Assessment of guidelines for bariatric and metabolic surgery: a systematic review and evaluation using appraisal of guidelines for research and evaluation II (AGREE II).

BACKGROUND: In recent years, multiple guidelines on bariatric and metabolic surgery were published, however, their quality remains unknown, leaving providers with uncertainty when using them to make perioperative decisions. This study aims to evaluate the quality of existing guidelines for perioperative bariatric surgery care. METHODS: A comprehensive search of MEDLINE and EMBASE were conducted from January 2010 to October 2022 for bariatric clinical practice guidelines. Guideline evaluation was carried out using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework. RESULTS: The initial search yielded 1483 citations, of which, 26 were included in final analysis. The overall median domain scores for guidelines were: (1) scope and purpose: 87.5% (IQR: 57-94%), (2) stakeholder involvement: 49% (IQR: 40-64%), (3) rigor of development: 42.5% (IQR: 22-68%), (4) clarity of presentation: 85% (IQR: 81-90%), (5) applicability: 6% (IQR: 3-16%), (6) editorial independence: 50% (IQR: 48-67%), (7) overall impressions: 48% (IQR: 33-67%). Only six guidelines achieved an overall score >70%. CONCLUSIONS: Bariatric surgery guidelines effectively outlined their aim and presented recommendations. However, many did not adequately seek patient input, state search criteria, use evidence rating tools, and consider resource implications. Future guidelines should reference the AGREE II framework in study design.

Recommendations for Optimal Endoscopic Localization of Colorectal Neoplasms: A Delphi Consensus of National Experts.

BACKGROUND: Colonoscopy is the standard of care for diagnosis and evaluation of colorectal cancers before surgery. However, varied practices and heterogenous documentation affects communication between endoscopists and operating surgeons, hampering surgical planning. OBJECTIVE: This study aimed to develop recommendations for the use of standardized localization and reporting practices for colorectal lesions identified during lower GI endoscopy. DESIGN: A systematic review of existing endoscopy guidelines and thorough narrative review of the overall endoscopy literature were performed to identify existing practices recommended globally. SETTING: An online Delphi process was used to establish consensus recommendations based on a literature review. PATIENTS: Colorectal surgeons and gastroenterologists from across Canada who had previously demonstrated leadership in endoscopy, managed large endoscopy programs, produced high-impact publications in the field of endoscopy, or participated in the development of endoscopy guidelines were selected to participate. PRIMARY OUTCOME MEASURES: The primary outcomes measured were colorectal lesion localization and documentation practice recommendations important to planning surgical or advanced endoscopic excisions. RESULTS: A total of 129 of 197 statements achieved consensus after 3 rounds of voting by 23 experts from across Canada. There was more than 90% participation in each round. Recommendations varied according to lesion location in the cecum, colon, or rectum and whether the referral was planned for surgical or advanced endoscopic resection. Recommendations were provided for appropriate documentation, indications, location, and method of tattoo placement, in addition to photograph and real-time 3-dimensional scope configuration device use. LIMITATIONS: Because of a paucity of evidence, recommendations are based primarily on expert opinion. There may be bias, as all representatives were based in Canada. CONCLUSIONS: Best practices to optimize endoscopic lesion localization and communication are not addressed in previous guidelines. This consensus involving national experts in colorectal surgery and gastroenterology provides a framework for efficient and effective colorectal lesion localization. See Video Abstract at http://links.lww.com/DCR/C71 . RECOMENDACIONES PARA LA LOCALIZACIN ENDOSCPICA PTIMA DE LAS NEOPLASIAS COLORRECTALES UN CONSENSO DELPHI DE EXPERTOS NACIONALES: ANTECEDENTES:La colonoscopia es el estándar de atención para el diagnóstico y la evaluación de los cánceres colorrectales antes de la cirugía. Sin embargo, las prácticas variadas y la documentación heterogénea afectan la comunicación entre los endoscopistas y los cirujanos operadores, lo que dificulta la planificación quirúrgica.OBJETIVO:Este estudio tuvo como objetivo desarrollar recomendaciones para el uso de prácticas estandarizadas de localización y notificación de lesiones colorrectales identificadas en la endoscopia gastrointestinal inferior.DISEÑO:Se realizó una revisión sistemática de las pautas de endoscopia existentes y una revisión narrativa exhaustiva de la literatura general sobre endoscopia para identificar las prácticas existentes recomendadas a nivel mundial. Se utilizó un proceso Delphi en línea para establecer recomendaciones de consenso basadas en la revisión de la literatura.PARTICIPANTES:Se seleccionaron para participar cirujanos colorrectales y gastroenterólogos de todo Canadá que previamente habían demostrado liderazgo en endoscopia, manejado grandes programas de endoscopia, producido publicaciones de alto impacto en el campo de la endoscopia o que habían participado en el desarrollo de pautas de endoscopia.RESULTADOS:Localización de lesiones colorrectales y recomendaciones prácticas de documentación importantes para planificar escisiones quirúrgicas o endoscópicas avanzadas.RESULTADOS:129 de 197 declaraciones lograron consenso después de tres rondas de votación de 23 expertos de todo Canadá. Hubo >90% de participación en cada ronda. Las recomendaciones variaron según la ubicación de la lesión en el ciego, colon o recto, y si se planificó la derivación para resección quirúrgica o endoscópica avanzada. Se proporcionaron recomendaciones para la documentación adecuada, las indicaciones, la ubicación y el método de colocación del tatuaje, además de la fotografía y el uso del dispositivo de configuración del alcance 3D en tiempo real.LIMITACIONES:Debido a la escasez de evidencia, las recomendaciones se basan principalmente en la opinión de expertos. Puede haber sesgo, ya que los representantes tenían su sede en Canadá.CONCLUSIONES:Las mejores prácticas para optimizar la localización y comunicación de lesiones endoscópicas no se abordan en las guías anteriores. Este consenso que involucra a expertos nacionales en cirugía colorrectal y gastroenterología proporciona un marco para la localización eficiente y efectiva de lesiones colorrectales. Consulte Video Resumen en http://links.lww.com/DCR/C71 . (Traducción-Dr. Mauricio Santamaria ).

Variability in Communication and Reporting Practices Between Gastroenterologists and General Surgeons Contributes to Repeat Preoperative Endoscopy for Colorectal Neoplasms: A Qualitative Analysis.

