Trend of minimally invasive and open surgery experience of general surgery residents: Accreditation Council for Graduate Medical Education general surgery case log in Thailand.

Purpose: Minimally invasive surgery (MIS) offers patients several benefits, such as smaller incisions, and fast recovery times. General surgery residents should be trained in both open and MIS. We aimed to examine the trends of minimally invasive and open procedures performed by general surgery residents in Thailand. Methods: A retrospective review of the Royal College of Surgeons of Thailand and Accreditation Council for Graduate Medical Education general surgery case logs from 2007 to 2018 was performed for common open and laparoscopic general surgery operations. The data were grouped by three time periods, which were 2007-2010, 2011-2014, and 2015-2018, and analyzed to explore changes in the operative trends. Results: For Thai residents, the mean number of laparoscopic operations per person per year increased from 5.97 to 9.36 (56.78% increase) and open increased from 20.02 to 27.16 (35.67% increase). There was a significant increase in the average number of minimally invasive procedures performed among cholecystectomy (5.83, 6.57, 8.10; p < 0.001) and inguinal hernia repair (0.33, 0.35, 0.66; p < 0.001). Compared to general surgery residents in the United States, Thai residents had more experience with open appendectomy, but significantly less experience with all other operations/procedures. Conclusion: The number of open and minimally invasive procedures performed or assisted by Thai general surgery residents has slowly increased, but generally lags behind residents in the United States. The Thai education program must be updated to improve residents' technical skills in open and laparoscopic surgery to remain competitive with their global partners.

Accuracy of Nonenhanced CT vs Contrast-Enhanced CT for Diagnosis of Acute Appendicitis in Adults.

BACKGROUND: Acute appendicitis is one of the most common causes of acute abdominal pain requiring emergency intervention. It is often difficult for the clinician to make an accurate diagnosis due to nonspecific and overlapping clinical symptoms. Computed tomography (CT) has become the imaging modality of choice for the evaluation of suspected acute appendicitis. The main purpose of our study was to compare nonenhanced CT (NECT) with contrast-enhanced CT (CECT) for the diagnosis of acute appendicitis. MATERIAL AND METHODS: A total of 140 patients were enrolled in the study. Two abdominal radiologists-masked to both the clinical information and the final diagnosis-retrospectively reviewed the computed tomographic findings and made an imaging diagnosis based on (1) NECT only, (2) CECT only, and (3) both NECT and CECT. With the final diagnosis as the reference standard, the accuracy of each CT technique was estimated. RESULTS: The respective sensitivity, specificity, and accuracy for NECT, CECT, and NECT + CECT for the diagnosis of acute appendicitis were 80.7%, 86.7%, and 84.3%; 86.0%, 81.9%, and 83.6%; and, 87.7%, 80.7%, and 83.6%. There was no significant difference in the diagnosis of acute appendicitis among the 3 techniques. In order to make a correct diagnosis, the presence of at least 3 imaging findings for NECT or at least 4 for CECT had the best diagnostic accuracy. We also found that 9.25 mm was the optimal cut-off threshold for the detection of patients with acute appendicitis. CONCLUSION: Our study allowed direct comparison between NECT, CECT, and NECT + CECT combined. There was no difference in the ability of each CT technique for diagnosing patients with acute appendicitis. For a patient whom iodinated contrast media is contraindicated or a patient who has an increased risk of severe adverse reaction, we would encourage the use of NECT because it provides comparable diagnostic accuracy without further exposing such patient to the contrast media.

Adaptation to Open-Book Online Examination During the COVID-19 Pandemic.

INTRODUCTION: COVID-19 altered medical education systems worldwide as many medical schools quickly changed to online assessment systems. However, the feasibility of online assessment and how it compares to traditional examinations is unclear. METHODS: We compared 4th year medical students' online surgery clerkship assessment scores to the traditional written examinations. The percent of correct scores using online open-book examination was compared to the results of the traditional closed-book examination in the previous three rotations. Additional correlation between grade point average(GPA) and examination performance were reviewed. RESULTS: Compared with the traditional groups, medical students who took the online, open-book examination had a significantly higher mean score in both MCQ(85.21 vs. 77.36, 72.43, 83.00, p<0.001) and essay examinations (187.36 vs. 158.77, 152.17, 152.29, p<0.001), but a significantly lower mean score in short answer examination (60.09 vs. 66.79, 67.73, 64.82, p<0.001). The online open-book examination group had a significantly lower correlation between the essay score and their GPA than the previous traditional groups (z=2.81 p=0.005, z=2.23 p=0.026, z=2.19 p=0.029). CONCLUSION: Although an online, open-book examination was feasible during the COVID-19 pandemic, this study indicates that mean scores are significantly different which has important implications regarding grading and standard setting. More research is required to assess other effects of this new assessment on long-term knowledge retention and application.

Implementation of the ACS/ APDS Resident Skills Curriculum reveals a need for rater training: An analysis using generalizability theory.

