Construct validity of fresh frozen human cadaver as a training model in minimal access surgery.

BACKGROUND: The construct validity of fresh human cadaver as a training tool has not been established previously. The aims of this study were to investigate the construct validity of fresh frozen human cadaver as a method of training in minimal access surgery and determine if novices can be rapidly trained using this model to a safe level of performance. METHODS: Junior surgical trainees, novices (<3 laparoscopic procedure performed) in laparoscopic surgery, performed 10 repetitions of a set of structured laparoscopic tasks on fresh frozen cadavers. Expert laparoscopists (>100 laparoscopic procedures) performed 3 repetitions of identical tasks. Performances were scored using a validated, objective Global Operative Assessment of Laparoscopic Skills scale. Scores for 3 consecutive repetitions were compared between experts and novices to determine construct validity. Furthermore, to determine if the novices reached a safe level, a trimmed mean of the experts score was used to define a benchmark. Mann-Whitney Utest was used for construct validity analysis and 1-sample t test to compare performances of the novice group with the benchmark safe score. RESULTS: Ten novices and 2 experts were recruited. Four out of 5 tasks (nondominant to dominant hand transfer; simulated appendicectomy; intracorporeal and extracorporeal knot tying) showed construct validity. Novices' scores became comparable to benchmark scores between the eighth and tenth repetition. CONCLUSION: Minimal access surgical training using fresh frozen human cadavers appears to have construct validity. The laparoscopic skills of novices can be accelerated through to a safe level within 8 to 10 repetitions.

Case-based discussions: UK surgical trainee perceptions.

BACKGROUND: An increasing emphasis on accountability led to the development of the Intercollegiate Surgical Curriculum Project (ISCP) in the UK. A major feature of ISCP was a focus on competence with the institution of formative assessments to aid learning and provide portfolio evidence. Case-based discussions (CBDs) are one of the main formative assessments used at all stages of training. The aim of this study was to review the use of CBDs by surgical trainees to determine if and when they are useful, and whether they are perceived as being used correctly. METHODS: Semi-structured interviews were carried out with both higher and core surgical trainees. Inductive reasoning principles were used to analyse and interpret the responses to open questions. Common themes were determined and thematic analysis was carried out. RESULTS: Forty-two surgical trainees (21 core and 21 higher trainees) were interviewed. Core trainees felt that CBDs were more likely to be used correctly, and both groups thought that they were a positive feature of training. Few stated that they were used to shape training needs. Positive themes identified included the provision of feedback, identifying learning portfolio evidence and encouraging reflection. Negative themes included a 'tick-box' mentality and that the value was diminished by a lack of engagement with the process from trainers. Case-based discussions are one of the main formative assessments used at all stages of training CONCLUSION: Trainees regarded CBDs as a positive feature allowing the discussion of complicated cases, and encouraging higher thinking and reflection; however, concerns were raised regarding their implementation, which has led to a diminishing of their value.

Surgical Trainers' Experience and Perspectives on Workplace-Based Assessments.

BACKGROUND: Workplace-based assessments (WBAs) were designed to provide formative feedback to trainees throughout their surgical career. Several studies highlight dissatisfaction with WBAs, and some feel they lack validity and reliability and exist as a "tick-box exercise." No studies have looked at the attitudes of the assessor. AIM: The aim of this study was to evaluate perceptions and experience of the 4 intercollegiate surgical curriculum programme WBAs by assessors. METHODS: An 18-item electronic questionnaire, including 6-point Likert scoring questions, was e-mailed to all surgical program directors for distribution to general surgery trainers within their deanery. RESULTS: In total, 64 responses were received. All trainers had been trained in using WBAs. Trainers had the most experience with procedure-based assessments (PBAs)-72% of trainers had completed more than 25 PBAs. Trainers felt PBAs were the most beneficial WBA, and both PBAs and case-based discussions were regarded as significantly more useful than mini-clinical evaluation exercise (p < 0.05). More than 74% stated that WBAs were mainly initiated by trainees, and only 10% had specific sessions allocated to complete WBAs. CONCLUSION: WBAs are regarded as beneficial to trainees. The results suggest that assessors feel case-based discussions and PBAs, which assess higher thinking and practice of complex practical skills, respectively, are significantly more useful than assessments involved in observing more straightforward clinical and procedural interactions.

Laparoscopic colorectal cancer surgery.

Colorectal cancer remains the second most common cause of cancer death in the USA and western Europe, with more than 34,000 new cases per year in the UK alone. Annual expenditure is in excess of pounds sterling 300 million, required for surgical, adjuvant and palliative treatment. Laparoscopic colorectal surgery has yet to gain the widespread support observed with gallbladder surgery. Randomized controlled trials are ongoing, evaluating the short- and long-term risks and benefits of laparoscopic versus conventional open surgery. Although long-term results are awaited, there is evidence of short-term benefits and no obvious evidence of laparoscopic techniques conferring any additional harm in terms of tumor recurrence or disease-free survival. This review explores the likely benefits and areas of continued concern. Information resources provide a background to colorectal cancer for nonclinicians and new strategies and a 5-year view are presented.

Basic laparoscopic skills training using fresh frozen cadaver: a randomized controlled trial.