BACKGROUND: Surgeons commonly repeat preoperative endoscopy before planned colorectal resections. The reasons for this are not entirely clear, and repeat endoscopy may lead to delays in curative resection, increased costs, and patient discomfort. OBJECTIVE: This study aimed to determine practice patterns, localization techniques, and processes of communication undertaken by endoscopy specialists in a high-volume regional health authority. DESIGN: This was a qualitative study involving standardized, semi-structured, in-depth interviews that were conducted in person. Data were analyzed using a thematic analysis approach. SETTINGS: The study was conducted at Canadian tertiary and community facilities. PARTICIPANTS: Ten general surgeons and 10 gastroenterologists were included using a convenience sampling technique. MAIN OUTCOME MEASURES: Interview questions were developed to understand the perspectives and practice patterns of endoscopists when approaching patients diagnosed with colorectal lesions requiring surgical resection. The decision-making process to perform a repeat preoperative endoscopy was assessed. RESULTS: Three key themes emerged: 1) patterns of communication, 2) feedback, and 3) trust. Thematic analysis revealed that poor communication and ambiguous documentation increased the likelihood of performing repeat preoperative endoscopy. Inconsistencies in tattooing practices and lesion location were important factors. Negative experiences and factors related to interprofessional trust emerged as key contributors to repeat preoperative endoscopy. LIMITATIONS: The transferability of findings to health care systems outside Canada may be limited and requires further study. CONCLUSIONS: Suboptimal endoscopic reporting contributes to gaps in communication among endoscopists. In addition, lack of consistent feedback and mutual trust may increase the likelihood of performing repeat preoperative lower endoscopy. Inconsistent tattooing practices pose significant concerns for accurate intraoperative lesion localization. Establishing collaborative work environments through joint educational initiatives may enhance communication and mitigate unnecessary repeat procedures. These results support the need for standardized guidelines and endoscopic reporting in the management of colorectal lesions. See Video Abstract at http://links.lww.com/DCR/B879 . LA VARIABILIDAD EN LAS PRCTICAS DE COMUNICACIN Y PRESENTACIN DE INFORMES ENTRE GASTROENTERLOGOS Y CIRUJANOS GENERALES CONTRIBUYE A REPETIR LA ENDOSCOPIA PREOPERATORIA PARA LAS NEOPLASIAS COLORRECTALES UN ANLISIS CUALITATIVO: ANTECEDENTES:Los cirujanos suelen repetir la endoscopia preoperatoria antes de las resecciones colorrectales planificadas. Las razones de esto no están del todo claras y la repetición de la endoscopia puede provocar retrasos en la resección curativa, aumento de los costos y malestar del paciente.OBJETIVO:Nuestro objetivo fue determinar patrones de práctica, técnicas de localización y procesos de comunicación realizados por especialistas en endoscopia, en una autoridad sanitaria regional, de alto volumen.DISEÑO:Este fue un estudio cualitativo, que involucró entrevistas estandarizadas, semiestructuradas y en profundidad que se llevaron a cabo en persona. Los datos se analizaron mediante un enfoque de análisis temático.ENTORNO CLINICO:El estudio se llevó a cabo en instalaciones comunitarias y terciarias canadienses.PARTICIPANTES:Se incluyeron 10 cirujanos generales y 10 gastroenterólogos, utilizando una técnica de muestreo por conveniencia.PRINCIPALES MEDIDAS DE VALORACION:Las preguntas de la entrevista se desarrollaron para comprender las perspectivas y los patrones de práctica de los endoscopistas, cuando se acercan a pacientes diagnosticados con lesiones colorrectales que requieren resección quirúrgica. Se evaluó el proceso de toma de decisiones para realizar una nueva endoscopia preoperatoria.RESULTADOS:Surgieron tres temas clave: 1) patrones de comunicación, 2) retroalimentación y 3) confianza. El análisis temático reveló que la pobre comunicación y la ambigua documentación aumentaron la probabilidad de realizar una nueva endoscopia preoperatoria. Las inconsistencias en las prácticas de tatuaje y la ubicación de las lesiones fueron factores importantes. Las experiencias pasadas negativas y los factores relacionados con la confianza interprofesional surgieron como contribuyentes clave para repetir la endoscopia preoperatoria.LIMITACIONES:La transferibilidad de los hallazgos a los sistemas de atención médica fuera de Canadá, puede ser limitada y requiere más estudios.CONCLUSIONES:Los informes endoscópicos subóptimos contribuyen a las brechas en la comunicación entre los endoscopistas. Además, la falta de retroalimentación consistente y la confianza mutua pueden aumentar la probabilidad de realizar una nueva endoscopia baja preoperatoria. Las prácticas inconsistentes de tatuaje, plantean preocupaciones importantes para la localización precisa de las lesiones intraoperatorias. El establecimiento de entornos de trabajo colaborativo a través de iniciativas educativas conjuntas pueden mejorar la comunicación y mitigar la repetición de procedimientos innecesarios. Estos resultados apoyan la necesidad de pautas estandarizadas e informes endoscópicos en el tratamiento de las lesiones colorrectales. Consulte Video Resumen en http://links.lww.com/DCR/B879 . (Traducción-Dr. Fidel Ruiz Healy ).

Oncological Outcomes of Transanal Endoscopic Surgery for the Surgical Management of T2 and T3 Rectal Cancer.

