Saliva stress biomarkers in ERCP trainees before and after familiarisation with ERCP on a virtual simulator

BackgroundStress during the early ERCP learning curve may interfere with acquisition of skills during training. The purpose of this study was to compare stress biomarkers in the saliva of trainees before and after familiarisation with ERCP exercises on a virtual simulator.MethodsAltogether 26 endoscopists under training, 14 women and 12 men, completed the three phases of this study: Phase 1. Three different ERCP procedures were performed on the simulator. Saliva for α-amylase (sAA), Chromogranin A (sCgA), and Cortisol (sC) were collected before (baseline), halfway through the exercise (ex.), and 10 min after completion of the exercise (comp.); Phase 2. A three-week familiarisation period where at least 30 different cases were performed on the virtual ERCP simulator; and Phase 3. Identical to Phase 1 where saliva samples were once again collected at baseline, during, and after the exercise. Percentage differences in biomarker levels between baseline and exercise (Diffex) and between baseline and completion (Diffcomp) during Phase 1 and Phase 3 were calculated for each stress marker.ResultsMean % changes, Diffex and Diffcomp, were significantly positive (p < 0.05) for all markers in both Phase 1 and Phase 3. Diffex in Phase 1 was significantly greater than Diffex in Phase 3 (p < 0.05) for sAA and sCgA. Diffcomp for sAA in Phase 1 was significantly greater than Diffcomp in Phase 3 (p < 0.05). No significant differences were found in sC concentration between Phases 1 and 3.ConclusionThis study shows that familiarisation with the ERCP simulator greatly reduced stress as measured by the three saliva stress biomarkers used with sAA being the best. It also suggests that familiarisation with an ERCP simulator might reduce stress in the clinical setting

Validity of a virtual reality endoscopic retrograde cholangiopancreatography simulator: can it distinguish experts from novices?

BackgroundThere is a lack of evidence regarding the effectiveness of virtual simulators as a means to acquire hands-on exposure to endoscopic retrograde cholangiopancreatography (ERCP). The present study aimed to assess the outcome and construct validity of virtual ERCP when training on the GI II Mentor simulator.MethodsA group of seven experienced endoscopists were compared with 31 novices. After a short introduction, they were requested to carry out three virtual ERCP procedures: diagnosing and removing a common bile duct (CBD) stone; diagnosing and taking brush cytology from a hilar stenosis; and, finally, diagnosing and treating a cystic leakage with a BD stent. For each task, the total time required to complete the task, time required to correctly view the papilla, total time of irradiation, time to deep cannulation, time to define diagnosis, time to complete sphincterotomy, and time to complete the respective intervention were measured. Cannulation of the BD, correct diagnosis, sphincterotomy, and time to complete intervention were assessed by an assessor blinded to the status of the endoscopist who performed the virtual ERCP.ResultsThe time required to visualize the papilla and to cannulate deeply when removing the BD stone was significantly shorter for the experts (both p < 0.05). The time to visualize the papilla, cannulate deeply, reach a diagnosis, complete sphincterotomy, and complete the intervention was significantly shorter for the experts when managing cystic leakage (all p < 0.05). In diagnosing and taking brush cytology from a hilar stenosis, there was only a trend toward the experts needing less time for the deep cannulation of the BD (p = 0.077).ConclusionThe performance differed between experts and novices, especially in the management of cystic leakage. This corroborates the construct validity of the GI II Mentor simulator

Timing of elective cholecystectomy after acute cholecystitis : a population-based register study

Background: Acute cholecystectomy is standard treatment for acute cholecystitis. However, many patients are still treated conservatively and undergo delayed elective surgery. The aim of this study was to determine the ideal time to perform an elective cholecystectomy after acute cholecystitis. Methods: All patients treated for acute cholecystitis in Sweden between 2006 and 2013 were identified through the Swedish Patient Register. This cohort was cross-linked with the Swedish Register for Gallstone Surgery, GallRiks, where information on surgical outcome was retrieved. The impact of the time interval after discharge from hospital to elective surgery was analysed by multivariate logistic regression adjusting for gender and age. Results: After exclusion of patients not subjected to surgery, not registered in GallRiks and patients treated with acute cholecystectomy, 8532 remained. This cohort was divided into six-time categories. Using the first time interval < 11 days from discharge to elective surgery as the reference category the chance of completing surgery with a minimally invasive technique was increased for all categories (p < 0.05). The risk for perioperative complication and cystic duct leakage was reduced if surgery was undertaken > 30 days after discharge (both p < 0.05). The risk for bile duct injury was significantly increased if the procedure was undertaken > 365 days after discharge (p = 0.030). The chance of completing the procedure within 100 min was not affected by time. Conclusion: For patients undergoing elective cholecystectomy after acute cholecystitis, the safety of the procedure increases if surgery is performed more than 30 days after discharge from the primary admission

