8%) of the colon and rectal surgery resident respondents participated in the formal robotic training course. The average respondent reported that 84% of colectomy cases and 74.8% of rectal resections done after residency training by all respondents were by the MIS approach. The laparoscopic approach was most prevalent for colectomies for both course participants (laparoscopic 55.1%, hand assisted lap 14.5%, and robotic 15.7%) and nonparticipants (laparoscopic 53.8%, hand assisted lap 12.3%, and robotic 15.9%). For rectal resections, the robotic approach was the preferred option for course participants (laparoscopic 24.5%, hand assist lap 14.0%, and robotic 39.2%) whereas laparoscopic and open approaches were used more often by nonparticipants (laparoscopic 36.8%, hand assist lap 8.0%, robotic 26.8%, and open 28.4%). Barriers to robotic implementation included lack of robotic mentors, inadequate robotic assistance, and the preference for the laparoscopic approach. CONCLUSION The usage of MIS by young recently fellowship-trained colorectal surgeons is higher than previously reported. The proportion of rectal cases done robotically is higher compared to colon cases and with an apparent decrease in open rather than laparoscopic surgery, suggesting selective usage of robotic surgery for more challenging cases in the pelvis. Methods to more effectively increase the usage of minimally invasive approaches in colorectal surgery warrant further evaluation.
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Affiliation(s)
- David E Disbrow
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Stephanie M Pannell
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Beth-Ann Shanker
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Jeremy Albright
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Juan Wu
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Amir Bastawrous
- Swedish Colon and Rectal Clinic, Swedish Cancer Institute, Swedish Medical Center, Seattle, Washington
| | - Mark Soliman
- Colon and Rectal Clinic of Orlando, Orlando, Florida
| | - Jane Ferraro
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Robert K Cleary
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan.
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Awad M, Awad F, Carter F, Jervis B, Buzink S, Foster J, Jakimowicz J, Francis NK. Consensus views on the optimum training curriculum for advanced minimally invasive surgery: A delphi study. Int J Surg 2018; 53:137-142. [DOI: 10.1016/j.ijsu.2018.03.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 02/09/2018] [Accepted: 03/19/2018] [Indexed: 12/18/2022]
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Visser E, van Rossum PSN, van Veer H, Al-Naimi K, Chaudry MA, Cuesta MA, Gisbertz SS, Gutschow CA, Hölscher AH, Luyer MDP, Mariette C, Moorthy K, Nieuwenhuijzen GAP, Nilsson M, Räsänen JV, Schneider PM, Schröder W, Cheong E, van Hillegersberg R. A structured training program for minimally invasive esophagectomy for esophageal cancer- a Delphi consensus study in Europe. Dis Esophagus 2018; 31:4601761. [PMID: 29121243 DOI: 10.1093/dote/dox124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/18/2017] [Indexed: 12/11/2022]
Abstract
Evidence suggests that structured training programs for laparoscopic procedures can ensure a safe standard of skill acquisition prior to independent practice. Although minimally invasive esophagectomy (MIO) is technically demanding, no consensus on requirements for training for the MIO procedure exists. The aim of this study is to determine essential steps required for a structured training program in MIO using the Delphi consensus methodology. Eighteen MIO experts from 13 European hospitals were asked to participate in this study. The consensus process consisted of two structured meetings with the expert panel, and two Delphi questionnaire rounds. A list of items required for training MIO were constructed for three key domains of MIO, including (1) requisite criteria for units wishing to be trained and (2) to proctor MIO, and (3) a framework of a MIO training program. Items were rated by the experts on a scale 1-5, where 1 signified 'not important' and 5 represented 'very important.' Consensus for each domain was defined as achieving Cronbach alpha ≥0.70. Items were considered as fundamental when ≥75% of experts rated it important (4) or very important (5). Both Delphi rounds were completed by 16 (89%) of the 18 invited experts, with a median experience of 18 years with minimally invasive surgery. Consensus was achieved for all three key domains. Following two rounds of a 107-item questionnaire, 50 items were rated as essential for training MIO. A consensus among European MIO experts on essential items required for training MIO is presented. The identified items can serve as directive principles and core standards for creating a comprehensive training program for MIO.