BACKGROUND: Transanal endoscopic surgery is an organ-sparing treatment for early rectal cancer. Patients with advanced lesions are recommended for total mesorectal excision. However, some patients have prohibitive comorbidities or refuse major surgery. OBJECTIVE: To assess the cancer outcomes of patients with T2 or T3 rectal cancers who received transanal endoscopic surgery as their sole surgical treatment. DESIGN: This study used a prospectively maintained database. SETTING: A tertiary hospital in Canada. PATIENTS: Patients who underwent transanal endoscopic surgery for pathology-confirmed T2 or T3 rectal adenocarcinomas from 2007-2020 were included. MAIN OUTCOME MEASURES: Disease-free survival and overall survival, stratified by tumor stage and reason for transanal endoscopic surgery. RESULTS: Among the included 132 patients (T2, n = 96; T3, n = 36), average follow-up was 22 months. Twenty-eight decline oncologic resection, whereas 104 had preclusive comorbidities. Fifteen patients (11.4%) had disease recurrence (4 local, 11 metastatic). Three-year disease-free survival was 86.5% (95% CI, 77.1-95.9) for T2 and 67.9% (95% CI, 46.3-89.5) for T3 tumors. Mean disease-free survival was longer for T2 (75.0 mo; 95% CI, 67.8-82.1) compared to T3 cancers (50 mo; 95% CI, 37.7-62.3; p = 0.037). Three-year disease-free survival for patients who declined radical excision was 84.0% (95% CI, 67.1-100) versus 80.7% (95% CI, 69.7-91.7) in patients too comorbid for surgery. Three-year overall survival rate was 84.9% (95% CI, 73.9-95.9) for T2 and 49.0% (95% CI, 26.7-71.3) for T3 tumors. Patients who declined radical resection had similar 3-year overall survival (89.7%; 95% CI, 76.2-100) compared to patients who were unable to undergo excision because of medical comorbidities (98.1%; 95% CI, 95.6-100). LIMITATIONS: Small sample, single institution, and surgeon experience. CONCLUSIONS: Oncologic outcomes are compromised in patients treated by transanal endoscopic surgery for T2 and T3 rectal cancer. Transanal endoscopic surgery remains an option for informed patients who prefer to avoid radical resection. See Video Abstract at http://links.lww.com/DCR/C200 . RESULTADOS ONCOLGICOS DE LA CIRUGA ENDOSCPICA TRANSANAL PARA EL MANEJO QUIRRGICO DEL CNCER DE RECTO T Y T: ANTECEDENTES:La cirugía endoscópica transanal es un tratamiento de conservación de órganos para el cáncer de recto en estadio temprano. A los pacisentes con lesiones avanzadas se les recomienda la escisión total del mesorrecto. Sin embargo, algunos pacientes tienen comorbilidades prohibitivas o rechazan una cirugía mayor.OBJETIVO:Evaluar los resultados del cáncer de pacientes con cáncer de recto T2 o T3 que recibieron cirugía endoscópica transanal como único tratamiento quirúrgico.DISEÑO:Este estudio utilizó una base de datos mantenida prospectivamente.ENTORNO CLINICO:Un hospital terciario en CanadáPACIENTES:Aquellos que se sometieron a cirugía endoscópica transanal por adenocarcinomas rectales T2 o T3 confirmados por patología de 2007-2020. Se excluyeron los pacientes cuya cirugía se realizó por recurrencia del cáncer o posteriormente fueron sometidos a resección radical.PRINCIPALES MEDIDAS DE VALORACIÓN:Supervivencia libre de enfermedad y supervivencia global, estratificada por estadio del tumor y motivo de la cirugía endoscópica transanal.RESULTADOS:Se incluyeron 132 pacientes (T2, n = 96; T3, n = 36). El seguimiento medio fue de 22 meses (DE ± 23,4). 104 pacientes tenían comorbilidades significativas, mientras que 28 rechazaron la resección oncológica. Quince pacientes (11,4%) tuvieron recurrencia de la enfermedad (4 locales, 11 metastásicos). La supervivencia libre de enfermedad a los tres años para los tumores T2 fue del 86,5 % (IC del 95%: 77,1-95,9) y del 67,9% (IC del 95%: 46,3-89,5) para los tumores T3. La supervivencia libre de enfermedad media fue más prolongada para los cánceres T2 (75,0 meses, IC del 95%: 67,8 a 82,1) en comparación con los cánceres T3 (50 meses, IC del 95%: 37,7 a 62,3, p = 0,037). La supervivencia sin enfermedad a los tres años para los pacientes que rechazaron la escisión mesorrectal total fue del 84,0% (IC del 95%: 67,1-100), mientras que los pacientes con demasiada comorbilidad médica para la cirugía tuvieron una supervivencia sin enfermedad a los tres años del 80,7% (IC del 95%: 69.7-91.7). La supervivencia general a los tres años fue del 84,9% (IC del 95%: 73,9 a 95,9) para los tumores T2 y del 49,0% (IC del 95%: 26,7 a 71,3) para los tumores T3. Los pacientes que rechazaron la resección radical tuvieron una supervivencia general similar a los tres años (89,7%, IC del 95%: 76,2-100), en comparación con los pacientes que no pudieron someterse a una escisión mesorrectal total debido a comorbilidades médicas (98,1%, IC del 95%: 95,6-100).LIMITACIONES:Muestra pequeña, institución única, experiencia del cirujano.CONCLUSIONES:Los resultados oncológicos están comprometidos en pacientes tratados con cirugía endoscópica transanal por cáncer de recto T2 y T3. Sin embargo, la cirugía endoscópica transanal sigue siendo una opción para pacientes informados que prefieren evitar la resección radical. Consulte Video Resumen en http://links.lww.com/DCR/C200 . (Traducción-Dr. Ingrid Melo ).

Prescription drug usage as measure of comorbidity resolution after bariatric surgery: a population-based cohort study.

BACKGROUND: Obesity is a chronic and progressive disease associated with significant morbidity, mortality, and health-care costs. Bariatric surgery is the most effective intervention for sustainable weight loss and resolution of obesity-related comorbidities. Studies examining comorbidity resolution largely rely on individual self-reported outcomes and electronic record reviews. We present a population-based study looking at prescription medication utilization before and after bariatric surgery as a measure of comorbidity resolution. METHODS: All patients enrolled in the Center for Metabolic and Bariatric Surgery who underwent either gastric bypass or sleeve gastrectomy between 2013 and 2019 in Manitoba were included. Demographic information, follow up, and outpatient prescription dispensation data were obtained from the Manitoba Population Research Data Repository housed at the Manitoba Centre for Health Policy for 5 years pre- and post-surgery. RESULTS: A total of 1184 patients were included. Antidepressants and selective serotonin reuptake inhibitors were the most commonly prescribed classes, and along with thyroid medication, utilization remained stable after bariatric surgery. Proton pump inhibitors and opioid class drugs increased at 1 year after surgery then returned to baseline. Glucose and lipid-lowering medications, including statins, biguanides, sulfonylureas, and insulin, were decreased. Antihypertensives, including ACE inhibitors, calcium channel blockers, angiotensin receptors blockers, thiazides, and beta blockers, similarly decreased. CONCLUSION: This is the first Canadian study employing a provincial-wide prescription database to measure long-term comorbidity resolution after bariatric surgery. The use of administrative data eliminates potential biases and inaccuracies in follow up and self-reported outcomes. Consistent with the literature, prescriptions for the treatment of metabolic syndrome all decreased and were sustained at long-term follow up. Further studies are needed to delineate the effects of altered pharmaceutical utilization on patient quality of life and health-care expenditures.

Rates and predictors of repeat preoperative endoscopy for elective colorectal resections: how can we avoid repeated procedures?

BACKGROUND: Despite limited endoscopy resources, repeat endoscopy prior to surgery is commonly practised. Our aim was to determine repeat preoperative endoscopy rates and factors influencing this practice at a high-volume Canadian tertiary centre. METHOD: A retrospective cohort study was conducted on all patients undergoing elective colorectal resections for benign and malignant neoplasms at a tertiary centre in Winnipeg, Canada between 2007 and 2017. Multivariable logistic regression analysis was used to identify predictors of repeat preoperative endoscopy. RESULTS: Of 1062 patients identified, mean age was 68 years and 56% were male. Rate of repeat preoperative endoscopy was 29%. On multivariable analysis, male sex (OR 1.68, CI 1.19-2.34, p = 0.003) and lesions located in the left colon (OR 2.73, CI 1.79-4.14, p < 0.001), rectosigmoid (OR 9.11, CI 2.14-38.8, p = 0.003), and rectum (OR 4.06, CI 2.58-6.38, p < 0.001) were at increased odds of undergoing repeat preoperative endoscopy. Patients with a tattoo placed at index endoscopy were at markedly lower odds of undergoing repeat preoperative endoscopy (OR 0.48, CI 0.34-0.68, p < 0.001). Index endoscopist specialty was not a significant predictor of repeat endoscopy (OR 0.76, CI 0.54-1.06, p = 0.09). CONCLUSIONS: Repeat preoperative lower endoscopy is commonly practised and may be unnecessary if appropriate identification and documentation of lesions has been achieved. Tattooing of suspicious lesions is a key modifiable factor associated with reduced likelihood of repeat preoperative endoscopy. This study highlights the need for standardized guidelines and endoscopy reporting practices given the delays and costs associated with repeat preoperative endoscopy.

