Generating a Prioritized List of Operative Procedures for Simulation-based Assessment of General Surgery Trainees Through Consensus.

OBJECTIVE: To develop appropriate content for high-stakes simulation-based assessments of operative competence in general surgery training through consensus. BACKGROUND: Valid methods of summative operative competence assessment are required by competency-based training programs in surgery. METHOD: An online Delphi consensus study was conducted. Procedures were derived from the competency expectations outlined by the Joint Committee on Surgical Training Curriculum 2021, and subsequent brainstorming. Procedures were rated according to their perceived importance, perceived procedural risk, how frequently they are performed, and simualtion feasibility by a purposive sample of 30 surgical trainers and a 5-person steering group. A modified Copenhagen Academy for Medical Education and Simulation Needs Assessment Formula was applied to the generated data to produce ranked procedural lists, which were returned to participants for re-prioritization. RESULTS: Prioritized lists were generated for simulation-based operative competence assessments at 2 key stages of training; the end of 'phase 2' prior to the development of a sub-specialty interest, and the end of 'phase 3', that is, end-of-training certification. A total of 21 and 16 procedures were deemed suitable for assessments at each of these stages, respectively. CONCLUSIONS: This study describes a national needs assessment approach to content generation for simulation-based assessments of operative competence in general surgery using Delphi consensus methodology. The prioritized procedural lists generated by this study can be used to further develop operative skill assessments for use in high-stakes scenarios, such as trainee progression, entrustment, and end-of-training certification, before subsequent validity testing.

Management Strategies for Malignant Left-Sided Colonic Obstruction: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Propensity Score Matching Studies.

BACKGROUND: The optimal treatment strategy for left-sided malignant colonic obstruction remains controversial. Emergency colonic resection has been the standard of care; however, self-expanding metallic stenting as a bridge to surgery may offer short-term advantages, although oncological concerns exist. Decompressing stoma may provide a valid alternative, with limited evidence. OBJECTIVE: To perform a systematic review and Bayesian arm random-effects model network meta-analysis comparing the approaches for management of malignant left-sided colonic obstruction. DATA SOURCES: A systematic review of PubMed, Embase, Cochrane Library, and Google Scholar databases was conducted from inception to August 22, 2023. STUDY SELECTION: Randomized controlled trials and propensity score-matched studies. INTERVENTIONS: Emergency colonic resection, self-expanding metallic stent, and decompressing stoma. MAIN OUTCOME MEASURES: Oncologic efficacy, morbidity, successful minimally invasive surgery, primary anastomosis, and permanent stoma rates. RESULTS: Nineteen of 5225 articles identified met our inclusion criteria. Stenting (risk ratio 0.57; 95% credible interval, 0.33-0.79) and decompressing stomas (risk ratio 0.46, 95% credible interval: 0.18-0.92) resulted in a significant reduction in the permanent stoma rate. Stenting facilitated minimally invasive surgery more frequently (risk ratio 4.10; 95% credible interval, 1.45-13.13) and had lower overall morbidity (risk ratio 0.58; 95% credible interval, 0.35-0.86). A pairwise analysis of primary anastomosis rates showed increased stenting (risk ratio 1.40; 95% credible interval, 1.31-1.49) compared with emergency resection. There was a significant decrease in the 90-day mortality with stenting (risk ratio 0.63; 95% credible interval, 0.41-0.95) compared with resection. There were no differences in disease-free and overall survival rates, respectively. LIMITATIONS: There is a lack of randomized controlled trials and propensity score matching data comparing short-term and long-term outcomes for diverting stomas compared to self-expanding metallic stents. Two trials compared self-expanding metallic stents and diverting stomas in left-sided malignant colonic obstruction. CONCLUSIONS: This study provides high-level evidence that a bridge-to-surgery strategy is safe for the management of left-sided malignant colonic obstruction and may facilitate minimally invasive surgery, increase primary anastomosis rates, and reduce permanent stoma rates and postoperative morbidity compared with emergency colonic resection.

