Effect of publishing surgeon-specific outcomes on surgical training.

BACKGROUND: Over the past 10 years, the National Health Service in England has started to publish surgeon-specific outcomes publicly. The aim of this study was to investigate how this has affected training case exposure for surgeons in training. METHODS: Anonymized data were collected from the Intercollegiate Surgical Curriculum Programme database for operations in each specialty with published surgeon outcomes, involving surgical trainees on an approved training programme between 1 January 2011 and 31 December 2016. Trainee and supervisor involvement in operations before and after the start of publication of surgeon-specific outcomes were compared using mixed-effects models. RESULTS: A total of 163 076 recorded operative procedures were included. A statistically significant improvement in exposure to training procedures was observed for anterior resection of rectum, carotid endarterectomy, gastrectomy, meningioma excision, prostatectomy and thyroidectomy following the introduction of publication of surgeon outcomes. In coronary artery bypass grafting (CABG) and total hip replacement (THR), however, there was a reduction in involvement in training procedures. This was apparent for both trainee and supervisor involvement in CABG, and for trainee involvement in THR. CONCLUSION: Exposure to training procedures has improved rather than declined in the UK in the majority of surgical specialties, since the publication of surgeon-specific outcomes.

A systematic review of Clostridium difficile infection following reversal of ileostomy.

AIM: The incidence of Clostridium difficile infection (CDI) has been reported to be as high as 4% following ileostomy reversal. CDI can be associated with significant morbidity. A systematic review on this subject has not been previously reported; our aim was to review the literature to establish incidence and to evaluate the factors that may contribute to an increased risk of CDI following ileostomy reversal. METHOD: A systematic review of Ovid, Embase and Medline was undertaken. Search terms included C. difficile, reversal of ileostomy and ileostomy closure. Articles were included where at least one case of C. difficile-associated diarrhoea following reversal of defunctioning ileostomy was reported. Data extraction for articles was performed by two authors, using predefined data fields. The primary outcome measure was incidence of CDI amongst patients undergoing ileostomy reversal. Secondary outcomes were defunctioning time, antibiotic regime, acid suppression, time to onset of symptoms and study conclusions including colectomy and mortality rate. RESULTS: Eleven articles were included (five case reports and six cohort studies). The overall incidence of CDI was 1.8% (242/13 728). The mean defunctioning time was 8.7 months (range 6-12). A variety of antibiotic regimes were described. Mean time to onset of symptoms was 6 days (range 3-14). Use of acid suppression, colectomy or mortality rate were frequently not reported. CONCLUSION: CDI should be recognized as a potentially life-threatening complication of ileostomy closure. Careful consideration should be given to peri-operative antibiotic regime, acid suppression, timing of reversal and appropriate preoperative counselling of patients.

Prone extralevator abdominoperineal excision of the rectum with porcine collagen perineal reconstruction (Permacol™): high primary perineal wound healing rates.

PURPOSE: Extralevator abdominoperineal excision of the rectum (elAPER) is arguably the modern surgical approach to low rectal cancer and yet results in large defects that may necessitate plastic surgical reconstruction. This study aims to evaluate the quality of prone elAPER surgery with Permacol™ repair of the perineum. The primary end point studied was the rate of primary perineal wound healing. METHODS: Data were prospectively collected for consecutive patients having prone elAPER at a single institution to assess surgical morbidity together with pathological and cancer-specific outcomes. RESULTS: Between 2006 and 2012, 48 patients had prone elAPER with median age of 63 (40-86). Thirty-four patients (72.3%) received neoadjuvant treatment. Median length of stay was 9 days (6-66). With a prone approach, three patients had specimen perforation (6.4%) and seven patients had circumferential margin involvement (14.9%). Complete perineal wound healing was achieved in 34 patients (73.9%) at 4 weeks. Four patients (8.3%) were unhealed at 6 months; one patient required a perineal sinus to be laid open, and another patient required plastic surgical reconstruction. No perineal wound herniae have been identified during follow-up. CONCLUSIONS: Acceptable oncological outcomes are achieved with the prone extralevator approach. The technique achieves high rates of primary healing, making it an attractive option in centres without access to plastic reconstructive expertise.

Systematic review of survival following liver or lung metastasectomy for metastatic anal squamous cell carcinoma.

