Rates and Predictors of Endoscopic and Clinical Recurrence After Primary Ileocolic Resection for Crohn's Disease

BACKGROUND AND AIMS

The utility of postoperative medical prophylaxis (POMP) and the treatment of mild endoscopic recurrence remain controversial.

METHODS

This study is a retrospective review of patients undergoing a primary ileocolic resection for CD at a single academic center. Endoscopic recurrence (ER) was defined using the Rutgeerts score (RS), and clinical recurrence (CR) was defined as symptoms of CD with endoscopic or radiologic evidence of neo-terminal ileal disease.

RESULTS

There were 171 patients who met inclusion criteria. The cumulative probability of ER (RS ≥ i-1) at 1, 2, and 5 years was 29, 51, and 77 %, respectively. The only independent predictors of ER were the absence of POMP (HR 1.50; P = 0.03) and penetrating disease behavior (HR 1.50; P = 0.05). The cumulative probability of CR at 1, 2, and 5 years was 8, 13, and 27 %, respectively. There was a higher rate of clinical recurrence in patients with RS-2 compared to RS-1 on the initial postoperative endoscopy (HR 2.50; P = 0.02). In 11 patients not exposed to POMP with i-1 on initial endoscopy, only 2 patients (18 %) progressed endoscopically during the study period while 5 patients (45 %) regressed to i-0 on subsequent endoscopy without treatment.

CONCLUSIONS

Postoperative medical prophylaxis decreased the likelihood of ER while certain phenotypes of CD appear to increase the risk of developing ER and CR. There may be a role for watchful waiting in patients with mild endoscopic recurrence on the initial postoperative endoscopy.

Feasibility study of a telehealth delivered, psychoeducational support group for allogeneic hematopoietic stem cell transplant patients

OBJECTIVE

This study investigates the feasibility and efficacy of a telehealth delivered psychoeducational support group for allogeneic hematopoietic stem cell transplant (AHSCT) survivors.

METHODS

All AHSCT survivors 0-3 years post-transplant from the Tom Baker Cancer Centre, Calgary, Alta., Canada were contacted over a 4-year period and invited to participate. Groups were led by trained facilitators and the didactic content included many of the concerns commonly reported by AHSCT survivors. Participants met with facilitators and other group members via videoconferencing equipment located at various community health centres across Alberta, British Columbia, and Saskatchewan.

RESULTS

Of the 19 AHSCT survivors who chose to participate, 74% attended five or more of the six sessions and 100% stated that they were satisfied with the program. The groups were found to be feasible and well liked by all participants. While participants appeared to have gained a greater appreciation of life, they did not demonstrate any significant improvements in quality of life, spirituality and meaning making, distress, or positive growth as measured by the questionnaires in the pre/post-package.

CONCLUSIONS

Attendance and satisfaction ratings suggest that participants gleaned some benefit from participation. Psychoeducational support groups via videoconferencing may provide a viable alternative for those with limited access to psychosocial support. Clearly, more rigorous research is required to determine the utility of these psychoeducational support groups.

Operating from the other side of the table: control dynamics and the surgeon educator

BACKGROUND

Critical moments in operations cause the surgeon to transition from a relatively "automatic" mode of operating to a more attentive mode-previously referred to as "slowing down when you should." Using this framework, this study explored how academic surgeons manage and balance the often competing responsibilities of patient safety and education during the slowing-down moments.

STUDY DESIGN

This study used a constructivist approach to grounded theory methodology to explore an emergent theme of control among academic surgeons. Twenty-eight surgeons were interviewed across 4 academic teaching hospitals, and 5 general (hepato-pancreatico-biliary) surgeons were observed. Thematic analysis of the transcripts and field notes was conducted and iteratively elaborated and refined as data collection progressed with all team members. A reflexive approach was adopted throughout.