Assessing current handover practices in surgery: A survey of non-consultant hospital doctors in Ireland.

BACKGROUND: Handovers of care are potentially hazardous moments in the patient journey and can lead to harm if conducted poorly. Through a national survey of surgical doctors in Ireland, this paper assesses contemporary surgical handover practices and evaluates barriers and facilitators of effective handover. METHODS: After ethical approval and pre-testing with a representative sample, a cross-sectional, online survey was distributed to non-consultant hospital doctors (NCHDs) working in the Republic of Ireland. A mixed-methods approach was used, combining data using triangulation design. MAIN FINDINGS: A total of 201 responses were received (18.5%). Most participants were senior house officers or senior registrars (49.7% and 37.3%). Most people (85.1%) reported that information received during handover was missing or incorrect at least some of the time. One-third of respondents reported that a near-miss had occurred as a result of handover within the past three months, and handover-related errors resulted in minor (16.9%), moderate (4.9%), or major (1.5%) harm. Only 11.4% had received any formal training. Reported barriers to handover included negative attitudes, a lack of institutional support, and competing clinical activities. Facilitators included process standardisation, improved access to resources, and staff engagement. CONCLUSIONS: Surgical NCHDs working in Irish hospitals reported poor compliance with international best practice for handover and identified potential harms. Process standardisation, appropriate staff training, and the provision of necessary handover-related resources is required at a national level to address this significant patient safety concern.

Baseline Assessments of Psychomotor Aptitude Are Associated With the Future Operative Performance of Surgical Trainees: A Prospective Observational Cohort Study.

OBJECTIVE: This study sought to investigate the association between validated psychomotor ability tests and future in-theater and simulated operative performance. BACKGROUND: Assessments of visuospatial ability, perceptual ability, and manual dexterity correlate with simulated operative performance. Data showing the predictive value of such assessments in relation to future performance in the workplace is lacking. METHODS: Core surgical residents in Ireland recruited from 2016 to 2019 participated in assessments of baseline perceptual, visuospatial, and psychomotor ability; Pictorial Surface Orientation (PicSOr) testing, digital visuospatial ability testing, and manual dexterity testing. Operative performance was prospectively assessed using the in-theater Supervised Structured Assessment of Operative Performance (SSAOP) tool, and simulation-based Operative Surgical Skill (OSS) assessments performed over a 2-year core training period. SSAOP assessments were scored using a 15-point checklist and a global 5-point operative performance score. OSS assessments were scored using procedure-specific checklists. Univariate correlations and multiple linear regression analyses were used to explore the association between fundamental ability measures and operative performance. RESULTS: A total of 242 residents completed baseline psychomotor ability assessments. Aggregated fundamental ability scores were associated with performance in submitted workplace-based SSAOP assessments using the Total Checklist score ( P =0.002) and Overall Performance scores ( P =0.002), independent of operative experience, and undergraduate centile scores. Aggregated ability scores were also positively associated with simulation-based OSS assessment scores on multivariable analysis ( P =0.03). CONCLUSION: This study indicates that visuospatial, psychomotor, and perceptual ability testing scores are associated with the future operative performance of surgical residents.

Survival outcomes after synchronous para-aortic lymph node metastasis in colorectal cancer: A systematic review.

BACKGROUND: Synchronous para-aortic lymph node metastasis (PALNM) in colorectal cancer (CRC) is a relatively rare clinical entity. There is a lack of consensus on management of these patients, and the role of para-aortic lymph node dissection (PALND) remains controversial. This systematic review aims to describe the survival outcomes in colorectal cancer with synchronous PALNM when lymph node dissection is performed. METHODS: A systematic review of Pubmed, Embase and Web of Science databases for PALND in CRC was performed. Studies including patients with synchronous PALNM undergoing resection with curative intent, published from the year 2000 onwards, were included. RESULTS: Twelve retrospective studies were included. Four studies reported survival outcomes for rectal cancer, two for colon cancer and six as colorectal. Survival outcomes for 356 patients were included. Average 5-year overall survival (OS) was 22.4%, 33.9% and 37.7% in the rectal, colon and colorectal groups respectively. Three year OS in the groups was 53.6%, 46.2% and 65.7%. CONCLUSION: There remains a lack of quality data to confidently make recommendations regarding the management of synchronous PALNM in colon and rectal cancer cohorts. Retrospective data suggests a benefit in highly selective cohorts and therefore a case-by-case evaluation remains the standard of care.