Merged virtual reality teaching of the fundamentals of laparoscopic surgery: a randomized controlled trial.

BACKGROUND: The COVID-19 pandemic challenges our ability to provide surgical education, as our ability to gather and train together has been restricted due to safety concerns. However, the importance of quality surgical education has remained. High-fidelity simulation platforms have been developed that merge virtual reality video streams to allow for remote instruction and collaboration. This study sought to validate the use of a merged virtual reality (MVR) platform for the instruction and assessment of the fundamentals of laparoscopic surgery (FLS) skills. METHODS: This was a prospective randomized controlled non-inferiority study. Thirty participants were randomized between three groups: The standard group received in-person instruction and expert feedback, the experimental group received identical training via the MVR platform, and the control group practiced on their own, but received no feedback. All participants were pre-tested for baseline performance at the beginning of the study. Change in performance was evaluated immediately after training and one month later for retention. Ordinary one-way analysis of variance was used to evaluate the effects of time, group, and time-on-group. RESULTS: The pre-test confirmed baseline homogeneity between the groups. MVR was non-inferior to standard in-person training for total FLS times on either the post-test (p = 0.632) or the retention test (p = 0.829). Performance was also identical between MVR and standard training groups for each of the individual FLS tasks. Each group improved significantly in nearly all tasks after practice; however, the standard and MVR training groups both improved significantly more than controls for the ligating loop, extracorporeal suturing, intracorporeal suturing, and total FLS task training but did not reach statistical significance for peg transfer and pattern cut tasks. CONCLUSION: This randomized, controlled trial has demonstrated the use of an MVR platform as non-inferior to in-person instruction for the FLS program, forming the foundation for future work on remote instruction and collaboration.

Development of consensus-derived quality indicators for laparoscopic sleeve gastrectomy operative reports.

BACKGROUND: Synoptic operative reporting has been used as a solution to the poor quality of narrative reports. The aim of this study was to develop operative report quality indicators for the laparoscopic sleeve gastrectomy and to generate parameters by which these reports can be evaluated and improved. METHODS: A Delphi protocol was used to determine quality indicators for LSG. Bariatric surgeons across Canada were recruited along with key physician stakeholders to participate via a secure web-based platform. Transferrable consensus items for LSG from previously developed Roux-en-Y gastric bypass operative indictors were put forward for consideration. Participants also initially submitted potential QIs. These were grouped by theme. Items were rated on 5-point Likert scales in subsequent rounds. Scores of 70% or higher were used for inclusion and 30% or less denoted exclusion. Elements scoring 30% to 70% agreement were recirculated by runoff in subsequent rounds to generate the final list of quality indicators. RESULTS: Seven bariatric surgeons, representing all regions preforming LSG in Canada, were invited to participate in the Delphi group. Multidisciplinary invitees included one academic minimally invasive/acute care surgeon, one tertiary abdominal radiologist, and one academic gastroenterologist with bariatric expertise. Two rounds were required to achieve consensus. Both rounds achieved a 100% response (10/10). In round 1, forty items reached consensus. In Round 2, an additional 28 items reached consensus, with three items excluded, bringing the total number of quality indicators to 65. CONCLUSION: This study establishes consensus-derived multidisciplinary quality indicators for LSG operative reports. Application of these findings aims to advance the quality and completeness of operative reporting in LSG in order to improve communication of important surgical details and quality measures to the multidisciplinary team involved in bariatric surgery care.

Contextual interference for skills development and transfer in laparoscopic surgery: a randomized controlled trial.

INTRODUCTION: Past education literature has shown benefits for random practice schedules (termed contextual interference) for skills retention and transfer to novel tasks. The purpose of fundamentals of laparoscopic surgery (FLS) training is to develop skills in simulation and transfer to new in vivo intraoperative experiences. The study objective was to assess whether individuals trained over a fixed number of trials in the FLS tasks would outperform untrained controls on an unpracticed previously validated bile duct cannulation task and scoring system and to determine whether random training schedules conferred any relative advantage. METHODS: 44 trainees with no laparoscopic experience were recruited to participate. 35 were randomized to practice the FLS tasks using either a blocked or random training schedule. Nine were randomized to no additional training (controls). Participant performance was measured throughout training to monitor skills acquisition and were then tested on an unpracticed bile duct cannulation simulation task 4 to 6 weeks later. Outcomes included previously validated FLS scores and hand-motion analyses. RESULTS: All 44 participants completed the study. Trained individuals in both groups showed significant improvements in all FLS tasks after training. There were no differences between groups in performance on the cannulation task median scores (Blocked: 89.8 [IQR:37.6]; Random: 83.2 [32.3]; Control: 83.6 [19.1]; p = 0.955), number of hand motions (Blocked: 42.5 [IQR:130.3]; Random: 75.3 [111.3]; Control: 63.0 [71.8]; p = 0.912), or distance traveled by participants hands (Blocked: 2.0 m [IQR:5.8]; Random: 3.8 [8.9]; Control: 2.6 [2.5]; p = 0.816). Cannulation task performance had no correlation with total FLS performance, R2 linear = 0.014, p = 0.445. CONCLUSIONS: Skills acquired from conventional FLS tasks did not effectively transfer to a laparoscopic bile duct cannulation task. Neither blocked nor random practice schedules conferred a relative advantage. These findings provide evidence that cannulation is a distinct skill from what is taught and assessed in FLS.

Repeat preoperative endoscopy after regional implementation of electronic synoptic endoscopy reporting: a retrospective comparative study.

