Learning inguinal hernia repair? A survey of current practice and of preferred methods of surgical residents

Purpose: During surgical residency, many learning methods are available to learn an inguinal hernia repair (IHR). This study aimed to investigate which learning methods are most commonly used and which are perceived as most important by surgical residents for open and endoscopic IHR. Methods: European general surgery residents were invited to participate in a 9-item web-based survey that inquired which of the learning methods were used (checking one or more of 13 options) and what their perceived importance was on a 5-point Likert scale (1 = completely not important to 5 = very important). Results: In total, 323 residents participated. The five most commonly used learning methods for open and endoscopic IHR were apprenticeship style learning in the operation room (OR) (98% and 96%, respectively), textbooks (67% and 49%, respectively), lectures (50% and 44%, respectively), video-demonstrations (53% and 66%, respectively) and journal articles (54% and 54%, respectively). The three most important learning methods for the open and endoscopic IHR were participation in the OR [5.00 (5.00–5.00) and 5.00 (5.00–5.00), respectively], video-demonstrations [4.00 (4.00–5.00) and 4.00 (4.00–5.00), respectively], and hands-on hernia courses [4.00 (4.00–5.00) and 4.00 (4.00–5.00), respectively]. Conclusion: This study demonstrated a discrepancy between learning methods that are currently used by surgical residents to learn the open and endoscopic IHR and preferred learning methods. There is a need for more emphasis on practising before entering the OR. This would support surgical residents’ training by first observing, then practising and finally performing the surgery in the OR

Optimization of treatment strategies and prognostication for patients with esophageal cancer

In dit proefschrift staan klinische onderzoeksvragen centraal die betrekking hebben op slokdarmkanker. Op het moment van diagnose is bij 40% van de patiënten sprake van lokaal gevorderde ziekte (d.w.z. uitbreiding van de tumor door de slokdarmwand en / of uitzaaiingen in omliggende lymfeklieren). De focus van dit proefschrift ligt op deze groep patiënten, die momenteel een combinatiebehandeling van bestraling, chemotherapie en chirurgie wordt aangeboden. Deel I belicht onderwerpen die verband houden met de fase tussen vaststelling van de slokdarmtumor en de uiteindelijke chirurgische behandeling. In deze fase zijn diagnostiek en voorbehandeling cruciale thema’s. Zo wordt geconcludeerd dat een PET-CT scan onmisbaar is om na de voorbehandeling (bestraling en chemotherapie) uit te sluiten dat patiënten uitzaaiingen in andere organen hebben, hetgeen een reden is om van de uiteindelijke slokdarmoperatie af te zien. Daarnaast wordt op basis van een vergelijkende studie gesteld dat een combinatie van bestraling en chemotherapie de voorkeur verdient boven alleen chemotherapie in de voorbehandeling van slokdarmkanker, omdat laatstgenoemde behandeling meer bijwerkingen kent. Een geïntensiveerde versie van deze combinatiebehandeling kan ook tumoren met ingroei in vitale structuren (zoals de luchtpijp of de grote lichaamsslagader) geschikt maken voor chirurgische verwijdering. In deel II van het proefschrift worden nieuwe chirurgische technieken beschreven en worden suggesties gedaan om de nauwkeurigheid te vergroten van de voorspellingen die na de slokdarmoperatie worden gedaan ten aanzien van (ziektevrije) overlevingskansen. De voornaamste conclusie in dit verband is dat niet alleen het aantal lymfeklieruitzaaiingen, maar vooral ook de locatie van deze uitzaaiingen belangrijke voorspellende waarde bevat

Treatment strategies in recurrent esophageal or junctional cancer

Little evidence is available about survival rates in patients with recurrent disease after potentially curative surgery for esophageal or junctional cancer. Only in limited occasions, potentially curative salvage strategies are available. The aim of this study is to analyze survival rates and patterns of dissemination, and to identify independent prognostic factors in a consecutive series of patients who develop recurrent esophageal or junctional cancer. Between 1994 and 2015, patients who developed disease recurrence after neoadjuvant chemo(radio)therapy followed by radical esophagectomy for esophageal or junctional cancer were retrospectively analyzed. The Kaplan- Meier estimates were performed to calculate and compare overall survival between patients with different patterns of dissemination and to compare between different treatment strategies. Furthermore, univariate and multivariate Cox-regression analyses were performed to identify independent prognostic factors for post recurrence survival. In this study, we included 219 patients. The median overall survival of all included patients was 3.2 months (range: 0.0- 101.1 months). The median overall survival in patients with exclusively locoregional recurrence (n = 23, 10.8%) was 4.9 months (range: 0.1- 55.6) and 2.9 months (range: 0.0-101.1) in patients who had distant metastases (n = 189, 89.2%), P = 0.003. Patients who received treatment aimed at complete tumor eradication (n = 28, 13.7%) had a median overall survival of 13.6 months (range: 1.1-101.1) and palliative treated patients (n = 94, 46.1%) of 4.7 months (range: 0.3-25.6), P < 0.001. In a selected group of patients survival of more than 20 months was achieved. Univariate and multivariate Cox-regression analysis showed that a higher age at the diagnosis of recurrent disease (hazard ratio: 1.087, P ≤ 0.001), an irradical resection of the primary tumor (hazard ratio: 3.355, P = < 0.001), the number of positive lymph nodes after neoadjuvant therapy (hazard ratios: ypN2 = 1.724 (P = 0.024) and ypN3 = 2.082 (P = 0.028) and the presence of a single hematogenous distant metastases (hazard ratio: 2.281, P = 0.003) or more than one hematogenous distant metastasis (hazard ratio: 2.385, P = 0.005) were associated with a shorter postrecurrence survival. The prognosis of patients who develop recurrent esophageal or junctional cancer is poor. In a selected group of patients however relatively long survival can be achieved. This offers new perspectives to improve treatment strategies and survival rates