RESULTS

An interesting control dynamic emerged as surgeons discussed the need to maintain a sense of control of an operation regardless of how much manual control they had. A dual responsibility to education and patient safety was apparent, with surgeons describing and demonstrating numerous strategies for negotiating manual control with the trainee during the critical slowing-down moments. An assessment of the trainee was implicit in the negotiation process. Numerous complications of control were identified ("bargaining," "skidding") as a product of this control dynamic.

CONCLUSIONS

Operating from the "other side of the table" sets up a control dynamic that requires manipulation and negotiation on the part of the academic surgeon. Understanding these issues informs surgeons in their supervisory role, offering avenues for optimizing surgical training.

Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial

OBJECTIVE

Surgical skills laboratories have become an important venue for early skill acquisition. The principles that govern training in this novel educational environment remain largely unknown; the commonest method of training, especially for continuing medical education (CME), is a single multihour event. This study addresses the impact of an alternative method, where learning is distributed over a number of training sessions. The acquisition and transfer of a new skill to a life-like model is assessed.

METHODS

Thirty-eight junior surgical residents, randomly assigned to either massed (1 day) or distributed (weekly) practice regimens, were taught a new skill (microvascular anastomosis). Each group spent the same amount of time in practice. Performance was assessed pretraining, immediately post-training, and 1 month post-training. The ultimate test of anastomotic skill was assessed with a transfer test to a live, anesthetized rat. Previously validated computer-based and expert-based outcome measures were used. In addition, clinically relevant outcomes were assessed.

RESULTS

Both groups showed immediate improvement in performance, but the distributed group performed significantly better on the retention test in most outcome measures (time, number of hand movements, and expert global ratings; all P values <0.05). The distributed group also outperformed the massed group on the live rat anastomosis in all expert-based measures (global ratings, checklist score, final product analysis, competency for OR; all P values <0.05).

CONCLUSIONS

Our current model of training surgical skills using short courses (for both CME and structured residency curricula) may be suboptimal. Residents retain and transfer skills better if taught in a distributed manner. Despite the greater logistical challenge, we need to restructure training schedules to allow for distributed practice.

Control of laparoscopic instrument motion in an inanimate bench model: implications for the training and evaluation of technical skills

Laparoscopic surgery requires new methods of technical competency evaluation, as well as training. The first purpose was to assess the differences in motion characteristics between the tip of the instrument and the wrist. The second purpose was to determine whether similar control strategies are used to move instruments in virtual reality and bench model environments. Surgically naive participants were required to tap a laparoscopic instrument between two targets that differed in size and separation distance. Large amplitude movements were controlled with the movements of the wrist and small amplitude with the wrist and the fingers (p<.001). Participants utilized the flexibility of the skin of the laparoscopic trainer to facilitate their movements. These results suggest that monitoring the motions of the instrument tip is a more precise indication of its motions than are motions of the wrist when movements of small amplitudes are produced. Moreover, in order to increase fidelity, VR trainers should simulate the flexibility of the real structures around the insertion of the instrument.

Structural flexibility of laparoscopic instruments: implication for the design of virtual reality simulators

In accordance with the Practice Specificity Theory, training on models that closely resemble real life scenarios is most beneficial to learning. Research in the virtual reality (VR) simulation, as a potential teaching and evaluation tool, concentrated on the design of trainers to resemble operating room (OR) conditions. The purpose of the present investigation was to determine the structural flexibility of laparoscopic instruments of different materials and diameters under a wide range of stresses. Incorporating the mechanical properties of these instruments into the algorithms can prove to further increase the fidelity of VR simulators. The amount of deviation from pre-stress position in the instruments' shaft was measured with infrared markers and used as the index of structural flexibility. All instruments deviated considerably with the largest deviations observed for the small disposable, and lowest for the large reusable instruments. There was a linear relation between the stress and deviation for all instruments, which varied as a function of diameter. Similar instrument deviations were observed during cholecystectomy performed on porcine liver. Our findings show that laparoscopic instruments are not rigid bodies and are prone to significant deviations during standard laparoscopic procedures. This suggests that the structural flexibility of laparoscopic instruments should be modeled in the design of VR simulators.