Training and assessment using the LapSim laparoscopic simulator: a scoping review of validity evidence.

INTRODUCTION: The LapSim (Surgical Science, Sweden) laparoscopic simulator is a high-fidelity virtual reality simulator for use in endoscopic surgical training. This review critiques the current validity evidence for the LapSim laparoscopic simulator, specifically with respect to its potential use as a tool and method of training and assessment in surgery. METHODS: A scoping review of the MEDLINE (PubMed), EMBASE, Cochrane and Web of Science databases was conducted in accordance with PRISMA guidelines (2020)-scoping review extension. Articles were included if they presented validity evidence for the use of the LapSim in operative skill training or assessment, in accordance with Messick's validity framework. European Association of Endoscopic Surgeons (EAES) guidelines (2005) were used to provide recommendations for the use of the LapSim in operative performance training and assessments. RESULTS: Forty-nine articles were included. An EAES level 2 recommendation was provided with regard to the internal consistency reliability of automated performance metrics in assessing performance. An EAES recommendation of 2 was awarded with respect to the ability of the LapSim to discriminate based on case volume and overall laparoscopic experience (relationships with other variables). Performance assessment metrics on the LapSim correlate with improved performance in the operating room (EAES level of recommendation 1-consequential validity). CONCLUSION: The LapSim has accumulated substantial evidence supporting the validity of its use in surgical training and assessment. Future studies should explore the relationship between the achievement of performance benchmarks on the LapSim and subsequent patient outcomes, and interrogate the benefits of implementing virtual reality simulation training and assessment curricula in post-graduate surgical training programmes.

Assessing Operative Skill in the Competency-based Education Era: Lessons From the UK and Ireland.

INTRODUCTION: Decisions regarding the operative competence of surgical residents in the United Kingdom and Ireland are informed by operative workplace-based assessments (WBAs) and operative number targets for index procedures. This review seeks to outline the validity evidence of these assessment methods. METHODS: A review of the MEDLINE (Pubmed), EMBASE and Cochrane Library databases was undertaken in accordance with the Joanna Briggs Institute Protocol for Scoping Reviews (2020). Articles were included if they provided evidence of the validity of procedure-based assessments, direct observation of procedural skills, or indicative operative number targets. The educational impact of each article was evaluated using a modified Kirkpatrick model. RESULTS: Twenty-eight articles outlining validity evidence of WBAs and operative number targets were synthesised by narrative review. Five studies documented users' views on current assessment methods (Kirkpatrick level 1). Two articles recorded changes in attitudes towards current operative assessments (level 2a). Ten studies documented the ability of current assessments to record improvements in operative competence (level 2b). Ten studies measured a change in behaviour as a result of the introduction of these assessments (level 3). One article studied the ability of operative assessments to predict clinical outcomes (level 4b). CONCLUSIONS: Operative WBAs are reliable. Scores achieved correlate with both time spent in training and recorded operative experience. Trainers and residents have concerns regarding the subjectivity of these assessments and the opportunistic nature in which they are used. Operative number targets are not criterion-referenced, lack validity evidence, and may be set too low to ensure operative competence.

Prostate radiotherapy and the risk of secondary rectal cancer-a meta-analysis.

