Resolution and recurrence of anemia following repair of paraesophageal hernias.

BACKGROUND: Iron deficiency anemia is a common paraesophageal hernia (PEH) symptom and may improve after repair. When present, anemia has also been proposed to be associated with an increase in length of hospital stay, morbidity, and mortality after PEH repair. This study aimed to determine anemia-related factors in patients with PEH, the rate of anemia resolution after PEH repair, and the risk of anemia recurrence when repair failed. METHODS: We included patients who received a PEH repair between June 2019 and June 2020 and had 24 months of postoperative follow-up. Demographics and comorbidities were recorded. Anemia was defined as pre-operative hemoglobin values < 12.0 for females and < 13.0 for males, or if patients were receiving iron supplementation. Anemia resolution was determined at 6 months post-op. Length of hospital stay, morbidity, and mortality was recorded. Logistic regression and ANCOVA were used for binary and continuous outcomes respectively. RESULTS: Of 394 patients who underwent PEH repair during the study period, 101 (25.6%) had anemia before surgery. Patients with pre-operative anemia had larger hernia sizes (6.55 cm ± 2.77 vs. 4.34 cm ± 2.50; p < 0.001). Of 68 patients with available data by 6 months after surgery, anemia resolved in 36 (52.9%). Hernia recurred in 6 patients (16.7%), 4 of whom also had anemia recurrence (66.7%). Preoperative anemia was associated with a higher length of hospital stay (3.31 days ± 0.54 vs 2.33 days ± 0.19 p = 0.046) and an increased risk of post-operative all-cause mortality (OR 2.7 CI 1.08-6.57 p = 0.05). Fundoplication type (p = 0.166), gastropexy, or mesh was not associated with an increased likelihood of resolution (OR 0.855 CI 0.326-2.243; p = 0.05) (OR 0.440 CI 0.150-1.287; p = 0.05). CONCLUSIONS: Anemia occurs in 1 out of 4 patients with PEH and is more frequent in patients with larger hernias. Anemia is associated with a longer hospital stay and all-cause mortality after surgery. Anemia recurrence coincided with hernia recurrence in roughly two-thirds of patients.

Surgical endoscopy education research: how are we doing?

BACKGROUND: Surgical endoscopy (SE), the official journal of the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association for Endoscopic Surgery, is an important source of new evidence pertaining to surgical education in the field. However, qualitative deficiencies in medical education research have prompted medical education leaders to advocate for increased methodological rigor. The purpose of this study is to review the quality of education-focused research published through SE. METHODS: A PubMed search examining all SE articles categorized as education-related research from 2010 to 2019 was conducted; studies not meeting inclusion criteria were excluded. Remaining publications were independently reviewed, classified, and scored by 7 raters using the medical education research study quality instrument (MERSQI). Intraclass correlation was calculated and data were examined with descriptive statistics. RESULTS: A total of 227 studies met inclusion criteria. There was no significant difference in number of publications by year (average 25.88 [SD 5.6]); 60% were conducted outside of the United States, and 47% (n = 106) were funded. The average MERSQI was 12.5 (SD 2). Most studies used two-group non-random (42%, n = 96) or post/cross-sectional designs (29%, n = 65). Thirty-six (16%) were randomized controlled trials. Multi-institutional studies comprised 24% (n = 54). Of the manuscripts, 96% (n = 217) reported at least one measure of validity evidence and 28% (n = 67) described three levels of validity evidence. Studies primarily reported changes in skills or knowledge (45%, n = 103) or satisfaction or general facts (44%, n = 99), while patient-related outcomes encompassed 3% (n = 6) of studies. ICC between raters was 0.93 (CI 0.90-0.93, p < 0.001). CONCLUSIONS: Based on publications to date, this journal's peer review process appears to facilitate the dissemination of education-related studies of moderate to good quality. However, there were uncovered deficits, ranging from validity evidence to study designs and level of outcomes. This journal's breadth of viewership offers a potential venue to advance education-related research.

Leaders by example: Best practices and advice on establishing a state-of-the art surgical simulation center that optimizes available resources.

BACKGROUND: The role of simulation-based education continues to expand exponentially. To excel in this environment as a surgical simulation leader requires unique knowledge, skills, and abilities that are different from those used in traditional clinically-based education. METHODS: Leaders in surgical simulation were invited to participate as discussants in a pre-conference course offered by the Association for Surgical Education. Highlights from their discussions were recorded. RESULTS: Recommendations were provided on topics such as building a simulation team, preparing for accreditation requirements, what to ask for during early stages of development, identifying tools and resources needed to meet educational goals, expanding surgical simulation programming, and building educational curricula. CONCLUSION: These recommendations provide new leaders in simulation with a unique combination of up-to-date best practices in simulation-based education, as well as valuable advice gained from lessons learned from the personal experiences of national leaders in the field of surgical simulation and education.