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Affiliation(s)
| | - P S N van Rossum
- Departments of Surgery.,Radiation Oncology, University Medical Center Utrecht, Utrecht
| | - H van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - M A Chaudry
- Department of Surgery, Royal Marsden Hospital NHS Foundation Trust
| | - M A Cuesta
- Department of Gastrointestinal Surgery, VU University Medical Center
| | - S S Gisbertz
- Department of Surgery, Academic Medical Center, Amsterdam
| | - C A Gutschow
- Department of Visceral and Transplantation Surgery, University Hospital Zurich
| | - A H Hölscher
- Department of Surgery, Center for Esophageal and Gastric Surgery, and Frankfurt
| | - M D P Luyer
- Department of Surgery, Catherina Hospital Eindhoven, Eindhoven, The Netherlands
| | - C Mariette
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - K Moorthy
- Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, London, United Kingdom
| | | | - M Nilsson
- Department of Surgery, Karolinski University Hospital.,Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - J V Räsänen
- Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - P M Schneider
- Department of Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - W Schröder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - E Cheong
- General Surgery, Norfolk and Norwich University Hospital, Norwich
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Francis NK, Curtis NJ, Crilly L, Noble E, Dyke T, Hipkiss R, Dalton R, Allison A, Salib E, Ockrim J. Does the number of operating specialists influence the conversion rate and outcomes after laparoscopic colorectal cancer surgery? Surg Endosc 2018; 32:3652-3658. [PMID: 29442241 DOI: 10.1007/s00464-018-6097-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 02/07/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic techniques in colorectal surgery have been widely utilised due to short-term patient benefits but conversion to open surgery is associated with adverse short- and long-term patient outcomes. The aim of this study was to investigate the influence of dual specialist operating on the conversion rate and patient outcomes following laparoscopic colorectal surgery. METHODS A prospectively populated colorectal cancer surgery database was reviewed. Cases were grouped into single or dual consultant procedures. Cluster analysis and odds ratio (OR) were used to identify risk factors for conversion. Primary outcome measures were conversion to open and five year overall survival (OS) calculated using the Kaplan-Meier log-rank method. RESULTS 750 patients underwent laparoscopic colorectal cancer resection between 2002 and 2015 (median age 73, 319 (42.5%) female, 282 (37.6%) rectal malignancies, 135 patients (18%) had two consultants). The single surgeon conversion rate was 20.4% compared to 5.5% for dual operating (OR 4.4, 95% CI 1.87-10.2, p < 0.001). There were no demographic or tumour differences between the laparoscopic/converted and number of surgeon groups. Two-step cluster analysis identified cluster I (lower risk) 406 patients, 8% converted and cluster II (higher risk) 261 patients, conversion rate 30%. Median follow-up was 48 months (range 0-168). Five-year OS was significantly inferior for both converted and single surgeon cases (63% vs. 77%, p < 0.001 and 61% vs. 70%, p = 0.033, respectively). CONCLUSION In selected colorectal cancer patients operated by fully trained laparoscopic surgeons, we observed a reduction in conversion with associated long-term survival benefit from dual operating specialists.
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Affiliation(s)
- Nader K Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK. .,Faculty of Science, University of Bath, Wessex House 3.22, Bath, BA2 7AY, UK.