BACKGROUND: Repeat preoperative endoscopy is common for patients with colorectal neoplasms. This can result in treatment delays, patient discomfort, and risks of colonoscopy-related complications. Repeat preoperative endoscopy has been attributed to poor communication between endoscopists and surgeons. In January 2019, mandatory electronic synoptic reporting for endoscopy was implemented to include elements consistent with quality indicators proposed in national guidelines. The aim of the present study is to assess whether the repeat preoperative endoscopy rate for colorectal lesions changed following synoptic report implementation. METHODS: A retrospective review was performed of 1690 consecutive patients who underwent elective surgical resection for colorectal neoplasms from January 2007 to June 2020 at a tertiary hospital in Canada. Patients who had an index endoscopy documented via synoptic report were compared to those reported via narrative report. Primary outcomes were rates of repeat preoperative endoscopy and inclusion of colonoscopy quality indicators: photo-documentation, tattoo placement, and bowel preparation score. RESULTS: In total, 1429 patients who underwent elective colorectal resection for colorectal cancers or polyps between January 2007 and June 2020 were included. 115 had index endoscopies recorded via synoptic report and 1314 by narrative report. The repeat preoperative endoscopy rate after endoscopies documented by narrative report was 29.07% (95% CI 26.63-31.61) and 25.22% (95% CI 17.58-34.17%) for synoptic report. Patients whose index endoscopies where performed by a practitioner other than their operating surgeon had a re-endoscopy rate of 36.03% (95% CI 32.82-39.33%) after narrative report and 38.81% (95% CI 27.14-51.50%) for synoptic report. Rates of tattoo placement, photo-documentation, and reporting of bowel preparation quality were all significantly increased with synoptic reports (p ≤ 0.003). CONCLUSIONS: Endoscopy synoptic reports based on current guidelines were not associated with a decrease in rates of repeat pre-operative endoscopy at a high-volume colorectal cancer centre. Future study should examine guideline deficiencies for this purpose and make necessary modifications.

Quality indicators for operative reporting in transanal endoscopic surgery.

Transanal endoscopic surgery (TES) platforms have become quite popular. Many surgeons across the country have begun excising rectal lesions using these platforms; however, the perioperative decision-making surrounding these excisions can be quite variable. To facilitate care between providers, it would be helpful to standardize the way TES is reported. Synoptic operative reports have previously been established as an effective and efficient communication tool. For patients with rectal cancer, synoptic reports are required for pathology, radiology and major oncologic resections, but never previously for TES. We used a Delphi process including 15 stakeholders from across Canada to develop a TES synoptic report. Participants submitted items according to 6 categories: team characteristics, patient demographics, preoperative work-up, lesion characteristics, procedure details and postoperative details. Twenty-six surgeon-entered and 41 auto-populated items reached final inclusion. This will allow generation of a synoptic reporting template to improve perioperative communication for these patients.

Predictors and rates of prior endoscopic tattoo localization amongst individuals undergoing elective colorectal resections for benign and malignant lesions.

BACKGROUND: Appropriate tattooing of suspicious lesions during colonoscopy is critical for surgical planning. However, variability exists in tattoo placement, technique, and reporting. Our aim is to determine the rates and predictors of tattoo placement, tattoo location in relation to the lesion, and localization accuracy during lower endoscopy for individuals undergoing elective colorectal resections. METHODS: We performed a retrospective chart review on all patients undergoing elective colorectal resections for benign and malignant neoplasms between 2007 and 2017 at a high volume Canadian tertiary centre. Patient demographics, endoscopic, and tumour-related characteristics were collected. Multivariable logistic regression analysis was used to identify predictors of tattoo localization. RESULTS: Of the 1062 patients identified, laparoscopic resection occurred in 59% of patients. 57% of patients underwent tattooing for tumour localization at index endoscopy. Tattoos were placed distal (27%), both proximal and distal (4%), and just proximal (2%) to the lesion. However, in the majority of cases the tattoo location was not documented (67%). On multivariate analysis, patients who had lesions located in the transverse colon (OR: 1.93, 95% CI 1.04-3.59), had surgery performed after 2010 (2011-2014: OR: 1.88, 95% CI 1.31-2.68; 2015-2017: OR: 2.87, 95% CI 1.93-4.26), underwent laparoscopic resections (OR: 1.69, 95% CI 1.22-2.33), and had their index endoscopy performed in an urban setting (OR: 5.92, 95% CI 3.23-10.87), were at higher odds of having a tattoo placed at index endoscopy. CONCLUSION: Endoscopic tattoo placement and location in relation to the lesion varies widely, with reports containing suboptimal documentation. Lesion location and laparoscopic procedures were significant predictors of tattoo placement. This study highlights the need for standardized tattooing practices and reporting amongst endoscopists. One of the focus of quality improvement efforts should be educational initiatives for rural endoscopists.

The incidence of iron deficiency anemia post-Roux-en-Y gastric bypass and sleeve gastrectomy: a systematic review.

SETTING: The physiological and anatomical changes that occur as a consequence of bariatric surgery result in macro- and micro-nutritional deficiencies, especially iron deficiency. The reported incidence of iron deficiency and associated anemia after bariatric surgery varies widely across studies. OBJECTIVES: The aim of this systematic review is to quantify the impact of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on the incidence of iron deficiency. METHODS: Databases including Ovid Medline, Ovid Embase, Helthstar, Scopus, Cochrane (CDSR), LILACS, and ClinicalKey were searched for original articles with additional snowballing search. Search terms included Obesity, nutrient deficiency, iron deficiency, iron deficiency anemia, bariatric surgery, Roux-en-Y gastric bypass, and sleeve gastrectomy. Original articles reporting the incidence of iron deficiency and anemia pre- and post-RYGB and SG from January 2000 to January 2015 with minimum 1-year follow-up were selected. Data extraction from selected studies was based on protocol-defined criteria. RESULTS: There were 1133 articles screened and 20 studies were included in the final analysis. The overall incidence of iron deficiency was 15.2% pre-operatively and 16.6% post-operatively. When analyzed by procedure, the incidence of iron deficiency was 12.9% pre-RYGB versus 24.5% post-RYGB and 36.6% pre-SG versus 12.4% post-SG. The incidence of iron deficiency-related anemia was 16.7% post-RYGB and 1.6% post-SG. Risk factors for iron deficiency were premenopausal females, duration of follow-up, and pre-operative iron deficiency. Prophylactic iron supplementation was reported in 16 studies and 2 studies provided therapeutic iron supplementation only for iron-deficient patients. Iron dosage varied from 7 to 80 mg daily across studies. CONCLUSION: Iron deficiency is frequent in people with obesity and may be exacerbated by bariatric surgery, especially RYGB. Further investigation is warranted to determine appropriate iron supplementation dosages following bariatric surgery. Careful nutritional surveillance is important, especially for premenopausal females and those with pre-existing iron deficiency.

Iron deficiency in bariatric surgery patients: a single-centre experience over 5 years.