PURPOSE: Radiotherapy is being used increasingly in the treatment of prostate cancer. However, ionising radiation may confer a small risk of a radiation-induced secondary malignancy. We aim to assess the risk of rectal cancer following pelvic radiotherapy for prostate cancer. METHODS: A search was conducted of the PubMed/MEDLINE, EMBASE and Web of Science databases identifying studies reporting on the risk of rectal cancer following prostatic radiotherapy. Studies must have included an appropriate control group of non-irradiated prostate cancer patients. A meta-analysis was performed to assess the risk of prostatic radiotherapy on subsequent rectal cancer diagnosis. RESULTS: In total, 4757 articles were screened with eight studies meeting the predetermined criteria. A total of 796,386 patients were included in this meta-analysis which showed an increased odds ratio (OR) for subsequent rectal cancer in prostate cancer patients treated with radiotherapy compared to those treated by non-radiotherapy means (OR 1.45, 1.07-1.97, p = 0.02). CONCLUSION: These findings confirm that prostate radiotherapy significantly increases the risk of subsequent rectal cancer. This risk has implications for treatment selection, surveillance and patient counselling. However, it is crucial that this information is presented in a rational and comprehensible manner that does not disproportionately frighten or deter patients from what might be their most suitable treatment modality.

Training to proficiency in surgery using simulation: is there a moral obligation?

A deontological approach to surgical ethics advocates that patients have the right to receive the best care that can be provided. The 'learning curve' in surgical skill is an observable and measurable phenomenon. Surgical training may therefore carry risk to patients. This can occur directly, through inadvertent harm, or indirectly through theatre inefficiency and associated costs. Trainee surgeon operating, however, is necessary from a utilitarian perspective, with potential risk balanced by the greater societal need to train future independent surgeons.New technology means that the surgical learning curve could take place, at least in part, outside of the operating theatre. Simulation-based deliberate practice could be used to obtain a predetermined level of proficiency in a safe environment, followed by simulation-based assessment of operative competence. Such an approach would require an overhaul of the current training paradigm and significant investment in simulator technology. This may increasingly be viewed as necessary in light of well-discussed pressures on surgical trainees and trainers.This article discusses the obligations to trainees, trainers and training bodies raised by simulation technology, and outlines the current arguments both against and in favour of a simulation-based training-to-proficiency model in surgery. The significant changes to the current training paradigm that would be required to implement such a model are also discussed.

Optimal surgical management strategy for treatment of primary anorectal malignant melanoma-a systematic review and meta-analysis.

BACKGROUND: Primary mucosal anorectal malignant melanoma (AMM) is an invasive malignancy with poor survival. Management options have been variable, due to limited data and lack of randomised control trials available on the optimal surgical strategy. The aim of this review was to compare local excision versus radical resection. METHODS: A systematic search of articles in PubMed, Ovid, Scopus, and the Cochrane Library database was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The outcomes of interest were the impact that surgical strategy had on survival (primary) and recurrence rates (secondary) for the treatment of AMM, comparing sphincter sparing local excision (LE) versus extensive abdominoperineal resection (APR). RESULTS: Ten studies met the predefined criteria. Overall, there were 303 patients, with a median age of 58.2 years. Sixty-one percent (n = 187/303) had radical surgery (abdominoperineal resection) for the primary treatment of AMM. Overall, 5-year survival for the APR and LE was 23% and 32% respectively. Meta-analysis on the median OS noted no statistical difference between the two groups. However, local recurrence occurred in 20.82% and 47.04% in the APR and LE groups respectively. Meta-analysis observed a statistically significant reduction in recurrence when patients had an APR as primary treatment (OR 0.15, 95% CI = 0.08-0.28, p < 0.00001). CONCLUSION: Though local recurrence rates are more common with local excision of AMM, this does not confer an inferior OS when comparing LE versus APR. The decision to proceed with LE vs. APR should be made on a case-by-case basis.

Perspectives on simulation-based assessment of operative skill in surgical training.

