What errors make a laparoscopic cancer surgery unsafe? An ad hoc analysis of competency assessment in the National Training Programme for laparoscopic colorectal surgery in England.

BACKGROUND: The National Training Programme for laparoscopic colorectal surgery in England was implemented to ensure training was supervised, structured, safe and effective. Delegates were required to pass a competency assessment (sign-off) before undertaking independent practice. This study described the types of errors identified and associated these errors with competency to progress to independent laparoscopic colorectal practice. METHODS: All sign-off submissions from the start of the process in January 2008 until July 2013 were included. Content analysis was used to categorise errors. Bayes factor (BF) was used to measure the impact of individual error on assessment outcome. A smaller BF indicates that an error has stronger associations with unsuccessful assessments. Bayesian network was employed to graphically represent the reasoning process whereby the chance of successful assessment diminished with the identification of each error. Quality of the error feedback was measured by the area under the ROC curve which linked the predictions from the Bayesian model to the expert verdict. RESULTS: Among 370 assessments analysed, 240 passed and 130 failed. On average, 2.5 different types of error were identified in each assessment. Cases that were more likely to fail had three or more different types of error (χ(2) = 72, p < 0.0001) and demonstrated poorer technical skills (CAT score <2.7, χ(2) = 164, p < 0.0001). Case complexity or right- versus left-sided resection did not have a significant impact. Errors associated with dissection (BF = 0.18), anastomosis (BF = 0.23) and oncological quality (BF = 0.19) were critical determinants of surgical competence, each reducing the odds of pass by at least fourfold. The area under the ROC curve was 0.84. CONCLUSIONS: Errors associated with dissection, anastomosis and oncological quality were critical determinants of surgical competency. The detailed error analysis reported in this study can guide the design of future surgical education and clinical training programmes.

The angiographic anatomy of the small arteries and their collaterals in colorectal resections: some insights into anastomotic perfusion.

OBJECTIVE: The aim of this study was to examine by screening angiography the anatomy of the small arteries and their collaterals in colorectal resections in order to identify factors that might be implicated in anastomotic leak. SUMMARY BACKGROUND DATA: Anastomotic leak is more frequent following low anterior resection. Vascular compromise is frequently implicated but poorly understood as a mechanism. METHODS: High definition screening angiography was performed on 17 colorectal resection specimens. RESULTS: (1) The small arteries of the colon (the vasa recta that arise from the marginal artery) show variability in their spacing and in their collaterals based on their anatomical positions. At the splenic flexure and the proximal and mid descending colons, the vasa recta are spaced 2-cm apart and have few collaterals. At the right, transverse, distal descending and sigmoid colons, the vasa recta are spaced <1 cm apart and have more extensive collaterals. (2) The small arteries of the rectum are spaced <1 cm apart and also show variability in their collaterals based on their anatomical level. In the mid-to-upper rectum there are good collaterals between the small arteries within the mesorectum based upon the bifurcation of the superior rectal artery and its main branches. In the lower rectum, however, there are only a few and very variable intramural collaterals between the small arteries. CONCLUSIONS: Based on these findings, unrecognized disruption of small artery collaterals during colorectal resection might be implicated in anastomotic leak and in particular might explain the higher leak rate in low anterior resection.

Stomal varices: a rare cause of stomal hemorrhage. A report of three cases.

Stomal varices secondary to portal hypertension are a rare but potentially fatal cause of hemorrhage. Management, determined by the site of the bleeding, centers on preventing additional bleeds and may include providing local pressure, applying silver nitrate, injection sclerotherapy, suture ligation of the bleeding point, and/or the placement of transjugular intrahepatic portosystemic shunts and refashioning the stoma. Two patients (60- and 69-year-old women) had panproctocolectomy for inflammatory bowel disease and presented at the authors' hospital with bleeding from the ileostomy 1 and 19 years, respectively, following the creation of their stomas. A third patient (a 72-year-old man) bled from an end colostomy following an abdominoperineal resection for Duke's C rectal adenocarcinoma performed 3 years previous. All three patients had recurrent admissions for stomal bleeding and stomal varices secondary to portal hypertension and were initially treated with local measures (pressure, silver nitrate, and suture ligation). Two had undergone revision of their stomas prior to current treatment. One patient responded to local treatment but later died due to liver failure, one stopped bleeding after transjugular portosystemic shunt placement, and one died from metastatic cancer. Clinicians should maintain a high index of suspicion of stomal varices in patients with underlying liver disease who present with recurrent stomal bleeds and provide appropriate treatment to stop active bleeding and reduce portal venous pressure.

A cost-minimization analysis of first intention laparoscopic compared to open right hemicolectomy for colon cancer.

BACKGROUND: The morbidity, mortality and survival following a laparoscopic right hemicolectomy for colon cancer are equivalent to an open operation. However, the cost of a longer operating time and consumables may offset savings from a shorter length of stay (LOS). A cost minimization study was undertaken to compare the relative costs. METHODS: A retrospective cohort study of consecutive elective right hemicolectomies for colon cancer performed over 5 years by two teams. One team performed an open operation (OG), the other intended to perform all operations laparoscopically (LG). Clinical outcomes and relative costs were evaluated. Results expressed as mean ± SEM. RESULTS: There were 58 patients in the open group and 56 in the first intention laparoscopic group, of which 77% were completed laparoscopically. There was no difference in age, gender or cancer stage. The complications, mortality and 5-year survival were similar. Anaesthetic (LG = 63 ± 3, OG = 62 ± 2 min) and surgical times (LG = 144 ± 8, OG = 143 ± 5 min) were similar. Consumables cost €571 more and the total theatre cost was €643 ± 256 higher in the laparoscopic group compared with the open group (p = 0.01). The LOS in the laparoscopic group (4.6 ± 0.5 days) was less than in the open group (8.3 ± 1 days, p < 0.01) saving €1960 ± 636 per patient. Overall, first intention laparoscopic right hemicolectomies saved €1316 ± 733 per patient. A probability sensitivity analysis indicated a 62% probability that a laparoscopic right hemicolectomy was cheaper than an open operation. CONCLUSION: Laparoscopic right hemicolectomy is oncologically equivalent but less costly and should be considered the procedure of choice for right-sided colon cancer unless contraindicated.