Objective metrics for hand-sewn bowel anastomoses can differentiate novice from expert surgeons.

BACKGROUND: Assessing performance automatically in a virtual reality trainer or from recorded videos is advantageous but needs validated objective metrics. The purpose of this study is to obtain expert consensus and validate task-specific metrics developed for assessing performance in double-layered end-to-end anastomosis. MATERIALS AND METHODS: Subjects were recruited into expert (PGY 4-5, colorectal surgery residents, and attendings) and novice (PGY 1-3) groups. Weighted average scores of experts for each metric item, completion time, and the total scores computed using global and task-specific metrics were computed for assessment. RESULTS: A total of 43 expert surgeons rated our task-specific metric items with weighted averages ranging from 3.33 to 4.5 on a 5-point Likert scale. A total of 20 subjects (10 novices and 10 experts) participated in validation study. The novice group completed the task significantly more slowly than the experienced group (37.67 ± 7.09 vs 25.47 ± 7.82 min, p = 0.001). In addition, both the global rating scale (23.47 ± 4.28 vs 28.3 ± 3.85, p = 0.016) and the task-specific metrics showed a significant difference in performance between the two groups (38.77 ± 2.83 vs 42.58 ± 4.56 p = 0.027) following partial least-squares (PLS) regression. Furthermore, PLS regression showed that only two metric items (Stay suture tension and Tool handling) could reliably differentiate the performance between the groups (20.41 ± 2.42 vs 24.28 ± 4.09 vs, p = 0.037). CONCLUSIONS: Our study shows that our task-specific metrics have significant discriminant validity and can be used to evaluate the technical skills for this procedure.

Wait Times for Melanoma Surgery: Is There an Association with Overall Survival?

INTRODUCTION: Wait times for access to care have been of increasing interest to public health care officials, health care providers, and the public. There is a paucity of data determining whether extended wait times for melanoma surgery influence patient outcomes. This study measured the association of wait times to surgical treatment with overall survival in patients with melanoma. METHODS: Population-based health administrative databases were used to identify all Ontario adults diagnosed with melanoma between 2004 and 2011, time to various treatment modalities, and death dates. Proportional hazards modeling using time-dependent covariates was used to determine the adjusted association of time from melanoma diagnosis to various post-diagnostic surgical interventions with overall survival. RESULTS: A total of 2573 patients were included. The 5-year overall survival was 81.1% [95% confidence interval (CI) 79.1-83.0]. Of all patients, 82.9% underwent a wide local excision (WLE) with a median wait time of 43 days [interquartile range (IQR) 24-64], 29.1% underwent a sentinel lymph node biopsy (SNB) with a median wait time of 59 days (IQR 41-81), and 35.0% underwent a lymph node dissection (LND) with a median wait time of 63 days (IQR 43-91). After adjusting for age, sex, rural residence, and risk of mortality from comorbidities, wait times to WLE [hazard ratio (HR) 0.97; 95% CI 0.87-1.08; p = 0.62], SNB [HR 1.04; 95% CI 0.68-1.59; p = 0.86], and LND [HR 0.99; 95% CI 0.89-1.11; p = 0.92] were not associated with overall survival. CONCLUSIONS: Overall survival for patients with melanoma was not influenced by wait times to WLE, SNB, and LND.

Dynamic article: combined endoscopic-laparoscopic surgery for complex colonic polyps: postoperative outcomes and video demonstration of 3 key operative techniques.

BACKGROUND: Combined endoscopic-laparoscopic surgery is a novel technique that can be used to avoid bowel resection for complex colon polyps that are not amenable to colonoscopic resection. OBJECTIVE: The aim of this study was to evaluate the safety and outcomes of combined endoscopic-laparoscopic surgery for complex colonic polyps. DESIGN: This study is a retrospective review of consecutive combined endoscopic-laparoscopic surgeries. SETTING: This study was conducted at a single institution. PATIENTS: All patients that underwent combined endoscopic-laparoscopic surgery for a complex colonic polyp at our center from October 2009 to October 2013 were followed. Each patient's lesion was assessed by a therapeutic endoscopist before referral for combined endoscopic-laparoscopic surgery, and was deemed unresectable based on size, broad base, or location of the polyp. MAIN OUTCOME MEASURES: Intraoperative and postoperative complications, length of hospital stay, and recurrence were the primary outcomes measured. RESULTS: Thirty consecutive patients underwent combined endoscopic-laparoscopic surgery. Twenty (66.7%) patients underwent laparoscopic-assisted colonoscopic polyp excision (10 of these excisions were facilitated by Endoloop placement at the polyp base), 9 (30%) patients underwent colonoscopic-assisted laparoscopic cecectomy, and 1 (3.3%) patient was converted from a colonoscopic-assisted laparoscopic cecectomy to a laparoscopic ileocolic resection. The median length of hospital stay was 2 days (range, 1-16). Twenty-nine (96.7%) of the final pathology results were benign, with 10 (33.3%) showing high-grade dysplasia. One (3.3%) final pathology result was positive for a well-differentiated adenocarcinoma. This patient subsequently underwent a laparoscopic right hemicolectomy and chemotherapy for node-positive disease. One (3.3%) patient experienced a recurrent benign polyp at the previous excision site, which was removed by colonoscopy. The time to detection of recurrence was 274 days. LIMITATIONS: This study looked at a small group of patients, over a short follow-up period. However, all consecutive patients were captured, and there were no losses to follow-up. CONCLUSIONS: Combined endoscopic-laparoscopic surgery for complex benign colonic polyps is a safe procedure, with good clinical outcomes and low recurrence rates.

Expert opinion on laparoscopic surgery for colorectal cancer parallels evidence from a cumulative meta-analysis of randomized controlled trials.

BACKGROUND: This study sought to synthesize survival outcomes from trials of laparoscopic and open colorectal cancer surgery, and to determine whether expert acceptance of this technology in the literature has parallel cumulative survival evidence. STUDY DESIGN: A systematic review of randomized trials was conducted. The primary outcome was survival, and meta-analysis of time-to-event data was conducted. Expert opinion in the literature (published reviews, guidelines, and textbook chapters) on the acceptability of laparoscopic colorectal cancer was graded using a 7-point scale. Pooled survival data were correlated in time with accumulating expert opinion scores. RESULTS: A total of 5,800 citations were screened. Of these, 39 publications pertaining to 23 individual trials were retained. As well, 414 reviews were included (28 guidelines, 30 textbook chapters, 20 systematic reviews, 336 narrative reviews). In total, 5,782 patients were randomized to laparoscopic (n = 3,031) and open (n = 2,751) colorectal surgery. Survival data were presented in 16 publications. Laparoscopic surgery was not inferior to open surgery in terms of overall survival (HR = 0.94, 95% CI 0.80, 1.09). Expert opinion in the literature pertaining to the oncologic acceptability of laparoscopic surgery for colon cancer correlated most closely with the publication of large RCTs in 2002-2004. Although increasingly accepted since 2006, laparoscopic surgery for rectal cancer remained controversial. CONCLUSIONS: Laparoscopic surgery for colon cancer is non-inferior to open surgery in terms of overall survival, and has been so since 2004. The majority expert opinion in the literature has considered these two techniques to be equivalent since 2002-2004. Laparoscopic surgery for rectal cancer has been increasingly accepted since 2006, but remains controversial. Knowledge translation efforts in this field appear to have paralleled the accumulation of clinical trial evidence.