INTRODUCTION: The perspectives of the wider surgical community toward simulation-based assessment (SBA) in training is a gap in the literature. This study aims to explore the factors associated with the acceptable use of SBA in surgical training, through the perceptions and experiences of a broad range of stakeholder representatives, building on findings from a review of the published literature. MATERIALS AND METHODS: Ten semi-structured interviews were conducted, using a sequential transformative qualitative methods approach, with representatives from identified key stakeholder groups; executive management, risk management, a practicing surgeon, an anaesthesiologist, a theatre-nursing representative, a representative from simulation industry, a patient, a medical student, a junior surgical trainee, and a senior surgical trainee. Interview transcripts underwent reflexive thematic analysis using an inductive and constructivist framework (NVIVO software, NVIVO 12, QSR International). RESULTS: Four themes emerged: the 'need' for SBA, the concept of a 'minimum standard', the 'optimum design' of an SBA framework, and 'fairness'. SBA is a potential solution to challenges in the current training environment. It emerged that it should not replace trainer judgement, but could ensure that trainees meet a minimum operative competency standard. SBA should be used to identify underperforming trainees early in training to provide targeted remediation. The application of SBA in high-stakes settings such as trainee selection, autonomy granting, and end-of training certification has perceived benefits over current assessment methods. CONCLUSIONS: This study builds on findings from prior research to explore factors regarding the acceptable use of simulation as an assessment method in surgical training, including perspectives from a broad range of stakeholder representatives. Findings can inform the development of simulation-based assessment curricula in surgical training.

A systematic review of simulation in open abdominal aortic aneurysm repair.

OBJECTIVE: Concerns about the long-term durability of endovascular aortic aneurysm repair and the requirement for explantation of stents in the case of infection demonstrate the continued need for open abdominal aortic aneurysm (AAA) repair. However, with the increased complexity and decreasing volume of open cases performed, maintenance of skills and training of younger surgeons are challenging. The aim of this review was to identify and to examine studies pertaining to open AAA simulation, with focus on methods and outcomes. METHODS: We performed a systematic review of the literature to identify primary research pertaining to open AAA repair through the use of simulators. The primary outcome was to identify predominant modes of simulator design and validated assessment tools that could demonstrate improvement in trainee skills. Secondary outcomes included identifying participant numbers needed to power studies and whether tools not validated externally contributed to the studies. RESULTS: There were 309 unique papers identified, from which five papers met the inclusion criteria. The selected papers used a combination of synthetic (commercial and homemade) and cadaveric simulators. A variety of validated and nonvalidated assessment metrics were used, including Objective Structured Assessment of Technical Skills, global rating scales, and realism surveys. Three of the five papers used blinding as part of their assessments. Mean participant numbers were 30.8 ± 25.7 and with the exception of one paper consisted entirely of surgical trainees in dedicated general or vascular surgery training programs. CONCLUSIONS: Several options are currently available for open AAA simulation, all of which demonstrate improved scoring metrics after simulator use. Validated scoring systems, the Objective Structured Assessment of Technical Skills in particular, were most frequently used to deliver objective results. Whereas junior trainees derive the most benefit, senior trainees also showed significant improvements, demonstrating that simulation benefits all levels of surgical trainees. Low numbers of participants were sufficient to achieve statistical benefit within individual studies.

Strictureplasty versus bowel resection for the surgical management of fibrostenotic Crohn's disease: a systematic review and meta-analysis.