INTRODUCTION: Metastatic anal squamous cell carcinoma (SCC) carries a poor prognosis and the evidence base for surgical resection of metastases remains limited. The aim of this study was to establish the survival outcomes for patients undergoing metastasectomy for anal SCC. METHODS: A systematic review was performed using the MEDLINE®, Embase®, Cochrane and PubMed® databases. Studies were considered for inclusion in the review if they involved patients aged >18 years with a diagnosis of stage IV anal SCC who underwent metastasectomy for liver and/or lung metastases. The primary outcome measure was overall survival. Secondary outcome measures were disease free survival, early morbidity according to the Clavien-Dindo classification and quality of life, measured using a validated scoring tool. Risk of bias was assessed with the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool. RESULTS: There were 10 studies with a total of 98 patients. There was heterogeneity in results reporting, with recurrence free survival the most reported outcome. For all studies reporting on liver metastasectomy, the one-year overall survival rate was 87%. In studies with adequate follow-up reported, the three and five-year overall survival rates were 53% and 38% respectively. Only one study reported on lung metastasectomy patients; the overall median survival was 24 months. None of the studies reported on quality of life measures. The ROBINS-I tool identified a critical risk of bias in six studies, a serious risk in one study and a moderate risk in three studies. CONCLUSIONS: The evidence base for metastasectomy in metastatic anal SCC is limited. Further information is required to inform future treatment methods and use of a standardised outcomes reporting method is needed to support this.

Outcomes of surgically managed recurrent parastomal hernia: the Sisyphean challenge of the hernia world.

PURPOSE: The management of a recurrent (symptomatic) parastomal hernia (PSH) presents a dilemma. The aim of this study was to review the outcome of patients who underwent a recurrent PSH repair. METHODS: Retrospective review of consecutive patients undergoing recurrent PSH repairs at a single institution between 2010 and 2019. Primary outcome recorded was recurrence. Secondary outcomes recorded were 30-day post-operative complications, surgical site occurrence (SSO) incidence and to assess if EHS classification altered with each recurrence. RESULTS: Thirty-eight patients underwent 59 recurrent PSH repairs during the study period. Median number of PSH repairs per patient from ostomy formation was 2 (2-8). Post-operative complications occurred following 52.5% of repairs. Recurrence rate for all recurrent PSH hernia repairs was 45.7%, with a median follow-up of 58 months (0-115). A trend was seen towards a shorter PSH recurrence-free survival in those who had at least two previous PSH repairs at the start of the study period when compared to those who had less. Recurrence was not associated with operative urgency, type of repair, mesh type or SSO occurrence. A significant decrease in recurrence was seen with retro-rectus mesh placement when compared to onlay (p = 0.003). EHS classification did not change between each recurrence in 70.8% of patients. CONCLUSION: Recurrence rates after recurrent PSH repair are high. The recurrence-free survival was worse after the second or more attempt at repair for recurrence. Further studies are warranted to explore prophylaxis, optimal repair method, and where re-recurrence occurs, the benefit of repeated surgical intervention.

Bioabsorbable mesh use in midline abdominal wall prophylaxis and repair achieving fascial closure: a cross-sectional review of stage of innovation.

BACKGROUND: Achieving stable closure of complex or contaminated abdominal wall incisions remains challenging. This study aimed to characterise the stage of innovation for bioabsorbable mesh devices used during both midline closure prophylaxis and complex abdominal wall reconstruction and to evaluate the quality of current evidence. METHODS: A systematic review of published and ongoing studies was performed until 31st December 2019. Inclusion criteria were studies where bioabsorbable mesh was used to support fascial closure either prophylactically after midline laparotomy or for repair of incisional hernia with midline incision. Exclusion criteria were: (1) study design was a systematic review, meta-analysis, letter, review, comment, or conference abstract; (2) included less than p patients; (3) only evaluated biological, synthetic or composite meshes. The primary outcome measure was the IDEAL framework stage of innovation. The key secondary outcome measure was the risk of bias in non-randomised studies of interventions (ROBINS-I) criteria for study quality. RESULTS: Twelve studies including 1287 patients were included. Three studies considered mesh prophylaxis and nine studies considered hernia repair. There were only two published studies of IDEAL 2B. The remainder was IDEAL 2A studies. The quality of the evidence was categorised as having a risk of bias of a moderate, serious or critical level in nine of the twelve included studies using the ROBINS-I tool. CONCLUSION: The evidence base for bioabsorbable mesh is limited. Better reporting and quality control of surgical techniques are needed. Although new trial results over the next decade will improve the evidence base, more trials in emergency and contaminated settings are required to establish the limits of indication.