Background: As the prevalence of obesity has increased, so too has the demand for bariatric surgery. This study aimed to determine the incidence of postoperative iron deficiency and anemia and the impact of an increased preoperative ferritin target on postoperative outcomes. Methods: Patients undergoing bariatric surgery in Winnipeg from 2010 to 2014 were included in the analysis. Data capture included age, sex and date of surgery and iron, ferritin and hemoglobin levels before surgery and 12 months postoperatively. Before 2014, there was no protocol for preoperative iron supplementation at our centre; in 2014, a more aggressive preoperative iron supplementation program was introduced to target a minimum preoperative ferritin level of 50 mg/L. Data were analyzed using unpaired t tests, paired t tests and χ2 tests. Results: A total of 399 patients were considered; 288 were included in the analysis. The incidence of iron and ferritin deficiency and anemia at 12 months postoperatively was 14.6%, 9.3% and 15.0%, respectively. In patients who underwent surgery before 2014, the 12-month postoperative levels of iron and ferritin were 12.9 mmol/L and 64.0 mg/L, respectively; patients who underwent surgery in 2014 had levels of 18.3 mmol/L and 124.0 mg/L, respectively (all p = 0.001). The 12-month postoperative hemoglobin levels did not significantly differ between the 2 groups. Conclusion: Bariatric surgery performed with more aggressive preoperative iron supplementation is associated with increased iron and ferritin levels at 1 year postoperatively. As this improves overall clinical outcomes by avoiding iron deficiency and anemia, a minimum preoperative ferritin target should be implemented in metabolic and bariatric surgery programs.

Contexte: L'augmentation de la prévalence de l'obésité s'est accompagnée d'un accroissement de la demande de chirurgie bariatrique. La présente étude visait à déterminer l'incidence de la carence en fer et de l'anémie postopératoires ainsi que les conséquences de la hausse du taux cible de ferritine avant l'intervention sur les issues postopératoires. Méthodes: L'analyse a porté sur des patients ayant subi une chirurgie bariatrique à Winnipeg entre 2010 et 2014. Les données recueillies faisaient état de l'âge, du sexe et de la date d'opération des patients, ainsi que de leurs taux de fer, de ferritine et d'hémoglobine avant la chirurgie et 12 mois après celle-ci. Avant 2014, notre centre n'avait pas de protocole de supplémentation préopératoire en fer; en 2014, il a instauré un programme de supplémentation rigoureux visant un taux préopératoire de ferritine d'au moins 50 mg/L. L'analyse des données a été faite au moyen de tests t non appariés, de tests t appariés et de tests χ2. Résultats: Au total, les cas de 399 patients ont été envisagés pour l'analyse, et 288 ont été retenus. L'incidence de la carence en fer, celle de la carence en ferritine et celle de l'anémie 12 mois après la chirurgie étaient de 14,6 %, de 9,3 % et de 15,0 %, respectivement. Chez les patients ayant été opérés avant 2014, les taux de fer et de ferritine à 12 mois étaient de 12,9 mmol/L et de 64,0 mg/L, respectivement, et chez ceux ayant été opérés en 2014, ils étaient de 18,3 mmol/L et de 124,0 mg/L, respectivement (p = 0,001 pour toutes les valeurs). En ce qui concerne le taux d'hémoglobine à 12 mois, aucune différence significative n'a été observée entre les 2 groupes. Conclusion: Les chirurgies bariatriques effectuées après une supplémentation rigoureuse en fer sont associées à des taux accrus de fer et de ferritine 1 an après l'intervention. Sachant que la prévention de la carence en fer et de l'anémie améliore les issues cliniques en général, les programmes de chirurgie métabolique et bariatrique devraient se fixer une cible quant au taux préopératoire minimal de ferritine.

Strategies to improve communication in telementoring in acute care coordination: a scoping review.

Background: Telementoring facilitates the coordination of advanced medical care in rural, remote or austere environments. Because the interpersonal element of telementoring has been relatively underexplored, we conducted a scoping review to identify strategies to improve communication in telementoring. Methods: Two independent reviewers searched all English-language articles in MEDLINE and Scopus from 1964 to 2017, as well as reference lists of relevant articles to identify articles addressing telementored interactions between health care providers. Search results were gathered in June 2017 and updated in January 2018. Identified articles were categorized by theme. Results: We identified 144 articles, of which 56 met our inclusion criteria. Forty-one articles focused on improving dispatcher-directed cardiopulmonary resuscitation (CPR). Major themes included the importance of language in identifying out-of-hospital cardiac arrest and how to provide instructions to enable administration of effective CPR. A standardized approach with scripted questions was associated with improved detection of out-of-hospital cardiac arrest, and a concise script was associated with improved CPR quality compared to no mentoring, unscripted mentoring or more complex instructions. Six articles focused on physician-physician consultation. Use of a handover tool that highlighted critical information outperformed an unstructured approach regarding transmission of vital information. Nine articles examined telementoring in trauma resuscitation. A common theme was the need to establish an understanding between mentor and provider regarding the limitations of the provider and his or her environment. Conclusion: The available data suggest that standardization coupled with short, concise validated scripts could improve efficacy, safety and engagement. Improvements will require multidisciplinary input, practice and deliberate efforts to address barriers.

Contexte: Le mentorat en ligne facilite la coordination des soins médicaux de pointe dans les environnements ruraux, éloignés ou rudimentaires. Toutefois, le facteur relationnel de ce type d'interaction est resté plutôt sous-exploré. C'est pourquoi nous avons réalisé une revue exploratoire pour dégager des stratégies d'amélioration de la communication en contexte de mentorat en ligne. Méthodes: Deux réviseurs indépendants ont cherché à recenser les articles portant sur les interactions de mentorat en ligne entre professionnels de la santé parmi tous les articles de langue anglaise publiés entre 1964 et 2017 indexés dans les bases de données MEDLINE et Scopus, ainsi que dans les listes bibliographiques des articles pertinents. Les résultats de recherche ont été recueillis en juin 2017 et actualisés en janvier 2018, et les articles recensés ont été regroupés par thèmes. Résultats: Nous avons retenu 144 articles, dont 56 répondant à nos critères d'inclusion. De ce total, 41 portaient sur l'amélioration de la réanimation cardiorespiratoire (RCR) dirigée par un répartiteur. Parmi les thèmes principaux, on retrouve l'importance du langage dans l'identification des arrêts cardiaques hors de l'hôpital, ainsi que la manière de fournir des instructions permettant de pratiquer une RCR efficace. Une approche normalisée avec des questions scénarisées a été associée à une meilleure détection des arrêts cardiaques hors de l'hôpital, alors qu'un scénario concis a été associé à une amélioration de la qualité de la RCR comparativement à une approche sans mentorat, avec mentorat non scénarisé ou avec des instructions plus complexes. Six des articles retenus portaient sur la consultation de type médecin­médecin. Ils ont conclu que l'utilisation d'un outil de transfert mettant en évidence l'information importante était plus efficace qu'une approche non structurée pour la transmission de renseignements vitaux. Finalement, 9 articles portaient sur le mentorat en ligne en réanimation traumatologique. Un des thèmes communs de ces articles était le besoin d'établir une compréhension mutuelle entre mentors et professionnels en ce qui concerne les restrictions de ces derniers et de leur environnement. Conclusion: Les données disponibles semblent indiquer que la normalisation associée à des scénarios courts, concis et éprouvés pourrait améliorer l'efficacité, la sécurité et l'engagement. Cependant, toute amélioration nécessitera un encadrement multidisciplinaire, de la pratique et des efforts délibérés pour surmonter les obstacles.

