Influence of thoracic epidural analgesia on postoperative pain relief and ileus after laparoscopic colorectal resection: Benefit with epidural analgesia

Background: Thoracic epidural analgesia (TEA) provides superior analgesia with a lower incidence of postoperative ileus when compared with systemic opiate analgesia in open colorectal surgery. However, in laparoscopic colorectal surgery the role of TEA is not well defined. This prospective observational study investigates the influence of TEA in laparoscopic colorectal resections. Methods: All patients undergoing colorectal resection between November 2004 and February 2007 were assessed for inclusion into a prospective randomized trial investigating the influence of bisacodyl on postoperative ileus. All patients treated by laparoscopic resection from this collective were eligible for the present study. Primary endpoints were use of analgesics and visual analogue scale (VAS) pain scores. Secondary endpoint concerned full gastrointestinal recovery, defined as the mean time to the occurrence of the following three events (GI-3): first flatus passed, first defecation, and first solid food tolerated. Results: 75 patients underwent laparoscopic colorectal resection, 39 in the TEA group and 36 in the non-TEA group. Patients with TEA required significantly less analgesics (metamizol median 3.0g [0-32g] versus 13.8g [0-28g] (p<0.001); opioids mean 12mg [±2.8mg standard error of mean, SEM] versus 103mg [±18.2mg SEM] (p<0.001). VAS scores were significantly lower in the TEA group (overall mean 1.67 [± 0.2 SEM] versus 2.58 [±0.2 SEM]; p=0.004). Mean time to gastrointestinal recovery (GI-3) was significantly shorter (2.96 [±0.2 SEM] days versus 3.81 [±0.3 SEM] days; p=0.025). Analysis of the subgroup of patients with laparoscopically completed resections showed corresponding results. Conclusion: TEA provides a significant benefit in terms of less analgesic consumption, better postoperative pain relief, and faster recovery of gastrointestinal function in patients undergoing laparoscopic colorectal resectio

Short-term Clinical Outcomes of a European Training Programme for Robotic Colorectal Surgery

Background Despite there being a considerable amount of published studies on robotic colorectal surgery (RCS) over the last few years, there is a lack of evidence regarding RCS training pathways. This study examines the short-term clinical outcomes of an international RCS training programme (the European Academy of Robotic Colorectal Surgery—EARCS). Methods Consecutive cases from 26 European colorectal units who conducted RCS between 2014 and 2018 were included in this study. The baseline characteristics and short-term outcomes of cases performed by EARCS delegates during training were analysed and compared with cases performed by EARCS graduates and proctors. Results Data from 1130 RCS procedures were collected and classified into three cohort groups (323 training, 626 graduates and 181 proctors). The training cases conversion rate was 2.2% and R1 resection rate was 1.5%. The three groups were similar in terms of baseline characteristics with the exception of malignant cases and rectal resections performed. With the exception of operative time, blood loss and hospital stay (training vs. graduate vs. proctor: operative time 302, 265, 255 min, p < 0.001; blood loss 50, 50, 30 ml, p < 0.001; hospital stay 7, 6, 6 days, p = 0.003), all remaining short-term outcomes (conversion, 30-day reoperation, 30-day readmission, 30-day mortality, clinical anastomotic leak, complications, R1 resection and lymph node yield) were comparable between the three groups. Conclusions Colorectal surgeons learning how to perform RCS under the EARCS-structured training pathway can safely achieve short-term clinical outcomes comparable to their trainers and overcome the learning process in a way that minimises patient harm

How can surgical skills in laparoscopic colon surgery be objectively assessed?—a scoping review

