Efficacy of a prototype endoscope with two deflecting working channels for endoscopic submucosal dissection: a prospective, comparative, ex vivo study.

BACKGROUND: Optimizing the visualization of the cutting line of the submucosal layer is essential to performing an effective and safe endoscopic submucosal dissection (ESD). OBJECTIVE: To evaluate the prototype R-scope compared with a conventional, double-channel endoscope in time required for ESD of mucosal lesions in distinct anatomical locations of the stomach. DESIGN: A prospective, comparative, ex vivo study. INTERVENTION: ESD. MAIN OUTCOME MEASUREMENTS: Procedure time (primary end point measure), specimen size, submucosal injection frequency, en bloc resection rate, and perforation rate (secondary end point measures). RESULTS: In the subgroup of resections in the greater and lesser curvature, the mean (+/- SD) procedure time was significantly less in the R-scope group compared with the conventional endoscope group (8.4 +/- 2.1 minutes vs 11.3 +/- 2.1 minutes, respectively; P = .006), and the mean (+/- SD) submucosal injection frequency was significantly less in the R-scope group compared with the conventional endoscope group (1.9 +/- 0.6 vs 2.5 +/- 0.5, respectively; P = .025). There were no significant differences in procedure time, specimen size, submucosal injection requirements, en bloc resection rate, and perforation rate between the two endoscopic groups of all combined anatomic lesions. LIMITATIONS: Small, ex vivo study. CONCLUSION: ESD by using the R-scope may provide an improved platform for quicker ESD, especially in greater and lesser curvature anatomical lesions of the stomach.

Malpractice carrier underwrites Fundamentals of Laparoscopic Surgery training and testing: a benchmark for patient safety.

BACKGROUND: Fundamentals of Laparoscopic Surgery (FLS) is a validated program developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to educate and assess competency in minimally invasive surgery (MIS). This study reports the first malpractice carrier-sponsored FLS course for surgeons in practice underwritten by the Controlled Risk Insurance Company of Harvard's Risk Management Foundation (CRICO/RMF). The study investigated the participating surgeons' pattern of MIS skills acquisition, subjective laparoscopic comfort level, operative activity, and perception of the FLS role in surgical education, credentialing, and patient safety. METHODS: A 1-day postgraduate continuous medical education (CME) course consisted of didactic presentations of the leading MIS faculty, proctored FLS hands-on training, psychomotor testing, and cognitive computer-based examination. Voluntary anonymous pre- and postcourse surveys were distributed to the participants at registration and at completion of both the didactic teaching and the skills modules of the program. RESULTS: The course was attended by 37 practicing surgeons in the Harvard system, and 86% of the survey forms were returned. The major driving forces for attending the course were directive from the chief/chairman (50%), improvement in MIS didactic knowledge (56%), and the belief that FLS would become a standard such as advanced trauma life support (ATLS), advanced cardiac life support (ACLS), or the like (53%). Surgeons reported that the FLS exam content was appropriate (Likert 4.41 +/- 0.91) and that mastery of the course material would improve safety (Likert 4.13 +/- 0.79) and technical knowledge of MIS (Likert 4.03 +/- 1.00). CONCLUSIONS: This unique cooperative effort between a liability carrier, a professional surgical society, and proactive surgeons should be considered a model for advancing competency and patient safety. The survey results indicate a positive view of FLS in surgical training, safety, and MIS education.

Framing family conversation after early diagnosis of iatrogenic injury and incidental findings.

BACKGROUND: Surgeons are rarely formally trained in giving bad news to patients. The aim of our study was to examine and compare techniques of disclosure of iatrogenic and incidental operative findings among surgical residents. METHODS: General surgery residents performed a laparoscopic cholecystectomy on the SurgicalSIM device in a mock operating room. Half (n = 8) were presented with a common bile duct injury, and half (n = 7) encountered metastatic gallbladder cancer during the operation. Both groups disclosed this information to a patient's scripted family member and completed a questionnaire. All encounters were videotaped and independently rated using a modified SPIKES protocol, a validated tool for delivering bad news. We compared disclosure of iatrogenic versus unexpected findings by year of training. Analysis was performed using the Mann-Whitney test. RESULTS: Regardless of the year of training, more residents were comfortable with disclosure of an incidental finding than disclosure of an iatrogenic injury (47 vs. 33%). Senior residents (PGY4-PGY5) had better ratings by SPIKES (p < 0.05), most notably for tailoring disclosure to what patient and family understand, exploring patient and family expectations, and offering to answer any questions (p < 0.05). Even though all residents felt more comfortable with disclosure of an incidental finding, the quality of the disclosure by SPIKES score was the same for iatrogenic and incidental operative findings (p = NS). CONCLUSION: In general, trainees are ill prepared for delivering bad news. Disclosure of iatrogenic injuries was more challenging compared to that of incidental findings. Senior residents do better than junior residents at delivering bad news.

Preliminary face and construct validation study of a virtual basic laparoscopic skill trainer.

BACKGROUND: The Virtual Basic Laparoscopic Skill Trainer (VBLaST) is a developing virtual-reality-based surgical skill training system that incorporates several of the tasks of the Fundamentals of Laparoscopic Surgery (FLS) training system. This study aimed to evaluate the face and construct validity of the VBLaST system. MATERIALS AND METHODS: Thirty-nine subjects were voluntarily recruited at the Beth Israel Deaconess Medical Center (Boston, MA) and classified into two groups: experts (PGY 5, fellow and practicing surgeons) and novice (PGY 1-4). They were then asked to perform three FLS tasks, consisting of peg transfer, pattern cutting, and endoloop, on both the VBLaST and FLS systems. The VBLaST performance scores were automatically computed, while the FLS scores were rated by a trained evaluator. Face validity was assessed using a 5-point Likert scale, varying from not realistic/useful (1) to very realistic/useful (5). RESULTS: Face-validity scores showed that the VBLaST system was significantly realistic in portraying the three FLS tasks (3.95 +/- 0.909), as well as the reality in trocar placement and tool movements (3.67 +/- 0.874). Construct-validity results show that VBLaST was able to differentiate between the expert and novice group (P = 0.015). However, of the two tasks used for evaluating VBLaST, only the peg-transfer task showed a significant difference between the expert and novice groups (P = 0.003). Spearman correlation coefficient analysis between the two scores showed significant correlation for the peg-transfer task (Spearman coefficient 0.364; P = 0.023). CONCLUSIONS: VBLaST demonstrated significant face and construct validity. A further set of studies, involving improvement to the current VBLaST system, is needed to thoroughly demonstrate face and construct validity for all the tasks.