Antibiotic prophylaxis and its effect on postprocedural adverse events in endoscopic retrograde cholangiopancreatography for primary sclerosing cholangitis

Background and Aim: Primary sclerosing cholangitis (PSC) is characterized by multiple strictures of the biliary tree. Patients with PSC frequently require repeated endoscopic retrograde cholangiopancreatography (ERCP) procedures. These procedures are encumbered by an increased incidence of infectious adverse events such as cholangitis. Evidence regarding whether antibiotic prophylaxis (AP) should be administered is sparse; however, prophylaxis is recommended. We aimed to determine whether AP affects the rate of postprocedural infectious and overall adverse events. Methods: We conducted a retrospective cohort study and extracted all ERCP procedures with indicated PSC performed between 1 January 2006 and 31 December 2019, which were registered in the Swedish Registry for Gallstone Surgery and ERCP (GallRiks). The exclusion criteria were incomplete 30-day follow-up, non-index procedures, or ongoing antibiotics. The main outcomes were postprocedural infectious adverse events and overall adverse events at the 30-day follow-up. Results: A total of 2144 procedures with indication of PSC were eligible for inclusion. AP was administered in 1407 (66%) of these procedures. Patients receiving AP were slightly younger (44 vs 46 years, P = 0.005) and had more comorbidities (ASA ≥3, 19.8% vs 13.6%; P < 0.001). Procedures with AP demonstrated an infectious adverse event rate of 3.3% compared to 4.5% for non-AP procedures (P = 0.19). Postprocedural infectious adverse events (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.48–1.21) and overall adverse events (OR 0.79, 95% CI 0.60–1.04) did not differ between AP and non-AP. Conclusion: Patients with PSC who undergo ERCP have the same frequency of adverse events regardless of whether AP was used

Bile leakage and the number of metal clips on the cystic duct during laparoscopic cholecystectomy

Background and objective: The most common way of closing the cystic duct in laparoscopic cholecystectomy is by using metal clips (>80%). Nevertheless, bile leakage occurs in 0.4%–2.0% of cases, and thus causes significant morbidity. However, the optimal number of clips needed to avoid bile leakage has not been determined. The primary aim of this study was to evaluate bile leakage and post-procedural adverse events after laparoscopic cholecystectomy concerning whether two or three clips were used to seal the cystic duct. Methods: Using a retrospective observational design, we gathered data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (ERCP) (GallRiks). From 2006 until 2019, 124,818 patients were eligible for inclusion. These were nested to cohorts of 75,322 (60.3%) for uncomplicated gallstone disease and 49,496 (39.7%) with complicated gallstone disease. The cohorts were grouped by the number (i.e. two or three) of metal clips applied to the proximal cystic duct. The main outcome was 30-day bile leakage and post-procedural adverse events. Results: No significant differences surfaced in the rate of bile leakage (0.8% vs 0.8%; P =.87) or post-procedural adverse events (three clips, 5.7% vs two clips, 5.4%; P =.16) for uncomplicated gallstone disease. However, for complicated disease, bile leakage (1.4% vs 1.0%; P <.001) and post-procedural adverse events (10.2% vs 8.6%; P <.001) significantly increased when the cystic duct was sealed with three clips compared with two. Conclusions: Because no differences in the rates of bile leakage or adverse events emerged in uncomplicated gallstone disease when a third clip was applied, a third clip for additional safety is not recommended in such cases. On the contrary, bile leakage and adverse events increased when a third clip was used in patients with complicated gallstone disease. This finding probably indicates a more difficult cholecystectomy rather than being caused by the third clip itself

Baseline characteristics in laparoscopic simulator performance: The impact of personal computer (PC)-gaming experience and visuospatial ability