BACKGROUND: In laparoscopic colorectal surgery, higher technical skills have been associated with improved patient outcome. With the growing interest in laparoscopic techniques, pressure on surgeons and certifying bodies is mounting to ensure that operative procedures are performed safely and efficiently. The aim of the present review was to comprehensively identify tools for skill assessment in laparoscopic colon surgery and to assess their validity as reported in the literature. METHODS: A systematic search was conducted in EMBASE and PubMed/MEDLINE in May 2021 to identify studies examining technical skills assessment tools in laparoscopic colon surgery. Available information on validity evidence (content, response process, internal structure, relation to other variables, and consequences) was evaluated for all included tools. RESULTS: Fourteen assessment tools were identified, of which most were procedure-specific and video-based. Most tools reported moderate validity evidence. Commonly not reported were rater training, assessment correlation with variables other than training level, and validity reproducibility and reliability in external educational settings. CONCLUSION: The results of this review show that several tools are available for evaluation of laparoscopic colon cancer surgery, but few authors present substantial validity for tool development and use. As we move towards the implementation of new techniques in laparoscopic colon surgery, it is imperative to establish validity before surgical skill assessment tools can be applied to new procedures and settings. Therefore, future studies ought to examine different aspects of tool validity, especially correlation with other variables, such as patient morbidity and pathological reports, which impact patient survival. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00464-021-08914-z

Development of a procedure-specific tool for skill assessment in left- and right-sided laparoscopic complete mesocolic excision

Aim: To (1) develop an assessment tool for laparoscopic complete mesocolic excision (LCME) and (2) report evidence of its content validity. Method: Assessment statements were revealed through (1) semi-structured expert interviews and (2) consensus by the Delphi method, both involving an expert panel of five LCME surgeons. All experts were interviewed and then asked to rate LCME describing statements from 1 (strongly disagree) to 5 (strongly agree). Responses were returned anonymously to the panel until consensus was reached. Statements were directly included as content in the assessment tool if ?60% of the experts responded "agree" or "strongly agree" (ratings 4 and 5), with the remaining responses being "neither agree nor disagree" (rating 3). Interclass correlation coefficient (ICC) was calculated for expert agreement evaluation. All included statements were subsequently reformulated as tool items and approved by the experts. Results: Four Delphi rounds were performed to reach consensus. Disagreement was reported for statements describing instrument handling around pancreas; visualisation of landmarks before inferior mesenteric artery ligation; lymphadenectomy around the inferior mesenteric artery, and division of the terminal ileum and transverse colon. ICC in the last Delphi-round was 0.84. The final tool content included 73 statements, converted to 48 right- and 40 left-sided items for LCME assessment. Conclusion: A procedure-specific, video-based tool, named complete mesocolic excision competency assessment tool (CMECAT), has been developed for LCME skill assessment. In the future, we hope it can facilitate assessment of LCME surgeons, resulting in improved patient outcome after colon cancer surgery

A Multispecialty Evaluation of Thiel Cadavers for Surgical Training

Background: Changes in UK legislation allow for surgical procedures to be performed on cadavers. The aim of this study was to assess Thiel cadavers as high-fidelity simulators and to examine their suitability for surgical training. Methods: Surgeons from various specialties were invited to attend a 1 day dissection workshop using Thiel cadavers. The surgeons completed a baseline questionnaire on cadaveric simulation. At the end of the workshop, they completed a similar questionnaire based on their experience with Thiel cadavers. Comparing the answers in the pre- and post-workshop questionnaires assessed whether using Thiel cadavers had changed the surgeons’ opinions of cadaveric simulation. Results: According to the 27 participants, simulation is important for surgical training and a full-procedure model is beneficial for all levels of training. Currently, there is dissatisfaction with existing models and a need for high-fidelity alternatives. After the workshop, surgeons concluded that Thiel cadavers are suitable for surgical simulation (p = 0.015). Thiel were found to be realistic (p < 0.001) to have reduced odour (p = 0.002) and be more cost-effective (p = 0.003). Ethical constraints were considered to be small. Conclusion: Thiel cadavers are suitable for training in most surgical specialties

Laparoscopic Colorectal Surgery Outcomes Improved After National Training Program (LAPCO) for Specialists in England