BACKGROUND: Strictureplasty (SPX) conserves bowel length and minimizes the risk of developing short bowel syndrome in patients undergoing surgery for Crohn's disease (CD). However, SPX may be associated with a higher risk of recurrence compared with bowel resection (BR). AIM: We sought to compare morbidity and recurrence following SPX and BR in patients with fibrostenotic CD. METHODS: A systematic review was performed according to PRISMA and MOOSE guidelines. Observational studies that compared outcomes of CD patients undergoing either SPX or BR were identified. Log hazard ratios (InHR) for recurrence-free survival (RFS) and their standard errors were calculated from Kaplan-Meier plots or Cox regression models and pooled using the inverse variance method. Dichotomous variables were pooled as odds ratios (OR) using the Mantel-Haenszel method. Continuous variables were pooled as weighted mean differences. RESULTS: Twelve studies of 1026 CD patients (SPX n = 444, 43.27%; BR with or without SPX n = 582, 56.72%) were eligible for inclusion. There was an increased likelihood of disease recurrence with SPX than with BR (OR 1.61; 95% CI, 1.03, 2.52; p = 0.04; I2 = 0%). Patients who had a SPX alone had a significantly reduced RFS than those who underwent BR (HR 1.47; 95% CI, 1.08, 2.01; p = 0.02; I2 = 0%). There was no difference in morbidity between the groups (OR 0.58; 95% CI, 0.26, 1.28; p = 0.18; I2 = 0%). CONCLUSION: SPX should only be performed in those patients with Crohn's strictures that are at high risk for short bowel syndrome and intestinal failure; otherwise, BR is the favored surgical technique for the management of fibrostenotic CD.

Endoscopic management versus transanal surgery for early primary or early locally recurrent rectal neoplasms-a systematic review and meta-analysis.

BACKGROUND: Both endoscopic techniques and transanal surgery are viable options that allow organ preservation for early rectal neoplasms. Whilst endoscopic approaches are less invasive and carry less morbidity, it is unclear whether they are as oncologically effective. AIM: To compare endoscopic techniques with transanal surgery in the management of early rectal neoplasms. METHODS: A systematic literature search was performed for randomised and observational studies comparing these techniques. The pre-specified main outcomes measured were en bloc and R0 resection rates and recurrence. Pair-wise meta-analysis was performed. RESULTS: This review included 1044 patients. Transanal surgery had increased R0 resection rates (odds ratio (OR) 2.66; 95% CI 1.64; 4.31; p < 0.001) versus endoscopic management. The latter was associated with higher rates of incomplete resection (OR 2.25; 95% CI 1.14, 4.46; p = 0.02) and further intervention (OR 1.78; 95% CI 1.09, 2.88; p = 0.02). There was no difference in the rates of late recurrence (OR 1.01; 95% CI 0.53, 1.91; p = 0.99) or further major surgery (OR 0.87; 95% CI 0.39, 1.94; p = 0.73) between the groups. Endoscopic treatment was associated with a shorter operating time (weighted mean difference (WMD) - 12.08; 95% CI - 18.97, - 5.19; p < 0.001) and LOS (WMD - 1.94; 95% CI - 2.43, - 1.44; p < 0.001), as well as lower rates of urinary retention post-operatively (OR 0.12; 95% CI 0.02, 0.63; p = 0.01). CONCLUSION: Endoscopic techniques should be favoured in the setting of benign early rectal neoplasms given their decreased morbidity and increased cost-effectiveness. However, where malignancy is suspected transanal surgery should be the preferred option given the superior R0 resection rate.

Meta-analysis of early bowel resection versus initial medical therapy in patient's with ileocolonic Crohn's disease.

BACKGROUND: Early bowel resection (EBR) in ileocolonic Crohn's disease (CD) may be associated with more durable remission compared with initial medical therapy (IMT) even when biologic therapy is included. AIM: To compare the efficacy of EBR versus IMT for ileocolonic CD METHODS: A systematic search was performed to identify studies that compared EBR (performed < 1 year from initial diagnosis) or IMT for the management of ileocolonic CD. Log hazard ratios (InHR) for relapse-free survival (RFS) and their standard errors were calculated from Kaplan-Meier plots and pooled using the inverse-variance method. Dichotomous variables were pooled as odds ratios (OR). Quality assessment of the included studies was performed using the Newcastle-Ottawa (NOS) and Jadad scales. RESULTS: A total of 7 studies with 1863 CD patients (EBR n = 581, 31.2%; IMT n = 1282, 68.8%) were eligible for inclusion. There was a moderate-to-high risk of bias. The median NOS was 8 (range 7-9). There was a reduced likelihood of overall (OR, 0.53; 95% confidence interval (95% CI), 0.34, 0.83; p = 0.005) and surgical (OR, 0.47; 95% CI, 0.24, 0.91; p = 0.03) relapse with EBR. There was also a less requirement for maintenance biologic therapy (OR, 0.24; 95% CI, 0.14, 0.42; p < 0.0001). Patients who underwent EBR had a significantly improved RFS than those who underwent IMT (HR, 0.62; 95% CI, 0.52, 0.73; p < 0.001). There was no difference in morbidity (OR, 1.67; 95% CI, 0.44, 6.36; p = 0.45) between the groups. CONCLUSION: EBR may be associated with less relapse and need for maintenance biologic therapy than IMT. 'Upfront' or early resection may represent a reasonable and cost-effective alternative to biologic therapy, especially in biologic-resistant subpopulations.