Use of the eLogbook in surgical training in the United Kingdom: A nationwide survey and consensus recommendations from the Association of Surgeons in Training.

INTRODUCTION: Accurate recording of operative cases is essential during training to demonstrate experience. However, indicative numbers delineating minimum desirable experience may incentivise exaggeration or misrepresentation of experience. This study aimed to determine perceptions of real-world eLogbook use among UK surgeons in training. MATERIAL AND METHODS: An anonymous online questionnaire was disseminated electronically using a pre-planned yield-maximisation strategy, incorporating regional champions, email and social media. Evaluation employed mixed methods in a combined interpretation of quantitative and qualitative data from the questionnaire. Recommendations for development of the eLogbook were itemised from respondents' free text items and a modified Delphi process, conducted within the Council of the UK national trainee representative body, the Association of Surgeons in Training, determined the strength of each recommendation. RESULTS: Analysis included 906 complete responses from training-grade surgeons (34.8% female) from all UK recognised specialties and all grades of training. More than two-thirds (68.5%) believed that overstatement or misrepresentation of case involvement occurs. A fifth (20.8%) reported witnessing trainees logging cases they had not actually participated in and almost a third (32.7%) had witnessed overstatement, yet few (15.1%) had raised such an issue with a supervisor. Most (85.2%) respondents had few or no eLogbook entries validated. More than a quarter of respondents felt pressure to overstate their involvement in cases (28.6%) and the number recorded (28.1%). Almost a third (31.5%) felt the required case number for completion of training was not achievable. Female trainees were less likely to feel well supervised (p = 0.022) and to perceive targets for completion of training were achievable (p = 0.005). Thematic analysis identified four key themes to explain logbook misuse: Pressure to achieve training milestones; eLogbook functionality issues; training deficiencies and probity. CONCLUSIONS: Inaccurate operative recording was widely reported, primarily in response to perceived pressure to achieve targets for career progression. Operative logbooks may not be as accurate as intended. Consensus recommendations are made for improvement in the eLogbook and its use.

Variation in training requirements within general surgery: comparison of 23 countries.

Background: Many differences exist in postgraduate surgical training programmes worldwide. The aim of this study was to provide an overview of the training requirements in general surgery across 23 different countries. Methods: A collaborator affiliated with each country collected data from the country's official training body website, where possible. The information collected included: management, teaching, academic and operative competencies, mandatory courses, years of postgraduate training (inclusive of intern years), working-hours regulations, selection process into training and formal examination. Results: Countries included were Australia, Belgium, Canada, Colombia, Denmark, Germany, Greece, Guatemala, India, Ireland, Italy, Kuwait, the Netherlands, New Zealand, Russia, Saudi Arabia, South Africa, South Korea, Sweden, Switzerland, UK, USA and Zambia. Frameworks for defining the outcomes of surgical training have been defined nationally in some countries, with some similarities to those in the UK and Ireland. However, some training programmes remain heterogeneous with regional variation, including those in many European countries. Some countries outline minimum operative case requirement (range 60-1600), mandatory courses, or operative, academic or management competencies. The length of postgraduate training ranges from 4 to 10 years. The maximum hours worked per week ranges from 38 to 88 h, but with no limit in some countries. Conclusion: Countries have specific and often differing requirements of their medical profession. Equivalence in training is granted on political agreements, not healthcare need or competencies acquired during training.