OBJECTIVE: To examine the impact of The National Training Programme for Laparoscopic Colorectal Surgery (Lapco) on the rate of laparoscopic surgery and clinical outcomes of cases performed by Lapco surgeons after completion of training.SUMMERY BACKGROUND DATA: Lapco provided competency-based supervised clinical training for specialist colorectal surgeons in England.METHODS: We compared the rate of laparoscopic surgery, mortality and morbidity for colorectal cancer resections by Lapco delegates and non-Lapco surgeons in 3-year periods preceding and following Lapco using difference in differences analysis. The changes in the rate of post-Lapco laparoscopic surgery with the Lapco sign-off competency assessment and in-training global assessment scores were examined using risk-adjusted cumulative sum to determine their predictive clinical validity with predefined competent scores of 3 and 5 respectively.RESULTS: 108 Lapco delegates performed 4586 elective colorectal resections pre-Lapco and 5115 post-Lapco while non-Lapco surgeons performed 72930 matched cases. Lapco delegates had a 37.8% increase in laparoscopic surgery which was greater than non-Lapco surgeons by 20.9% (95% CI, 18.5 to 23.3, p [less than] 0.001) with a relative decrease in 30-day mortality by -1.6% (95% CI, -3.4 to -0.2, p = 0.039) and 90-day mortality by -2.3% (95% CI, -4.3 to -0.4, p = 0.018). The change point of risk-adjusted cumulative sum was 3.12 for competency assessment tool and 4.74 for global assessment score whereas laparoscopic rate increased from 44% to 66% and 40% to 56% respectively.CONCLUSIONS: Lapco increased the rate of laparoscopic colorectal cancer surgery and reduced mortality and morbidity in England. In-training competency assessment tools predicted clinical performance after training

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Proficiency gain and competency assessment in laparoscopic colorectal surgery

Aims and objectives: The aim of this thesis was to investigate the proficiency gain curve and competency in laparoscopic colorectal surgery (LCS) for specialist colorectal surgeons. The objectives were (1) to analyse the shortfalls of proficiency gain curve analysis in LCS, (2) to develop methods to describe proficiency gain and competency in LCS and (3) to analyse proficiency gain and competency within the National Training Programme (NTP). Methods: Objective 1: Two systematic reviews and a meta-analysis of current evidence were performed. Objective 2: Semi-structured interviews and a Delphi method were applied to develop proficiency and competency assessment tools and clinical cases were used for validation. A novel observational clinical human reliability analysis (OCHRA) of clinical cases was developed and evaluated. Objective 3: clinical and educational data from the National Training Programme were used for the analysis of proficiency gain and competency using advanced statistical methods. Results: Using clinical data alone is insufficient for the description of proficiency gain and competency. A generic assessment scale (GAS form) and a competency assessment tool (CAT) were developed and validated. A combination of CAT and OCHRA has been shown to be highly sensitive and specific to determine competency. Analysis of clinical and educational data revealed a shortening of the proficiency gain curve using the approach of the NTP without the risk of increased rates adverse outcomes. Conclusion: Tools for proficiency gain and competency assessment of specialist surgeons have been shown to be valid and feasible and are fully implemented in the NTP. Data suggest that a novel technique can be introduced to specialists on a National level using a structured educational approach with safe clinical outcomes

Proficiency gain and competency assessment in laparoscopic colorectal surgery

Aims and objectives: The aim of this thesis was to investigate the proficiency gain curve and competency in laparoscopic colorectal surgery (LCS) for specialist colorectal surgeons. The objectives were (1) to analyse the shortfalls of proficiency gain curve analysis in LCS, (2) to develop methods to describe proficiency gain and competency in LCS and (3) to analyse proficiency gain and competency within the National Training Programme (NTP). Methods: Objective 1: Two systematic reviews and a meta-analysis of current evidence were performed. Objective 2: Semi-structured interviews and a Delphi method were applied to develop proficiency and competency assessment tools and clinical cases were used for validation. A novel observational clinical human reliability analysis (OCHRA) of clinical cases was developed and evaluated. Objective 3: clinical and educational data from the National Training Programme were used for the analysis of proficiency gain and competency using advanced statistical methods. Results: Using clinical data alone is insufficient for the description of proficiency gain and competency. A generic assessment scale (GAS form) and a competency assessment tool (CAT) were developed and validated. A combination of CAT and OCHRA has been shown to be highly sensitive and specific to determine competency. Analysis of clinical and educational data revealed a shortening of the proficiency gain curve using the approach of the NTP without the risk of increased rates adverse outcomes. Conclusion: Tools for proficiency gain and competency assessment of specialist surgeons have been shown to be valid and feasible and are fully implemented in the NTP. Data suggest that a novel technique can be introduced to specialists on a National level using a structured educational approach with safe clinical outcomes.EThOS - Electronic Theses Online ServiceGBUnited Kingdo