Simulated Colonoscopy Objective Performance Evaluation (SCOPE): a non-computer-based tool for assessment of endoscopic skills.

BACKGROUND: The Simulated Colonoscopy Objective Performance Evaluation (SCOPE) was developed to fill the need for a lower-cost, non-virtual-reality (VR)-based assessment tool. This study aimed to evaluate the ability of SCOPE to assess endoscopic skills objectively. METHODS: Four tasks were created using the Kyoto Kagaku colonoscopy model (Kyoto Kagaku Co., Ltd., Kyoto, Japan). The SCOPE tasks included Scope Manipulation (SM) requiring torque and tip deflection to align a shape in the colon with a matching shape on the monitor; Tool Targeting (TT) requiring coordination with biopsy forceps to contact a metal target; Loop Management (LM) requiring prevention, recognition, and reduction of a redundant sigmoid colon with navigation to the cecum; and Mucosal Inspection (MI) requiring identification of simulated polyps during withdrawal and retroflexion. Key performance metrics were identified, and a normalized scoring system was developed. For the study, 35 subjects were stratified into three cohorts based on colonoscopy experience: novice (0-50 colonoscopies; n = 11), intermediate (51-139 colonoscopies; n = 13), and experienced (>140 colonoscopies; n = 11). The subjects performed two trials of all four tasks. RESULTS: Across all four tasks, the experienced endoscopists (E) consistently outperformed the intermediates (I), who in turn outperformed the novices (N). The mean normalized scores with 95 % confidence intervals (CI) are as follows: SM: N (54; range, 26-82), I (92; range, 79-106), E (106; range, 93-118) (p = 0.0006). TT: N (40; range, 24-55), I (77; range, 63-91), E (88; range, 72-105) (p < 0.0001). LM: N (51; range, 24-79), I (80; range, 59-101), E (101; range, 98-105) (p = 0.003). MI: N (73; range, 53-92), I (85; range, 76-95), E (100; range, 91-108) (p = 0.013). Total score: N (218; range, 155-280), I (335; range, 299-371), E (395; range, 371-419) (p < 0.0001). The test-retest reliability (0.6) for the expert total score was respectable. CONCLUSIONS: The validity evidence from this study shows that scores on SCOPE tasks can differentiate between groups expected to have different levels of technical skill. This model shows promise as a low-technology tool for objective assessment or training of endoscopic skills.

Rives-Stoppa incisional hernia repair combined with laparoscopic separation of abdominal wall components: a novel approach to complex abdominal wall closure.

BACKGROUND: The Rives-Stoppa incisional hernia repair is the gold standard for mesh repair of complex incisional hernias. The risk of infection can be reduced if fascia is closed over the prosthetic mesh. Fascial closure in large defects may require extensive dissection and can result in devascularization of the overlying skin and denervation of the abdominal wall musculature. Laparoscopic components separation minimizes these risks while facilitating anterior fascial closure. The combined technique of Rives-Stoppa repair augmented by laparoscopic separation of abdominal wall components has not previously been reported. METHODS: We retrospectively reviewed our initial experience with this combined technique for incisional hernia repair. A Rives-Stoppa incisional hernia repair is performed with mesh placed in the retromuscular position. If the anterior fascia cannot be closed, a laparoscopic separation of abdominal wall components is performed to facilitate fascial closure without creation of skin flaps. RESULTS: Six patients were identified. Three patients developed hernias following laparotomy from severe injuries sustained during combat. The other patients included hernia after esophagectomy, retroperitoneal liposarcoma resection, and complicated diverticulitis. Average defect size was 270 cm(2). Complete primary fascial closure anterior to the mesh was achieved in 66% of the patients. No mortalities occurred and at short term follow-up no incisional hernia recurrences have developed. Early post operative complications included a superficial skin infection not involving mesh and a recurrent enterocutaneous fistula. CONCLUSIONS: The authors conclude that Rives-Stoppa repair augmented by laparoscopic components separation is an innovative method for reconstruction of complex abdominal wall defects. Laparoscopic components separation allows fascial closure to be achieved anterior to the mesh in large incisional hernias, which may reduce wound infection rates.

Assessment of reperfusion following thrombolysis with mean fibrillation and amplitude spectrum area in patients with sustained ventricular fibrillation.