The contribution of endoscopy quality measures to the development of interval colorectal cancers in the screening population: a systematic review.

BACKGROUND: Colon cancer is the second most common cause of cancer-related death and an important cause of morbidity. The natural history of carcinogenesis, via the adenoma-carcinoma sequence, permits screening, which reduces the relative risk of mortality by up to 16%. The efficacy of a screening programme is limited by the growth of interval colorectal cancers between screening examinations. Quantifying the rate of interval cancers and delineating contributing endoscopic factors are crucial to maximise the benefit of a screening program. METHODS: A systematic review was performed in accordance with PRISMA principles. Electronic databases were interrogated with a considered search strategy, and reference lists of retrieved papers were surveyed. For inclusion, studies included the rate of interval cancer (stated or calculated) and reported at least one of a predefined list of endoscopy characteristics. The primary outcome was to establish the rate of interval cancers. The secondary outcome was to determine the association between endoscopy quality measures and interval cancers. RESULTS: The search yielded 2067 papers. Seventy-six full text papers were reviewed. Fifteen papers met the inclusion criteria. In total, there were 117,793 colon cancers, 7281 of which were interval lesions, giving an overall rate of 6.2%. The adenoma detection rate (ADR) of the endoscopist performing the index operation was the most consistent endoscopy factor associated with development of interval cancers. The impact of setting, volume and bowel preparation varied between papers. CONCLUSION: Interval cancers reduce the efficacy of colorectal screening programmes. Ensuring the quality of the endoscopy process, specifically by increasing the ADR of practitioners, is crucial to the reduction of the rate of interval cancers.

Current Controversies in the Management of Diverticulitis: A Review.

BACKGROUND: Symptomatic diverticular disease is challenging for patients, clinicians and health services. The prevalence increases with age and BMI and as such, the burden of this disease is set to increase with higher rates of acute presentations already documented. The natural history of recurrent episodes, complications and symptom progression is not fully understood. Furthermore, medical and surgical management strategies are under constant appraisal, debate and evolution. METHODS: A review of the contemporary literature was performed to examine the emerging trend towards conservative treatment. RESULTS: Routine use of in-patient, intravenous antibiotics may not be required and outpatient management is possible for certain patients. Universal colonoscopy examination after uncomplicated acute diverticulitis is controversial but is mandatory after complicated episodes. Recent, high-profile, clinical trials suggest that less aggressive surgical management of both acute and chronic presentations may be feasible in some cases. CONCLUSIONS: Diverticulitis is a common yet challenging topic that demands clinicians to provide an individualised yet evidence-based approach.

Visuospatial abilities and fine motor experiences influence acquisition and maintenance of fundamentals of laparoscopic surgery (FLS) task performance.