| | - Nathan J Curtis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK.,Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, Level 10, Praed Street, London, W2 1NY, UK
| | - Louise Crilly
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - Emma Noble
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - Tamsin Dyke
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - Rob Hipkiss
- Information Management Team, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - Richard Dalton
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - Andrew Allison
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - Emad Salib
- Faculty of Health and Life Sciences, University of Liverpool, Brownlow Hill, Liverpool, L69 3BX, UK.,Aidmedical Statistical Support
| | - Jonathan Ockrim
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
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Mentored Trainees have Similar Short-Term Outcomes to a Consultant Trainer Following Laparoscopic Colorectal Resection. World J Surg 2018; 41:1896-1902. [PMID: 28255631 DOI: 10.1007/s00268-017-3925-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Markar SR, Mackenzie H, Ni M, Huddy JR, Askari A, Faiz O, Griffin SM, Lovat L, Hanna GB. The influence of procedural volume and proficiency gain on mortality from upper GI endoscopic mucosal resection. Gut 2018; 67:79-85. [PMID: 27797934 PMCID: PMC5754854 DOI: 10.1136/gutjnl-2015-311237] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 08/19/2016] [Accepted: 08/28/2016] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Endoscopic mucosal resection (EMR) is established for the management of benign and early malignant upper GI disease. The aim of this observational study was to establish the effect of endoscopist procedural volume on mortality. DESIGN Patients undergoing upper GI EMR between 1997 and 2012 were identified from the Hospital Episode Statistics database. The primary outcome was 30-day mortality and secondary outcomes were 90-day mortality, requirement for emergency intervention and elective cancer re-intervention. Risk-adjusted cumulative sum (RA-CUSUM) analysis was used to assess patient mortality risk during initial stage of endoscopist proficiency gain and the effect of endoscopist and hospital volume. Mortality was compared before and after the change point or threshold in the RA-CUSUM curve. RESULTS 11 051 patients underwent upper GI EMR. Endoscopist procedure volume was an independent predictor of 30-day mortality. Fifty-eight per cent of EMR procedures were performed by endoscopists with annual volume of 2 cases or less, and had a higher 30-day and 90-day mortality rate for patients with cancer, 6.1% vs 0.4% (p<0.001) and 12% vs 2.1% (p<0.001), respectively. The requirement for emergency intervention after EMR for cancer was also greater with low volume endoscopists (1.8% vs 0.1%, p=0.002). In patients with cancer, the RA-CUSUM curve change points for 30-day mortality and elective re-intervention were 4 cases and 43 cases, respectively. CONCLUSIONS EMR performed by high volume endoscopists is associated with reduced adverse outcomes. In order to reach proficiency, appropriate training and procedural volume accreditation training programmes are needed nationally.
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Affiliation(s)
- Sheraz R Markar
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Hugh Mackenzie
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Melody Ni
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Jeremy R Huddy
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Alan Askari
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - Omar Faiz
- Department of Surgery & Cancer, Imperial College London, London, UK,St Mark's Hospital and Academic Institute, Harrow, UK
| | - S Michael Griffin
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Laurence Lovat
- Division of Surgery & Interventional Science, University College London, London, UK
| | - George B Hanna
- Department of Surgery & Cancer, Imperial College London, London, UK
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Francis NK, Curtis NJ, Weegenaar C, Boorman PA, Brook A, Thorpe G, Keogh K, Grainger J, Davies J, Wheeler J, Brown SR, Steele RJ, Dawson P. Developing a national colorectal educational agenda: a survey of the Association of Coloproctology of Great Britain and Ireland. Colorectal Dis 2018; 20:68-73. [PMID: 28682454 DOI: 10.1111/codi.13804] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/02/2017] [Accepted: 05/17/2017] [Indexed: 02/06/2023]
Abstract
AIM In order to develop its education agenda, the Association of Coloproctology of Great Britain and Ireland (ACPGBI) sought the opinion of its members on current coloproctology training needs. The aims of this study were to canvass multidisciplinary needs and explore the perceived gaps and barriers to meeting them. METHOD A learner-needs analysis was performed between July 2015 and October 2016. A bespoke electronic survey was sent to 1453 colorectal healthcare professionals [ACPGBI membership (1173), colorectal nurse specialists and allied health professionals (NAHPs) (261) and regional chapter-leads (19)] seeking their needs, experiences and barriers to training across the coloproctology disciplines. RESULTS In all, 390 responses were received [26.8% overall; 180 consultants/trainees (15%); 196 NAHPs (75%); 14 (74%) chapter-leads]. Lack of funding and difficulties in obtaining study leave were the most frequently reported barriers to course and conference attendance. Transanal total mesorectal excision and laparoscopic training were the top educational needs for consultants and trainees respectively. 79% of NAHP respondents reported education gaps on a broad range of clinical and non-clinical topics. NAHPs lacked information on relevant training opportunities and 27% felt available courses were insufficient to meet their educational needs. Wide heterogeneity in ACPGBI chapter composition and activity was reported. All groups felt the ACPGBI should increase the number of courses offered with coloproctology knowledge updates commonly requested. CONCLUSION A series of training needs across the coloproctology disciplines have been identified. These will underpin the development of the educational agenda for the ACPGBI.
