Anal carcinomas: the role of endoanal ultrasound and magnetic resonance imaging in staging, response evaluation and follow-up.

Anal carcinoma is an important but rare condition, managed in specialist centres. Both endoanal ultrasound and magnetic resonance imaging (MRI) can be used in the locoregional staging and follow-up of patients with anal cancer, and both may assist in treatment planning and prognosis. Recent guidelines published by the European Society for Medical Oncology have recommended MRI as the technique of choice for assessment of locoregional disease. This paper describes the techniques for both endoanal ultrasound and MRI, and compares the relative merits and disadvantages of each in the local assessment of anal carcinoma.

The management of enterocutaneous fistula in a regional unit in the United kingdom: a prospective study.

BACKGROUND: Enterocutaneous fistula associated with type 2 intestinal failure is a challenging condition that involves a multidisciplinary approach to management. It is suggested that complex cases should only be managed in select national centers in the United Kingdom. METHODS: Over an 18-month period, we prospectively studied all patients referred to us with established enterocutaneous fistulas. Patients followed standardized protocols. Eradication of sepsis, appropriate wound management, establishment of nutritional support, and restoration of normal physiology were attempted. Definitive surgical management was deferred for at least 6 months after the last abdominal surgical intervention. Follow-up was for a minimum of 6 months. RESULTS: Of 55 patients, 10 were internal referrals and 45 were from institutions elsewhere. The mean age was 50 years. Nine patients had colonic fistulas. Forty-six had small bowel fistulas; 19 of these (35%) were associated with inflammatory bowel disease. Patients had undergone a median of 3 previous operations. Four fistulas (7%) healed spontaneously. Thirty-five patients (63%) underwent definitive surgery. Recurrent fistula occurred in 4 patients (13%); 1 required further surgery, and 3 healed spontaneously. The overall mortality rate was 7% (4/55 patients), with 3 patients dying before definitive surgery and 1 patient dying postoperatively. CONCLUSIONS: Our results compare favorably with data from designated national centers (overall mortality, 9.5%-10.8%; operative mortality, 3%-3.5%), suggesting that these patients can be effectively managed in regional units that have sufficient expertise, interest, and volume of patients. Rationalization of funding and referral of patients with type 2 intestinal failure to regional centers may allow national centers to conserve their scarce resources.

Spontaneous rupture of the spleen in type IV Ehlers-Danlos syndrome: report of a case.

The vascular type of Ehlers-Danlos syndrome, type IV, is associated with severe complications, including arterial rupture and visceral perforation. However, to our knowledge, there has been only one previous report of splenic rupture caused by a spontaneous hemorrhage in type IV Ehlers-Danlos syndrome. We report another case of this uncommon complication, occurring in a 35-year-old woman who presented after the sudden onset of acute abdominal pain. Patients should be stabilized quickly in the intensive care unit and the most timesaving surgical techniques used. Moreover, tissues must be handled with great care intraoperatively in view of their extreme fragility. Despite prompt and appropriate treatment, the prognosis is often dismal.

Actinomycosis of the sigmoid colon: A case report.

Abdominal actinomycosis is a chronic suppurative infection caused by Actinomyces species. The ileo-cecal region is most commonly affected, while the left side of the colon is more rarely involved. The infection has a tendency to infiltrate adjacent tissues and is therefore rarely confined to a single organ. Presentation may vary from non specific symptoms and signs to an acute abdomen. A computed tomography scan is helpful in identifying the inflammatory process and the organs involved. It also allows visual guidance for percutaneous drainage of abscesses, thus aiding diagnosis. Culture is difficult because of the anaerobic character and slow growth of actinomycetes. Colonoscopy is usually normal, but may shows signs of external compression. Preoperative diagnosis is rare and is established only in less than 10% of cases. In uncomplicated disease, high dose antibiotic therapy is the mainstay of treatment. Surgery is often performed because of a difficulty in diagnosis. Surgery and antibiotics are required in the case of complicated disease. Combined medical and surgical treatment achieves a cure in about 90% of cases. The authors report a case of sigmoid actinomycosis where diagnosis was made from the histology, and a review of the literature is presented.

The surgical efficiency score: a feasible, reliable, and valid method of skills assessment.