BACKGROUND: Minimally invasive surgery poses a unique learning curve due to the requirement for non-intuitive psychomotor skills. The fundamentals of laparoscopic surgery (FLS) program trains and certifies residents in such skills. However, innate predictors of FLS performance and maintenance remain to be described. This single-centre observational study aimed to assess for candidate factors influencing the acquisition and maintenance of FLS performance amongst a surgically naïve cohort. METHODS: Laparoscopically naïve medical students were recruited from pre-clinical university grades. Participants completed five visuospatial/psychomotor tests and a questionnaire surveying non-surgical experiences and personality traits. Individuals completed baseline assessments of FLS standard tasks followed by an intensive training course over week one and two on inanimate box trainers. A post-training assessment was performed in week three to evaluate acquisition. Participants were withdrawn from exposure and retested at four 1-month intervals to assess maintenance requirements. RESULTS: Forty-nine participants enrolled with 35 (71.4%) and 33 (67.3%) completing acquisition and maintenance phases, respectively. Mean age of participants was 19.3 (± 1.2) years with 68.6% female predominance. Participants demonstrated significant improvements in all five tasks during the acquisition (p < 0.05) period and maintenance of skills with task exposure at 1-month intervals. Significant predictors of skill acquisition included: card rotations for intracorporeal knot (p = 0.027) and combined tasks (p = 0.028) and cube comparisons for extracorporeal knot (p = 0.040). During skill maintenance: Card rotations predicted performance across all tasks (p < 0.05), Cube comparisons for tasks 1/2/4/5 (p < 0.05), PicSOR for peg transfer (p = 0.017) and grooved pegboard for peg transfer (p = 0.023) and ligating-loop (p = 0.038) tasks. Musical instrument experience demonstrated associations with skill acquisition in peg transfer (p = 0.042) and intracorporeal knot (p = 0.034) while video gaming predicted performance in these tasks (p < 0.05) during the maintenance phase. A sporting background or competitive personality did not influence skill performance. CONCLUSIONS: Multiple visuospatial abilities and non-surgical experiences positively influenced FLS performance during skill acquisition and/or maintenance. Further consideration to these individual factors may facilitate selection of more technically adaptable surgical residents.

Playing to your skills: a randomised controlled trial evaluating a dedicated video game for minimally invasive surgery.

BACKGROUND: Video gaming demands elements of visual attention, hand-eye coordination and depth perception which may be contiguous with laparoscopic skill development. General video gaming has demonstrated altered cortical plasticity and improved baseline/acquisition of minimally invasive skills. The present study aimed to evaluate for skill acquisition associated with a commercially available dedicated laparoscopic video game (Underground) and its unique (laparoscopic-like) controller for the Nintendo®Wii U™ console. METHODS: This single-blinded randomised controlled study was conducted with laparoscopically naive student volunteers of limited (< 3 h/week) video gaming backgrounds. Baseline laparoscopic skills were assessed using four basic tasks on the Virtual Reality (VR) simulator (LAP MentorTM, 3D systems, Colorado, USA). Twenty participants were randomised to two groups; Group A was requested to complete 5 h of video gaming (Underground) per week and Group B to avoid gaming beyond their normal frequency. After 4 weeks participants were reassessed using the same VR tasks. Changes in simulator performances were assessed for each group and for intergroup variances using mixed model regression. RESULTS: Significant inter- and intragroup performances were present for the video gaming and controls across four basic tasks. The video gaming group demonstrated significant improvements in thirty-one of the metrics examined including dominant (p ≤ 0.004) and non-dominant (p < 0.050) instrument movements, pathlengths (p ≤ 0.040), time taken (p ≤ 0.021) and end score [p ≤ 0.046, (task-dependent)]. The control group demonstrated improvements in fourteen measures. The video gaming group demonstrated significant (p < 0.05) improvements compared to the control in five metrics. Despite encouraged gameplay and the console in participants' domiciles, voluntary engagement was lower than directed due to factors including: game enjoyment (33.3%), lack of available time (22.2%) and entertainment distractions (11.1%). CONCLUSION: Our work revealed significant value in training using a dedicated laparoscopic video game for acquisition of virtual laparoscopic skills. This novel serious game may provide foundations for future surgical developments on game consoles in the home environment.