BACKGROUND: Improved microcirculatory reperfusion in patients with ventricular fibrillation (VF) enhances the electrical activity of the fibrillation process and increases the likelihood of successful defibrillation. METHODS: Changes in amplitude spectrum area (AMSA) and mean fibrillation (MF) in patients with sustained VF were analysed after administration of rt-PA variant tenecteplase in out-of-hospital cardiac arrest (OHCA) during cardiopulmonary resuscitation (CPR). RESULTS: A total of 69 ECG sequences from nine patients were evaluated. Patients who received tenecteplase showed significantly longer duration of VF (p = 0.016). While AMSA declined significantly during CPR (p = 0.001), MF did not differ between groups. There were two survivors in the treatment group and one in the control group. CONCLUSION: When tenecteplase was administered during CPR, VF lasted significantly longer than in controls. Changes in MF and AMSA did not indicate improved myocardial perfusion in patients who received tenecteplase during CPR.

Concurrent validity of augmented reality metrics applied to the fundamentals of laparoscopic surgery (FLS).

OBJECTIVE: Current skills assessment in the Fundamentals of Laparoscopic Surgery (FLS) program is labor intensive, requiring one proctor for every 1-2 subjects. The ProMIS Augmented Reality (AR) simulator (Haptica, Dublin IR) allows for objective assessment of physical tasks through instrument tracking technology. We hypothesized that the ProMIS metrics could differentiate between ability groups as well as standard FLS scoring with fewer personnel requirements METHODS: We recruited 60 volunteer subjects. Subjects were stratified based on their laparoscopic surgical experience. Those who had performed more than 100 laparoscopic procedures were considered experienced (n = 8). Those with fewer than 10 laparoscopic procedures were considered novices (n = 44). The rest were intermediates (n = 8). All subjects performed up to five trials of the peg transfer task from FLS in the ProMIS simulator. The FLS score, instrument path length, and instrument smoothness assessment were generated for each trial. RESULTS: For each of the five trials, experienced surgeons outperformed intermediates, who in turn outperformed novices. Statistically significant differences were seen between the groups across all trials for FLS score (p < 0.001), ProMIS path length (p < 0.001), and ProMIS smoothness (p < 0.001). When the FLS score was compared to the path length and smoothness metrics, a strong relationship between the scores was apparent for novices (r = 0.78, r = 0.94, p < 0.001) respectively), intermediates (r = 0.5, p = 0.2, r = 0.98, p < 0.001), and experienced surgeons (r = 0.86, p = 0.006, r = 0.99, p < 0.001). CONCLUSIONS: The construct that the standard scoring of the FLS peg transfer task can discriminate between experienced, intermediate, and novice surgeons is validated. The same construct is valid when the task is assessed using the metrics of the ProMIS. The high correlation between these scores establishes the concurrent validity of the ProMIS metrics. The use of AR for objective assessment of FLS tasks could reduce the personnel requirements of assessing these skills while maintaining the objectivity.

Attempted establishment of proficiency levels for laparoscopic performance on a national scale using simulation: the results from the 2004 SAGES Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) learning center study.

BACKGROUND: The Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) has been well validated as a training device for laparoscopic skills. It has been demonstrated that training to a level of proficiency on the simulator significantly improves operating room performance of laparoscopic cholecystectomy. The purpose of this project was to obtain a national standard of proficiency using the MIST-VR based on the performance of experienced laparoscopic surgeons. METHODS: Surgeons attending the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) 2004 Annual Scientific Meeting who had performed more than 100 laparoscopic procedures volunteered to participate. All the subjects completed a demographic questionnaire assessing laparoscopic and MIST-VR experience in the learning center of the SAGES 2004 meeting. Each subject performed two consecutive trials of the MIST-VR Core Skills 1 program at the medium setting. Each trial involved six basic tasks of increasing difficulty: acquire place (AP), transfer place (TP), traversal (TV), withdrawal insert (WI), diathermy task (DT), and manipulate diathermy (MD). Trial 1 was considered a "warm-up," and trial 2 functioned as the test trial proper. Subject performance was scored for time, errors, and economy of instrument movement for each task, and a cumulative total score was calculated. RESULTS: Trial 2 data are expressed as mean time in seconds in Table 2. CONCLUSION: Proficiency levels for laparoscopic skills have now been established on a national scale by experienced laparoscopic surgeons using the MIST-VR simulator. Residency programs, training centers, and practicing surgeons can now use these data as guidelines for performance criterion during MIST-VR skills training.

Objective assessment of visuospatial and psychomotor ability and flow of residents and senior endoscopists in simulated gastroscopy.