BACKGROUND: Technical skills assessments are being increasingly used in surgical residency programs, with the objectivity and validity of several techniques well established. However, many of these methods are labor and time intensive, limiting their feasibility. This study aims to compare more efficient techniques of skills appraisals with an established gold standard. METHODS: Thirty surgeons completed 2 previously validated laboratory-based surgical models: small bowel anastomosis and vein patch insertion. Gold standard evaluation was the Objective Structured Assessment of Technical Skills (OSATS) method. "Efficient" techniques used were (1) quality of final product (FP); (2) snapshot assessment (SS), in which task performance was edited to a 2-minute sound bite and scored with OSATS; and (3) the surgical efficiency score (SES), a combination of final product quality and hand-motion analysis. All human observer evaluations used retrospective video analysis with 3 trained observers. Nonparametric tests were used to analyze the results. RESULTS: With respect to small bowel anastomosis, correlations with OSATS were as follows: FP 0.341 (P=.07), SS 0.577 (P<.001), and SES 0.842 (P<.001). For vein patch insertion, the correlations were as follows: FP 0.545 (P=.001), SS 0.609 (P<.001), and SES 0.700 (P<.001). Interobserver concordance was high for both models with respect to FP (Cronbach's alpha 0.80 for small bowel anastomosis and 0.84 for vein patch insertion). With respect to SS, interobserver reliability was high for vein patch insertion (Cronbach's alpha 0.80) but only moderate for small bowel anastomosis (0.59). CONCLUSIONS: The surgical efficiency score and snap shot assessments both show significant correlations with the traditional OSATS appraisals and suggest that skills assessment can be made more feasible. Correlations were closer with the former and interobserver concordance more variable with the latter, suggesting the surgical efficiency score as the most reliable of the methods evaluated.

The reliability of multiple objective measures of surgery and the role of human performance.

BACKGROUND: There is a need for reliable and valid objective methods of technical skills in surgery. Six-bench surgical top stations have been combined to assess basic surgical trainees (BSTs) objectively. The current study examines its reliability and validity across repeat sittings. METHODS: Eleven surgical trainees (6 senior BSTs and 5 higher surgical trainees [HSTs]) undertook 5 sittings of the 6-station assessment designed to be completed within 90 minutes. The 6 stations consisted of knot tying, suturing, closure of enterotomy, excision of sebaceous cyst, laparoscopic task, and instrument examination. Methods of analysis employed were motion analysis, observation with criteria, and inbuilt simulation metrics. RESULTS: On analysis 3 knot tying and suturing stations exhibited significant differences in either time or movement; any difference was over by the second run. The intertest reliabilities were .66, .74, .55, .51, and .65 for the 5 runs. The intratest reliability across repeated sittings varied from .56 to .96. The inter-rater reliability for video assessment varied from .77 to .94. CONCLUSION: The assessment is reliable and valid across repeated sittings. Its use in assessment of basic technical skills needs to be encouraged.

Surgical skill is predicted by the ability to detect errors.

BACKGROUND: Objective analysis methods of surgical performance are now available so comparison between surgeons is available. One such method is by direct observation using the Objective Structured Assessment of Technical Skills (OSATS), but this is a time-consuming process; therefore, a simple screening tool for the ability to detect errors (previously validated) was analyzed and considered as a predictor of qualitative performance. METHODS: Thirty-eight volunteer surgeons were recruited to the skills laboratory to undertake 3 exercises. Two were bench-top surgical tasks that were scored using the global rating of the OSATS technique. The third task was the ability to detect simple errors in 22 synthetic models of common surgical procedures, some of which contained purposefully made errors. P<.05 was deemed to be statistically significant. RESULTS: The scores (interquartile ranges in parentheses) for the 3 sections were excision of sebaceous cyst=21 (19,24), closure of small bowel enterotomy=23 (21,27), and identification of errors=31 (27,34). Three scorers blinded to the operative models exhibited an interobserver reliability of .9 and .91 for the video tasks, respectively. Spearman's rank correlations between the error examination and performance on the 2 tasks were both statistically significant at .69 (cystectomy) and .54 (enterotomy). CONCLUSIONS: The ability to detect simple surgical errors is a predictor of technical skill and performance of bench tasks. What must be answered is whether the use of such models and principles can shorten the qualitative surgical learning curve.

Comparison of bench test evaluations of surgical skill with live operating performance assessments.