Impact of acute care surgery on timeliness of care and patient outcomes: a systematic review of the literature

Background: Dedicated emergency general surgery (EGS) service models were developed to improve efficiency of care and patient outcomes. The degree to which the EGS model delivers these benefits is debated. We performed a systematic review of the literature to identify whether the EGS service model is associated with greater efficiency and improved outcomes compared to the traditional model. Methods: We searched MEDLINE, Embase, Scopus and Web of Science (Core Collection) databases from their earliest date of coverage through March 2017. Primary outcomes for efficiency of care were surgical response time, time to operation and total length of stay in hospital. The primary outcome for evaluating patient outcomes was total complication rate. Results: The EGS service model generally improved efficiency of care and patient outcomes, but the outcome variables reported in the literature varied. Conclusion: Development of standardized metrics and comprehensive EGS databases would support quality control and performance improvement in EGS systems.

Contexte: Des modèles dédiés de services de chirurgie générale d'urgence (CGU) ont été développés pour améliorer l'efficience des soins et les résultats chez les patients. On ne s'entend toutefois pas sur l'ampleur des bénéfices conférés par le modèle CGU. Nous avons procédé à une revue systématique de la littérature afin de vérifier si le modèle CGU est associé à une plus grande efficience et à de meilleurs résultats comparativement au modèle classique. Méthodes: Nous avons interrogé les bases de données MEDLINE, Embase, Scopus et Web of Science (collection centrale) depuis la plus ancienne couverture du sujet et jusqu'à mars 2017. Les paramètres principaux pour l'efficience des soins étaient le temps de réponse, le délai avant l'intervention et la durée totale du séjour hospitalier. Le paramètre principal pour l'évaluation des résultats chez les patients était le taux de complications total. Résultats: Le modèle de service CGU améliore généralement l'efficience des soins et les résultats chez les patients, mais dans la littérature, les paramètres mesurés varient. Conclusion: Le développement de paramètres standardisés et de bases de données globales sur la CGU appuierait le contrôle de la qualité et l'amélioration du rendement des systèmes CGU.

Effect of Roux-en-Y gastric bypass on pharmacologic dependence in obese patients with type 2 diabetes

Background: More than half the diabetes-related health care costs in Canada relate to drug costs. We aimed to determine the effect of Roux-en-Y gastric bypass (RYGB) on the use of insulin and orally administered hypoglycemic medications in patients with diabetes. We also looked to determine overall cost savings with the procedure. Methods: We reviewed the bariatric clinic records of all patients with a confirmed diagnosis of type 2 diabetes mellitus who underwent RYGB between 2010/11 and 2014/15. Percentage estimated weight loss was recorded at 1 year, along with reductions in glycated hemoglobin (HbA1c) level and use of oral hypoglycemic therapy and insulin. We estimated medication costs using Manitoba-specific pricing data. Results: Fifty-two patients with at least 12 months of complete follow-up data were identified. The mean percentage estimated weight loss was 50.2%. The mean HbA1c level decreased from 7.6% to 6.0%, the mean number of orally administered hypoglycemics declined from 1.6 to 0.2, and the number of patients receiving insulin decreased from 18 (35%) to 3 (6%) (all p < 0.001). The rate of resolution of type 2 diabetes was 71%. Estimated mean annual per-patient medication costs decreased from $508.56 to $79.17 (p < 0.001). Potential overall health care savings could total $3769 per patient in the first year, decreasing to $1734 at 10 years. Conclusion: Roux-en-Y gastric bypass resulted in significant improvement in diabetic control, with a reduction in hypoglycemic medication use and associated costs in the early postoperative period. Potentially, large indirect and direct cost savings can be realized in the longer term.

Contexte: Plus de la moitié des coûts des soins de santé liés au diabète au Canada sont générés par les médicaments. Nous avons voulu déterminer l'effet de la dérivation gastrique de Roux-en-Y sur l'utilisation des agents hypoglycémiants oraux et de l'insuline chez les patients diabétiques. Nous avons aussi cherché à déterminer l'ensemble des économies associées à cette intervention. Méthodes: Nous avons passé en revue les dossiers cliniques bariatriques de tous les patients ayant un diagnostic confirmé de diabète de type 2 qui ont subi une dérivation gastrique de Roux-en-Y entre 2010­2011 et 2014­2015. La perte de poids ­ estimée en pourcentage ­ a été notée après un an, ainsi que les réductions des taux d'hémoglobine glyquée (HbA1c) et du recours aux hypoglycémiants oraux et à l'insuline. Nous avons estimé les coûts des médicaments à partir des données de tarification du Manitoba. Résultats: Cinquante-deux patients pour lesquels on disposait d'au moins 12 mois de données de suivi complètes ont été retenus. La perte de poids moyenne estimée en pourcentage était de 50,2 %. Le taux moyen d'HbA1c a diminué de 7,6 % à 6,0 %, le nombre moyen de comprimés d'hypoglycémiants oraux est passé de 1,6 à 0,2, et le nombre de patients sous insuline a diminué de 18 (35 %) à 3 (6 %) (tous p < 0,001). Le taux de résolution du diabète de type 2 était de 71 %. Le coût annuel moyen estimé des médicaments par patient est passé de 508,56 $ à 79,17 $ (p < 0,001). Les économies potentielles globales pour le système de santé pourraient totaliser 3769 $ par patient au cours de la première année, puis passer graduellement à 1734 $ au cours des 10 années suivantes. Conclusion: La dérivation gastrique de Roux-en-Y a permis d'améliorer significativement le contrôle du diabète, ainsi que de réduire le recours aux hypoglycémiants et les coûts associés au début de la période postopératoire. À plus long terme, d'importantes économies sur le plan des coûts indirects et directs pourraient potentiellement être réalisées.

Canadian general surgery residents' need formal curricula and objective performance assessments in gastrointestinal endoscopy training: a program director census.