BACKGROUND: Advanced medical simulators have predominantly been used to shorten the learning curve of endoscopy for medical students and young residents. Rarely have the effects of visuospatial ability and attitudes of intermediately experienced and experienced specialists been studied with regard to simulator training. The aim of this study was to assess the effects of visuospatial ability and attitude on performance in simulator training. METHODS: Eighteen surgical residents were included in the study. Prior to the simulated gastroscopy task, they performed a visuospatial test (the card rotation test). After the simulated gastroscopy task, they completed a questionnaire regarding flow experiences. Their results were compared with those of 11 expert endoscopists who performed the same tests. RESULTS: Total gastroscopy time was significantly shorter for the expert endoscopists compared to residents (2 min 11 sec, p = 0.003). There was also a trend of more mucosa inspected (p = 0.088) and higher efficiency of screening (p = 0.069) by the experts. The residents made fewer errors in the card rotation test than the expert endoscopists (2.5 +/- 0.8 vs 5.5 +/- 1.2, respectively; p = 0.034), and their visuospatial card rotation test results correlated better with their performance in the simulated gastroscopy. CONCLUSIONS: A virtual gastroscopy task presents more of an emotional as well as a psychomotoric challenge to intermediately experienced endoscopists than to senior experts. Our study demonstrates that these differences can be objectively assessed by the use of visuospatial ability tests, flowsheets, and an endoscopic simulator.

Correlation between perceptual, visuo-spatial, and psychomotor aptitude to duration of training required to reach performance goals on the MIST-VR surgical simulator.

Given the dynamic nature of modern surgical education, determining factors that may improve the efficiency of laparoscopic training is warranted. The objective of this study was to analyze whether perceptual, visuo-spatial, or psychomotor aptitude are related to the amount of training required to reach specific performance-based goals on a virtual reality surgical simulator. Sixteen MS4 medical students participated in an elective skills course intended to train laparoscopic skills. All were tested for perceptual, visuo-spatial, and psychomotor aptitude using previously validated psychological tests. Training involved as many instructor-guided 1-hour sessions as needed to reach performance goals on a custom designed MIST-VR manipulation-diathermy task (Mentice AB, Gothenberg, Sweden). Thirteen subjects reached performance goals by the end of the course. Two were excluded from analysis due to previous experience with the MIST-VR (total n = 11). Perceptual ability (r = -0.76, P = 0.007) and psychomotor skills (r = 0.62, P = 0.04) significantly correlated with the number of trials required. Visuo-spatial ability did not significantly correlate with training duration. The number of trials required to train subjects to performance goals on the MIST-VR manipulation diathermy task is significantly related to perceptual and psychomotor aptitude.

Laparoscopic palliative surgery for complicated colorectal cancer.

BACKGROUND: The aim of this study was to evaluate the feasibility and outcomes of the laparoscopic approach for the palliation of advanced complicated colorectal cancer (CRC). METHODS: We reviewed 21 laparoscopic palliative procedures for emergent complications of advanced CRC between 1994 and 2002. Intraoperative complications, estimated blood loss, transfusions, operative times, time to first bowel movement, length of hospital stay, and postoperative complications were assessed. RESULTS: Indications for surgery included perforation (n = 10), bleeding (n = 7), and obstruction (n = 4). A proximal diverting procedure was performed in all patients, and a concomitant colon resection was performed in 18 patients (86%). The mean operative time was 181 +/- 22 min. Estimated blood loss was 283 +/- 48 cc, with three patients (14%) requiring transfusions. The average length of hospital stay was 8.6 +/- 2 days, and time to first bowel movement was 61 +/- 9 h. The complication rate and the 30-day mortality rate were 33% and 0%, respectively. CONCLUSION: A laparoscopic approach to address advanced CRC is safe and effective and should be considered part of the surgeon's armamentarium for the palliation of advanced complicated CRC.

An improved film cassette for scoliosis radiography.

An improved film cassette for scoliosis radiography was constructed by joining two smaller cassettes for use with two 35 x 35-cm radiographic films. The new cassette has five advantages over previous scoliosis cassettes: a) lighter weight for easier handling, b) better film-screen contact, c) easier marking for patient identification, d) easier film loading and unloading, and e) lower film cost.

Use of a gradient intensifying screen for scoliosis radiography.

A gradient intensifying screen composed of rare earth phosphors and calcium tungstate was developed. It provides uniform film density when there is a graded increase in subject density. Use of this screen for scoliosis radiography provides an improved image and reduces radiation exposure.