Background: Learning via simulators is under constant development, and it is important to further optimize simulator training curricula. This study investigates the impact of personal computer-gaming experience, visuospatial skills, and repetitive training on laparoscopic simulator performance and specifically on the constituent parameters of the simulator score. Methods: Forty-sevenmedical students completed 3 consecutive-Minimally Invasive Surgical Trainer-Virtual Reality simulator trials. Previously, they performed a visuospatial test and completed a questionnaire regarding baseline characteristics and personal computer-gaming experience. Linear regression was used to analyze the relationship between simulator performance and type of personal computer-gaming experience and visuospatial ability. Results: During the first 2 Minimally Invasive Surgical Trainer-Virtual Reality simulation tasks, there was an association between personal computer-gaming experience and the coordination parameters of the score (eg, EconDiath task 1: P=.0047; EconDiath task 2: P=.0102; EconDiath task 3: P=.0836). The type of game category played seemed to have an impact on the coordination parameters (eg, EconDiath task 1-3 for sport games versus no-sport games: P=.01, P=.0013, and P=.01, respectively). In the first-Minimally Invasive Surgical Trainer task, visuospatial ability correlated with Minimally Invasive Surgical Trainer simulator performance but was abolished with repetitive training (overall Minimally Invasive Surgical Trainer score task 1-3: P = .0122, P = .0991, and P = .3506, respectively). Sex-specific differences were noted initially but were abolished with training. Conclusion: Sport games versus no-sport games demonstrated a significantly better Minimally Invasive Surgical Trainer performance. Furthermore, repetitive laparoscopic simulator training may compensate for a previous lack of personal computer-gaming experience, low visuospatial ability, and sex differences.(C) 2020 Published by Elsevier Inc

Tele-mentoring - a way to expand laparoscopic simulator training for medical students over large distances : a prospective randomized pilot study

BACKGROUND: Studies have shown the clinical benefits of laparoscopic simulator training. Decreasing numbers of operations by surgical residents have further increased the need for surgical simulator training. However, many surgical simulators in Sweden are often insufficiently used or not used at all. Furthermore, large geographical distances make access to curriculum-based surgical simulator training at established simulator centres difficult. The aim of this study was to evaluate whether tele-mentoring (TM) could be well tolerated and improve basic laparoscopic surgical skills of medical students 900 km away from the teacher. METHODS: Twenty students completed an informed consent and a pre-experimental questionnaire. The students were randomized into two groups: (1) TM (N = 10), receiving instructor feedback via video-link and (2) control group (CG, N = 10) with lone practice. Initial warm-up occurred in the Simball Box simulator with one Rope Race task followed by five consecutive Rope Race and three Peg Picker tasks. Afterwards, all students completed a second questionnaire. RESULTS: The whole group enjoyed the simulator training (prescore 73.3% versus postscore 89.2%, P &lt; 0.0001). With TM, the simulator Rope Race overall score increased (prescore 30.8% versus postscore 43.4%; P = 0.004), and the distance that the laparoscopic instruments moved decreased by 40% (P = 0.015), indicating better precision, whereas in the CG it did not. In Peg Picker, the overall scores increased, whereas total time and distance of the instruments decreased in both groups, indicating better performance and precision. CONCLUSIONS: Simulation training was highly appreciated overall. The TM group showed better overall performance with increased precision in what we believe to be the visuospatially more demanding Rope Race tasks compared to the CG. We suggest that surgical simulator tele-mentoring over long distances could be a viable way to both motivate and increase laparoscopic basic skills training in the future

Antibiotic prophylaxis in ERCP with failed cannulation

Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) with failed biliary cannulation is associated with a high rate of adverse events, but the role of prophylactic antibiotics remains unclear. The primary aim was to investigate if prophylactically administered antibiotics affect the frequency of overall adverse complications in patients where biliary cannulation fails during ERCP. The secondary aim was to investigate if specific infectious complications, also were affected by the antibiotic prophylaxis. Materials and methods: We analysed data from 96,818 ERCPs (2006–2018), from the Swedish National Quality Registry of Cholecystectomy and ERCP (GallRiks), excluding ERCPs with successful cannulation (n = 88,743), missing data (n = 2,014), or on-going antibiotic therapy (n = 1,062). Results: In total 4,996 procedures were included, 2,124 received (42.5%) and 2,872 (57.5%) did not receive antibiotic prophylaxis. There were fewer overall complications in the group receiving prophylaxis (13.6% vs. 17.1%, p <.001), which corresponded to a 24% adjusted odds reduction in the multivariable analysis (odds ratio [OR] 0.76; 95% confidence interval [CI] 0.65–0.89). In the prophylaxis group, there was a lower overall rate of infectious complications (2.1% vs. 3.2%; p =.038; OR 0.68; 95% CI 0.47–0.98) and abscesses (0.8% vs. 1.4%; p =.040; OR 0.54; 95% CI 0.31–0.96). However, no significant differences were seen in the rate of cholangitis (1.3% vs. 1.7%; p =.182; OR 0.74; 95% CI 0.46–1.18). Conclusion: This national quality registry study of ERCPs with failed cannulation showed a significant reduction in overall and infectious complications when prophylactic antibiotics were administered