BACKGROUND: The American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) Resident Skills Curriculum includes validated task-specific checklists and global rating scales (GRS) for Objective Structured Assessment of Technical Skills (OSATS). However, it does not include instructions on use of these assessment tools. Since consistency of ratings is a key feature of assessment, we explored rater reliability for two skills. METHODS: Surgical faculty assessed hand-sewn bowel and vascular anastomoses in real-time using the OSATS GRS. OSATS were video-taped and independently evaluated by a research resident and surgical attending. Rating consistency was estimated using intraclass correlation coefficients (ICC) and generalizability analysis. RESULTS: Three-rater ICC coefficients across 24 videos ranged from 0.12 to 0.75. Generalizability reliability coefficients ranged from 0.55 to 0.8. Percent variance attributable to raters ranged from 2.7% to 32.1%. Pairwise agreement showed considerable inconsistency for both tasks. CONCLUSIONS: Variability of ratings for these two skills indicate the need for rater training to increase scoring agreement and decrease rater variability for technical skill assessments.

Successful Conservative Treatment of an Elderly Patient with Corrosive Proctocolitis.

Corrosive proctocolitis has occurred after accidental contamination of endoscopes in most patients. But accidental administration of corrosive agents for bowel cleansing can occur. The agents implicated for chemical colitis is 15% hydrochloric acid and 2% ethoxylated alcohol. We present a case of corrosive proctocolitis, present with anal pain and bloody diarrhea. Endoscopy revealed edema, erythema, and friability of the colonic mucosa. An experience of successful nonoperative treatments has been demonstrated.

Morphological Classification of Intraductal Papillary Neoplasm of the Bile Duct with Survival Correlation

Background: Intraductal papillary neoplasm of the bile duct (IPNB) is a specific entity for which there has been no classification that correlates clinical presentation with patient survival. We, therefore, propose a new classification based on radio-pathological appearance correlated with clinical findings including outcome. Methods: We retrospectively reviewed the medical and pathological records of 103 IPNB patients who underwent curative-intent hepatic resection between January 2008 and December 2011. A morphological classification was then created based on the presence of (a) bile duct dilatation, (b) intraductal mass(es), (c) cystic lesion(s), and (d) macro-invasion of the liver. All clinical parameters and survival were analyzed. Results: The median survival of IPNB patients was 1,728 days (95%CI: 1,485 to 1,971 days). The proposed classification predicted survival very well (log-rank test; p < 0.01). For patients with the cystic variant and micro-papillary IPNB, there were no tumor-related deaths within 3 years of surgery and median survival was not reached during the follow-up. The respective median survival times for IPNBs with unilateral intrahepatic duct dilatation, bilateral intrahepatic duct dilatation, and macro-invasion were 1,888 days (95%CI 1,118- 2,657), 673 days (95%CI: 392- 953), and 578 days (95%CI: 285- 870). Conclusion: We propose a new classification for IPNBs which not only provides a view of patients in terms of their radio-pathologic status but also should help in guiding planning of surgical procedures.

Spontaneous Intramural Duodenal Hematoma: Pancreatitis, Obstructive Jaundice, and Upper Intestinal Obstruction.

Nontraumatic intramural duodenal hematoma can cause upper gastrointestinal tract obstruction, upper gastrointestinal hemorrhage, jaundice, and pancreatitis and may be present in patients with normal coagulation. However the pathogenesis of the condition and its relationship with acute pancreatitis remain unknown. We present a case of spontaneous intramural duodenal hematoma and a case of successful nonoperative treatments.

Patterns of Recurrence after Resection of Mass-Forming Type Intrahepatic Cholangiocarcinomas

Background: Intrahepatic cholangiocarcinoma (IHCCA) is an aggressive tumor for which surgical resection is a mainstay of treatment. However, recurrence after resection is common associated with a poor prognosis. Studies regarding recurrence of mass-forming IHCCA are rare; therefore, we investigated the pattern with our dataset. Methods: We retrospectively reviewed the medical and pathological records of 50 mass-forming IHCCA patients who underwent hepatic resection between January 2004 and December 2009 in order to determine the patterns of recurrence and prognosis. All demographic and operative parameters were analyzed for their effects on recurrence-free survival. Results: The median recurrence-free survival time was 188 days (95%CI: 149-299). The respective 1-, 2-, and 3-year recurrence-free survival rates were 16.2% (95%CI: 6.6-29.4), 5.4% (95%CI: 1.0-15.8) and 2.7% (95%CI: 0.2-12.0). There was an equal distribution of recurrence at solitary and multiple sites. Univariate analysis revealed no factors related to recurrence-free survival.Conclusion: The overall survival and recurrence-free survival after surgery for mass-forming IHCCA were found to be very poor. Almost all recurrences were detected within 2 years after surgery. Adjuvant chemotherapy after surgery may add benefit in the affected patients.