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Affiliation(s)
- N K Francis
- Yeovil District Hospital, Yeovil, UK.,University of Bath, Exeter, UK
| | | | | | | | | | - G Thorpe
- University of East Anglia, Norwich, UK
| | - K Keogh
- Royal Devon and Exeter Hospital, Exeter, UK
| | - J Grainger
- St Marks Hospital, Northwick Park, London, UK
| | - J Davies
- Addenbrooke's Hospital, Cambridge, UK
| | - J Wheeler
- Addenbrooke's Hospital, Cambridge, UK
| | - S R Brown
- Sheffield Teaching Hospitals, Dundee, UK
| | | | - P Dawson
- ACPGBI, West Middlesex University Hospital, London, UK
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Laparoscopic resection for primary and recurrent Crohn's disease: A case series of over 100 consecutive cases. Int J Surg 2017; 47:69-76. [DOI: 10.1016/j.ijsu.2017.09.055] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 09/13/2017] [Accepted: 09/16/2017] [Indexed: 12/11/2022]
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Evolution of Surgical Treatment for Rectal Cancer: a Review. J Gastrointest Surg 2017; 21:1166-1173. [PMID: 28444558 DOI: 10.1007/s11605-017-3427-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 04/06/2017] [Indexed: 02/08/2023]
Abstract
Surgery that produces an optimal total mesorectal excision (TME) resection specimen remains the cornerstone of curative rectal cancer management. In the modern era, despite the results of recent randomised trials, laparoscopic TME is a crucial technique in the TME surgery armamentarium. Laparoscopic surgery offers the benefit of magnified views that aid sharp and precise dissection. However operating in the confines of a narrow pelvis, particularly when the mesorectum is bulky, requires significant technical skill. This is compounded by limited angulation of laparoscopic instruments and staplers. The final challenge is to preserve the integrity of the mesorectum during delivery of the specimen. The principles of TME surgery, on which Bill Heald founded the Basingstoke Colorectal unit, can equally be applied to laparoscopic, transanal and robotic TME, but great care must be taken to preserve the key principle-that no steps are taken that have the potential to shed tumour cells or compromise the quality of the mesorectal specimen.
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Moran B, Cunningham C, Singh T, Sagar P, Bradbury J, Geh I, Karandikar S. Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Surgical Management. Colorectal Dis 2017. [PMID: 28632309 DOI: 10.1111/codi.13704] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Brendan Moran
- Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | | | | | | | | | - Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
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Curtis NJ, Davids J, Foster JD, Francis NK. Objective assessment of minimally invasive total mesorectal excision performance: a systematic review. Tech Coloproctol 2017; 21:259-268. [PMID: 28470365 DOI: 10.1007/s10151-017-1614-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 02/28/2017] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Laparoscopy is widely used in colorectal practice, but recent trial results have questioned its use in rectal cancer resections. Patient outcomes are directly linked to the quality of total mesorectal excision (TME) specimen. Objective assessment of intraoperative performance could help ensure competence and delivery of optimal outcomes. Objective tools may also contribute to TME intervention trials, but their nature, structure and utilisation is unknown. AIM To systemically review the available literature to report on the available tools for the objective assessment of minimally invasive TME operative performance and their use within multicentre laparoscopic TME randomised controlled trials. METHODS A systematic search of the PubMed and Cochrane databases was performed to identify tools used in the objective intraoperative assessment of minimally invasive TME performance in accordance with the PRISMA guidelines, independently by two authors. The identified tools were then evaluated within reported TME RCTs. RESULTS A total of 8642 abstracts were screened of which 12 papers met the inclusion criteria; ten prospective observational studies, one randomised trial and one educational consensus. Eight assessment methods were described, which include formative and summative tools. The tools were mostly adaptations of colonic surgery tools based on either operative video review or post-operative trainer rating. All studies reported objective assessment of intraoperative performance was feasible, but only 126 (7%) of the 1762 included laparoscopic cases were TME. No multicentre laparoscopic TME trial reported using any objective surgical performance assessment tool. CONCLUSION Objective intraoperative laparoscopic TME performance assessment is feasible, but most of the current tools are adaptation of colonic surgery. There is a need to develop dedicated assessment tools for minimal access rectal surgery. No multicentre minimally invasive TME RCT reported using any objective assessment tool.