BACKGROUND: Attempts at assessing surgical proficiency have generally used laboratory simulation to evaluate skill. The aim of this study was to compare technical ability as measured on a bench simulation with actual operative performance. STUDY DESIGN: Twenty-two general surgeons and trainees were recruited: consultants (n = 4), specialist registrars (n = 14), and senior house officers (n = 4). They were assessed while performing a saphenofemoral dissection on an anesthetized patient in the operating theater, and performing the same procedure on an inanimate model within the laboratory. The Objective Structured Assessment of Technical Skill method, consisting of a 7-parameter global rating (maximum score 35) and 17-point step-by-step checklist (maximum score 17) was used to measure performance in both environments. Face, content, and construct validity of the synthetic model were established as part of this study. RESULTS: There was a significant relationship between technical skill as measured on the bench test model and performance within the operating theater with respect to both global rating (Spearman correlation coefficient 0.824, p < 0.001; alpha coefficient 0.89) and checklist ratings (r = 0.514, p < 0.02; alpha coefficient 0.68) rating assessments. Global rating scores correlated with experience for both operative (r = 0.822, p < 0.001) and bench (r = 0.515, p < 0.05) settings. There was no difference in level of measured performance between operating theater and bench model (global rating mean 23.25 +/- 6.66 versus 23.75 +/- 5.62, respectively; paired t-test p = 0.559). CONCLUSIONS: Assessment of technical skill using inanimate procedural simulation translates to actual surgical performance within the operating theater. This further validates use of bench test evaluations to measure surgical technical ability.

Technical performance: relation between surgical dexterity and technical knowledge.

Technical performance consists of surgical knowledge, judgment, and dexterity. Although assessment of surgical dexterity is now possible, assessing technical knowledge and its relation to dexterity has not been elucidated. Surgeons of varying experience were recruited to the skills laboratory to undertake three assessments: simple surgical dexterity (at 14 stations scored by motion analysis), an operating room equipment examination, and a novel error analysis. The scores were correlated, and p < 0.05 was deemed to be significant. Thirty surgeons were recruited; and construct validity was exhibited in all areas. Correlations were shown to exist between the two knowledge examinations (Spearman's rho = 0.39). Correlations existed between all dexterity task parameters and the equipment examination, whereas they existed for only 15 of the 28 parameters of the error examination and were always weaker. The stronger correlations between dexterity and instrument and operating room (OR) equipment reflect greater surgical experience and time spent in the OR. The weaker correlations between the error analysis and dexterity suggest that these skills are learned at different times. The identification of common surgical errors should be more formally taught to ensure greater uniformity.

Multiple Objective Measures of Skill (MOMS): a new approach to the assessment of technical ability in surgical trainees.

OBJECTIVE: The assessment of surgical technical skills has become an important topic in recent years. This study presents the validation of a 6-task skills examination for junior surgical trainees (at the level of the Membership of the Royal College of Surgeons). SUMMARY BACKGROUND DATA: Six tasks were evaluated in a project that also examined the feasibility of this method of assessment. The tasks were knowledge of sutures and instruments; knowledge of surgical devices; knot formation; skin-pad suturing, closure of an enterotomy; excision of a skin lesion; and laparoscopic manipulation. Comparisons were made between a group of junior trainees (n = 13), and a group of seniors (n = 8). RESULTS: Each of the 6 tasks was able to be used to discriminate between the 2 groups. In all, there were 19 primary analyses across the 6 tasks, and 17 of these showed significant differences between the groups (P values ranging from 0.037 to < 0.001). There was generally a strong correlation between the analyses, and when a mean rank was calculated, the difference between groups was significant (P = 0.005 on Mann-Whitney U test; mean ranks 13.9 and 6.3 [of 21], for juniors and seniors respectively). Reliability of the 6-task assessment was very good at 0.70 (Cronbach's Alpha). CONCLUSIONS: A skills examination is a feasible and effective method of assessing the technical ability of basic surgical trainees.

The surgical error examination is a novel method for objective technical knowledge assessment.

BACKGROUND: Objective analysis of surgical skill is necessary. A novel method of assessment using simple error analysis in synthetic models is examined for construct validity. METHODS: Two examination protocols were devised using synthetic models. These contained either a purpose made error or were representative of good surgical practice. Protocol one contained models of skin closure and minor operations. Protocol two in addition more complex procedures. Face validity was established by the approval of senior surgeons. Junior surgeons were recruited to undertake the assessment. A p value of less than 0.05 was deemed to be significant. RESULTS: Eighty-nine surgeons were recruited. Both protocol one and two were able to discriminate between groups at statistically significant levels. CONCLUSIONS: Construct validity has been established by showing that error analysis is able to distinguish surgeons with varying levels of experience.