INTRODUCTION: Methods of developing and determining General Surgery (GS) residents' competency in gastrointestinal endoscopy in Canada are not currently standardized. This study aimed to assess the status of gastrointestinal endoscopy training in Royal College of Physicians and Surgeons of Canada (RCPSC) GS residency programs. METHODS: A 35-question survey was developed using GS gastrointestinal endoscopy curricula guidelines. All 17 RCPSC GS program directors were contacted to complete the questionnaire via the web-based SurveyMonkey.ca® platform. RESULTS: All 17 program directors completed the survey (100% response rate). Program demographics Sixteen programs reported having dedicated endoscopy rotations with a mean duration of 2.8 months (range 0-4, SD 1.1). Upon completion of dedicated endoscopy rotations, four programs (25%) reported having formal skills assessments and three (18.8%) reported formal knowledge examinations. All programs required endoscopy procedures be logged throughout residency, but only three (21.4%) included quality indicators. Only one program required residents to obtain Fundamentals of Endoscopic Surgery certification. Program outcomes The reported estimated mean number of procedures during residents' endoscopy rotations was 82 (range 10-150, standard deviation 33.6) gastroscopies and 156 (40-350, 76.3) colonoscopies. The mean number of procedures during residents' entire residencies was 150 (20-400, 98.6) gastroscopies and 241 (50-500, 76.3) colonoscopies. The number of months of dedicated endoscopy training significantly correlated with the total estimated number of endoscopic procedures performed (ρ = 0.67, p = 0.02). Eleven program directors (73.3%) believed residents were prepared for independent endoscopy practice, while four disagreed (26.7%). Program directors' perceptions of residents' preparedness were significantly correlated with the number of endoscopic procedures performed by residents (p < 0.01) but not the robustness of the endoscopy curriculum (p = 0.72). CONCLUSION: Endoscopy training in RCPSC GS residency programs is highly variable. Program directors' perceptions of residents' competency appear to be significantly correlated with procedure numbers and few have adopted formal curricula and performance assessments.

Synoptic operative reporting: assessing the completeness, accuracy, reliability, and efficiency of synoptic reporting for Roux-en-Y gastric bypass.

OBJECTIVE: Synoptic reporting (SR) is one solution to improve the quality of operative reports. However, SR has not been investigated in bariatric surgery despite an identified need by bariatric surgeons. SR for RYGB was developed using quality indicators (QIs) established by a national Delphi process. The objective of this study is to assess the completeness, accuracy, reliability, and efficiency of synoptic versus narrative operative reports (NR) in Roux-en-Y gastric bypass (RYGB). METHODS: A NR and SR were completed on 104 consecutive RYGBs. Two evaluators independently compared the reports to QIs. Completeness and accuracy measures were determined. Reliability was calculated using Bland-Altman plots and 95% limits of agreement (LOA). Time to complete SR and NR was also compared. RESULTS: The mean completion rate of SR was 99.8% (±SD 0.98%) compared to 64.0% (±SD 6.15%) for NR (t = 57.9, p < 0.001). All subsections of SR were >99% complete. This was significantly higher than for NR (p < 0.001) except for small bowel division details (p = 0.530). Accuracy was significantly higher for SR than NR (94.2% ± SD 4.31% vs. 53.6% ± SD 9.82%, respectively, p < 0.001). Rater agreement was excellent for both SR (0.11, 95% LOA -0.53 to 0.75) and NR (-0.26, 95% LOA -4.85 to 4.33) (p = 0.242), where 0 denotes perfect agreement. SR completion times were significantly shorter than NR (3:55 min ± SD 1:26 min and 4:50 min ± SD 0:50 min, respectively, p = 0.007). CONCLUSION: The RYGB SR is superior to NR for completeness and accuracy. This platform is also both reliable and efficient. This SR should be incorporated into clinical practice.

Effect of rater training on the reliability of technical skill assessments: a randomized controlled trial.

BACKGROUND: Rater training improves the reliability of observational assessment tools but has not been well studied for technical skills. This study assessed whether rater training could improve the reliability of technical skill assessment. METHODS: Academic and community surgeons in Royal College of Physicians and Surgeons of Canada surgical subspecialties were randomly allocated to either rater training (7-minute video incorporating frame-of-reference training elements) or no training. Participants then assessed trainees performing a suturing and knot-tying task using 3 assessment tools: a visual analogue scale, a task-specific checklist and a modified version of the Objective Structured Assessment of Technical Skill global rating scale (GRS). We measured interrater reliability (IRR) using intraclass correlation type 2. RESULTS: There were 24 surgeons in the training group and 23 in the no-training group. Mean assessment tool scores were not significantly different between the 2 groups. The training group had higher IRR than the no-training group on the visual analogue scale (0.71 v. 0.46), task-specific checklist (0.46 v. 0.33) and GRS (0.71 v. 0.61). However, confidence intervals were wide and overlapping for all 3 tools. CONCLUSION: For education purposes, the reliability of the visual analogue scale and GRS would be considered "good" for the training group but "moderate" for the no-training group. However, a significant difference in IRR was not shown, and reliability remained below the desired level of 0.8 for high-stakes testing. Training did not significantly improve assessment tool reliability. Although rater training may represent a way to improve reliability, further study is needed to determine effective training methods.

CONTEXTE: La formation des évaluateurs améliore la fiabilité des outils d'évaluation observationnels, mais n'a pas été rigoureusement étudiée au plan des habiletés techniques. Cette étude a tenté de vérifier si la formation des évaluateurs permettait d'améliorer la fiabilité de l'évaluation des habiletés techniques. MÉTHODES: On a assigné des chirurgiens universitaires et communautaires appartenant aux surspécialités chirurgicales du Collège royal des médecins et chirurgiens du Canada, soit à une formation des évaluateurs (vidéo de 7 minutes comprenant des éléments de formation afférents au cadre de référence), soit à l'absence de formation. les participants ont ensuite évalué des stagiaires qui effectuaient tâches, telles sutures et nœuds, à l'aide de trois outils d'évaluation : échelle analogique visuelle, liste de vérification spécifique à la tâche et version modifiée de l'échelle d'appréciation globale (ÉAG) de l'Objective Structured Assessment of Technical Skill. Nous avons mesuré la fiabilité interévaluateurs (FIÉ) à l'aide de la corrélation intraclasse de type 2. RÉSULTATS: Il y avait 24 chirurgiens dans le groupe soumis à la formation et 23 dans le groupe non soumis à la formation. Les scores moyens des outils d'évaluation n'ont pas été significativement différents entre les deux groupes. Le groupe soumis à la formation a présenté une FIÉ plus élevée que l'autre groupe à l'échelle analogique visuelle (0,71 c. 0,46), à la liste de vérification spécifique à la tâche (0,46 c. 0,33) et à l'ÉAG (0,71 c. 0,61). Par contre, les intervalles de confiance étaient larges et se recoupaient pour les trois outils. CONCLUSION: Aux fins de la formation, la fiabilité de l'échelle analogique visuelle et de l'ÉAG serait considérée «.bonne.¼ pour le groupe soumis à la formation, mais «.modérée.¼ pour le groupe non soumis à la formation. On n'a toutefois pas démontré de différence significative quant à la FIÉ et la fiabilité est demeurée inférieure au niveau souhaité de 0,8 pour les tests importants. La formation n'a pas significativement amélioré la fiabilité de l'outil d'évaluation. Même si la formation des évaluateurs représente potentiellement une façon d'améliorer la fiabilité, il faudra approfondir la recherche pour déterminer quelles méthodes de formation sont efficaces.