BACKGROUND: The purpose of this study was to determine whether training on fresh cadavers improves the laparoscopic skills performance of novices. METHODS: Junior surgical trainees, novices (<3 laparoscopic procedure performed) in laparoscopic surgery, were randomized into control (group A) and practice groups (group B). Group B performed 10 repetitions of a set of structured laparoscopic tasks on fresh frozen cadavers (FFCs) improvised from fundamentals of laparoscopic skills technical curriculum. Performance on cadavers was scored using a validated, objective Global Operative Assessment of Laparoscopic Skills scale. The baseline technical ability of the 2 groups and any transfer of skills from FFCs was measured using a full procedural laparoscopic cholecystectomy task on a virtual reality simulator before and after practice on FFCs, respectively. Nonparametric tests were used for analysis of the results. RESULTS: Twenty candidates were randomized; 1 withdrew before the study commenced, and 19 were analyzed (group A, n = 9; group B; n = 10). Four of 5 tasks (nondominant to dominant hand transfer, simulated appendectomy, intracorporeal, and extracorporeal knot tying) on FFCs showed significant improvement on learning curve analysis. After training, significant improvement was shown for safety of cautery (P = .040) and the left arm path length (P = .047) on the virtual reality simulator by the practice group. CONCLUSIONS: Training on FFCs significantly improves basic laparoscopic skills and can improve full procedural performance.

Review of the use of intralesional steroid injections in the management of ileocolonic Crohn's strictures.

Most patients with Crohn's disease present with either terminal ileal or colonic disease, with 70% requiring surgery by 10 years after diagnosis. Recurrent stricturing at the anastomotic site is common, often symptomatic and can require re-operation with its inherent risks. Balloon dilation has been shown to provide good symptom relief from such strictures. However, repeat dilations may be required, and further surgical intervention to an anastomotic stricture is needed in up to 30% of cases. Injection of corticosteroids has been suggested as an adjunct to dilation in order to improve outcomes. This paper reviews the current literature on the use of intralesional steroid injections following endoscopic balloon dilation of anastomotic and de novo Crohn's strictures. There have been only two randomised placebo controlled trials and five small non-controlled or retrospective studies. Study numbers vary from 10 to 29 patients. The two randomised trials conflict in their conclusions and numbers are small in these studies. Currently therefore, no firm support can be given to the routine use of intralesional steroid injections.

How perioperative fluid balance influences postoperative outcomes.

Fasting, anaesthesia and surgery affect the body's physiological capacity not only to control its external fluid and electrolyte balance but also the internal balance between the various body fluid compartments. Conversely, abnormalities of fluid and electrolyte balance may adversely affect organ function and surgical outcome. Perioperative fluid therapy has a direct bearing on outcome, and prescriptions should be tailored to the needs of the patient. The goal of fluid therapy in the elective setting is to maintain the effective circulatory volume while avoiding interstitial fluid overload whenever possible. Weight gain in elective surgical patients should be minimized in an attempt to achieve a 'zero fluid balance status'. On the other hand, these patients should arrive in the anaesthetic room in a state of normal fluid and electrolyte balance so as to avoid the need to resuscitate fluid-depleted patients in the anaesthetic room or after the induction of anaesthesia. Optimal fluid delivery should be part of an overall care package that involves minimization of the period of preoperative fasting, preoperative carbohydrate loading, thoracic epidural analgesia, avoidance of nasogastric tubes, early mobilization, and early return to oral feeding, as exemplified by the enhanced recovery after surgery programme.

Colorectal cancer: current care, future innovations and economic considerations.

For those involved in colorectal cancer management, the present day is an exciting time. There is a multitude of new techniques to be considered for early detection (screening). National population screening for 60-69-year olds in England is due to start this year. Also, minimally invasive surgical techniques and multimodal pathways of care are aiding faster recovery, and there are increasing options for both adjuvant and palliative therapies. This article summarizes how colorectal cancer is currently managed in the UK and discusses the developments that are in the early stages of clinical use or on the horizon. Current management is discussed in detail in the hope that innovators reading the article may identify areas for improvement and allow comparison of new interventions with what are currently the gold standards. As changes are moving so fast, this review will probably only relate to the next 10 years at most. It does not provide a detailed reference list to support all therapies but indicates the key publications that will enable more detailed reading.

Some interactions between gastrointestinal function and fluid and electrolyte homeostasis.

PURPOSE OF REVIEW: The gastrointestinal tract plays an important role in the maintenance of fluid and electrolyte balance, and its diseases cause disturbances in that balance. Conversely, fluid and electrolyte disorders may disturb gastrointestinal function. The purpose of this review is to highlight some recent literature describing these interactions against a background of fluid and electrolyte physiology in normal and disease states. RECENT FINDINGS: Gastrointestinal disease is the most common cause of fluid and electrolyte disturbance, and this can usually be corrected by the oral route, although parenteral replacement is sometimes required. The use of self-administered subcutaneous fluid and electrolyte administration at home is described. Reduced microcirculatory perfusion as a result of hypovolaemia or a rise in blood viscosity after packed cell transfusion may precipitate gut necrosis, particularly during enteral feeding. Positive salt and water balance postoperatively of as little as 3 l impairs gastrointestinal function and increases complications. Other states of salt and water retention may have similar effects, although further research is needed to define this. SUMMARY: The role of the gastrointestinal tract in controlling fluid and electrolyte balance is underestimated. Conversely, the effect of fluid and electrolyte imbalance on gastrointestinal function is apparent, but requires more research.