Laboratory-based validation of a novel suture technique for wound closure.

Wound closure in open surgery is a fundamental skill acquired early during the surgeon's career. Individual modifications are adopted frequently by the more experienced surgeon in an effort to increase efficiency. To date, there has been no objective measurement regarding whether these modifications significantly impact economy of movement or procedure time. The advent of the Imperial College Surgical Assessment Device (ICSAD) allows standardized, objective evaluation of a novel suture technique for wound closure (study group) developed by one of the senior authors (DBH) and compares the technique to the current method taught by the Royal College of Surgeons of Great Britain and Ireland (control group). Ten surgical registrars underwent both tasks in a standardized manner for five repetitions. Mean total movements and duration of procedure were decreased significantly for the study group (analysis of variance: = 0.018 and = 0.033 respectively) with an economy index (total movements/total time) of 0.79 movements per second for the control group vs. 0.67 for the study group. This study demonstrates ICSAD's usefulness in defining a novel suture technique as a more efficient method of cutaneous closure than the currently advocated technique.

Electromagnetic motion analysis in the assessment of surgical skill: Relationship between time and movement.

INTRODUCTION: Electromagnetic motion analysis is a promising method of assessing surgical skill in a skills-laboratory setting. There is a very strong correlation between movement and time data, and this study was conducted to determine whether this relationship is fixed, or whether it can vary. METHODS: : After a pilot study, four subjects were recruited. Each performed 30 trials of a simple standardized suturing task, alternating between 'normal', 'precise', and 'fast' strategies. The number of movements, and time to complete each task were recorded. RESULTS: Comparing the 'fast' to 'normal' strategies, there was a significant decrease in total number of movements per trial (P < 0.001), and time taken (P < 0.001). Regression analysis was performed to examine the relationship between the time taken and the number of movements, and revealed significant differences between both the fast (P = 0.006), and precise (P = 0.002) strategies, when compared to the normal strategy. DISCUSSION: This study confirms that the relationship between time and movements is not fixed, but varies with the operative strategy adopted for this simple suturing task.

The relationship between motion analysis and surgical technical assessments.

BACKGROUND: Recent attempts to gain a more objective measure of surgical technical skill include the use of structured checklists and motion analysis of surgeons' hand movements. We aim to show whether a correlation exists between these two methods of assessment. METHODS: Fifty subjects were recruited from four experience groups in general surgery, ranging from basic surgical trainees to consultants and were assessed performing a standardized laboratory-based task. Motion analysis using the Imperial College Surgical Assessment Device (ICSAD), which measures hand movements and time taken, and the Objective Structured Assessment of Technical Skill (OSATS) technique were used to measure skill. RESULTS: Number of movements made, time taken, and global rating score discriminated between performance and experience group (Kruskal-Wallis, P <0.001, P <0.01, P <0.001, respectively). There was a significant correlation between movements made and global rating score (Spearman coefficient 0.53, P <0.01). Checklist scoring was not an accurate predictor of experience. CONCLUSIONS: There is a strong correlation between hand motion analysis using ICSAD and OSATS global rating assessments in this model.

Relationship between skill and outcome in the laboratory-based model.

BACKGROUND: Recent attention has been directed at developing quantitative assessments of surgical skill. This study aims to demonstrate whether objectively measuring differences in manual dexterity has an impact on a simulated surgical procedure. METHODS: Six general surgical trainees performed 5 polytetrafluoroethylene graft to artery anastomoses on a vascular model by using a standardized technique. Manual dexterity was objectively measured with (1) electromagnetic motion analysis: trackers applied to the backs of hands recorded and analyzed both hand movements and procedural time and (2) 4-parameter evaluation of the final product. Outcome parameters were assessed by (1) rate of anastomotic leakage and (2) smallest cross-sectional area of the anastomosis. RESULTS: The 2 objective measures of manual dexterity correlated closely (Pearson coefficient, 0.423; P <.02). Trainees with better manual dexterity scores produced better outcome measures. Those with better motion analysis scores produced anastomoses that leaked less (Pearson coefficient, 0.514; P <.01) and those with higher global evaluation scores had a larger anastomotic cross-sectional area (Pearson coefficient, 0.495; P <.01). Time taken for the procedure did not appear to influence either outcome measure. CONCLUSIONS: There is a significant correlation between objective measures of manual dexterity and the outcome measures in this model. This suggests that the outcome of a procedure can be predicted by measuring surgical skill.