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Affiliation(s)
- N J Curtis
- Clinical Research Unit, Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK.,Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, Praed Street, London, UK
| | - J Davids
- Clinical Research Unit, Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK
| | - J D Foster
- Clinical Research Unit, Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK.,Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, Praed Street, London, UK
| | - N K Francis
- Clinical Research Unit, Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK. .,Faculty of Science, University of Bath, Wessex House 3.22, Bath, Somerset, UK.
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Patel K, Faiz O, Rutter M, Dunckley P, Thomas-Gibson S. The impact of the introduction of formalised polypectomy assessment on training in the UK. Frontline Gastroenterol 2017; 8:104-109. [PMID: 28250907 PMCID: PMC5318649 DOI: 10.1136/flgastro-2016-100718] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 06/12/2016] [Accepted: 06/27/2016] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE The aim was to describe the impact on polypectomy experience by the mandatory introduction of the Directly Observed Polypectomy Skills tool (DOPyS) and electronic portfolio as part of the formal colonoscopy certification process. DESIGN Applications for colonoscopy certification in the UK in the year prior to the introduction of DOPyS were analysed retrospectively and compared with data collected prospectively for those in the following year. SETTING UK National Health Service. PATIENTS None. INTERVENTIONS None. MAIN OUTCOME MEASURES The outcomes studied included whether evidence of exposure to polypectomy, endoscopic mucosal resection (EMR) and colonoscopy changed over the 2-year period. The nature of the polyps removed by trainees was also studied. RESULTS Thirty two per cent of candidates in the first year had evidence of any observed polypectomy with 7% of candidates referring to training in EMR. The median number of formative colonoscopy assessments was 3 (range 0-16). All of these candidates in the second year had evidence of polypectomy assessment, with a median number of DOPyS of 7 (range 3-27). Eighty nine per cent of applicants had evidence of assessed EMR. The median number of formative colonoscopy assessments in this cohort was 32 (range 9-199). There was a significant increase in the number of logged polypectomy assessments (p<0.001), experience of EMR (p<0.001) and formative colonoscopy assessments (p<0.001). There was no significant difference in the total number of colonoscopy procedures performed. CONCLUSIONS Structured polypectomy assessment improves trainees' documented exposure to therapeutic endoscopy as well as providing formal evidence of skills acquisition. As polypectomy plays an increasing role globally in colorectal cancer prevention, the DOPyS provides an effective means of assessing and certifying polypectomy.
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Affiliation(s)
- Kinesh Patel
- Wolfson Unit for Endoscopy, St Mark's Hospital, Harrow, UK
| | - Omar Faiz
- Wolfson Unit for Endoscopy, St Mark's Hospital, Harrow, UK
| | - Matt Rutter
- University Hospital of North Tees, Stockport, UK
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Markar S, Lagergren J. Minimising patient harm whilst gaining surgical proficiency. J Thorac Dis 2016; 8:E1427-E1428. [PMID: 27867649 DOI: 10.21037/jtd.2016.09.69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sheraz Markar
- Department of Surgery & Cancer, Imperial College London, London, UK;; Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jesper Lagergren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden;; Division of Cancer Studies, King's College London, London, UK
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