Antecedentes: Existen muchas diferencias entre los programas de formación quirúrgica de posgrado del mundo. El objetivo de este estudio fue proporcionar una visión general de los requisitos formativos en cirugía general en 23 países diferentes. Métodos: En cada uno de los países participantes, un colaborador recopiló datos de la página web del organismo oficial encargado de la formación, si era posible. La información incluyó: gestión, formación, competencias académicas y operatorias, cursos obligatorios, años de formación de postgrado (que incluía el período de internado), regulaciones sobre las horas de trabajo, proceso de selección para la formación y existencia de un examen final. Resultados: Se incluyeron los datos de Australia, Bélgica, Canadá, Colombia, Dinamarca, Alemania, Grecia, Guatemala, India, Irlanda, Italia, Kuwait, Países Bajos, Nueva Zelanda, Rusia, Arabia Saudita, Sudáfrica, Corea del Sur, Suecia, Suiza, Reino Unido, Estados Unidos de América y Zambia. En algunos países existen los marcos normativos para definir los resultados del programa de formación, con ciertas semejanzas a los del Reino Unido e Irlanda. Sin embargo, algunos programas de formación, incluso en muchos países europeos, son muy heterogéneos con variaciones regionales. Pocos países describen el número mínimo de procedimientos quirúrgicos (rango 60 a 1.600), los cursos obligatorios o competencias quirúrgicas, académicos o de gestión exigidos. La duración de la formación postgraduada osciló de los 4 a los 10 años. El número de horas trabajadas máximas por semana oscilaron entre 38 y 88, sin límite en algunos países. Conclusión: Cada país tiene unos requisitos específicos, a menudo diferentes, para la formación de sus médicos. La convalidación se otorga por acuerdos políticos, más que por las necesidades médicas o por las competencias adquiridas durante la formación.

Attracting medical students and doctors into surgical training in the UK and Ireland.

AIMS: Core surgical training (CST) programmes in the UK have seen a significant reduction in competition ratios over the past five years. This study aimed to determine motivating factors and perceived barriers to pursuing a career in surgery amongst junior doctors in training and medical students attending an annual conference. METHODS: A self-reported, electronic questionnaire was distributed to medical students, foundation year doctors, and doctors in postgraduate surgical training programmes (DIPST) who attended the Association of Surgeons in Training (ASiT) Conference in 2016. Respondents ranked factors attracting them to a career in surgery and factors that could improve perceptions of surgical careers. Chi-square test was used to test for differences between groups (a = 0.05, R Studio, V3.3.1). RESULTS: Of 394 respondents (response rate = 50.9%), 44.9% were medical students or foundation doctors ('Pre-CST') and 55.1% were DIPST ('Peri/post-CST'). Practical application of skills (97.4%), enjoyment of the theatre environment (95.4%) and positive experiences in surgical firms (84.7%) were primary driving factors towards a surgical career. Availability of private practice (32.2%), and sustainability of consultant jobs (49.0%) had less influence. For 'Pre-CST' respondents, role models (82.8% pre-CST v 74.9% peri-post CST, p < 0.05) and defined career progression (67.2% pre-CST v 47.0% peri-post CST, p < 0.001) were particularly important. 91% of all respondents agreed that a better balance of training and service within worked hours would improve perceptions of surgery. CONCLUSION: Addressing the motivating factors and perceived barriers to surgical careers will help bolster recruitment of the future surgical workforce.

Association of Surgeons in Training conference: Bournemouth 2017.

The Association of Surgeons in Training (ASiT) is a professional body and registered charity working to promote excellence in surgical training for the benefit of junior doctors and patients alike. The Association provides support at both regional and national levels throughout the United Kingdom and Republic of Ireland. Originally founded in 1976, ASiT is independent of the National Health Service (NHS), Surgical Royal Colleges, and specialty associations. The 2017 Annual Conference in Bournemouth brought together over 700 delegates for a diverse educational weekend with numerous expert guest speakers. With a theme of '#AdvancesIn,' we looked to celebrate cutting edge progress in training, clinical management, medical technology, leadership and entrepreneurialism. These updates were complimented by debates on current training in surgery and an array of focussed parallel sessions. For the first time, delegates were also able to interact with the conference digitally, with the debut of our conference smartphone App. The weekend started with 9 pre-conference courses covering a diverse range of topics including core laparoscopic, vascular, orthopaedics, neurosurgical skills, leadership and global surgery. Over 1000 abstract submissions were received and those successful competed for over 30 awards, representing nearly £4000 in trainee prizes and bursaries. As the only national surgical trainee meeting for all specialties, ASiT continues to grow and we look forward to an even larger and more successful international conference next year in Edinburgh 6-8th April 2018 with the theme of #nurturingexcellence.

Supporting doctors as healthcare quality and safety advocates: Recommendations from the Association of Surgeons in Training (ASiT).

BACKGROUND: As front-line healthcare staff, doctors in surgical training occupy a unique organisational space rotating through hospitals and services in which they witness first hand both good and bad practice. This puts trainees in a clear position to identify and raise patient safety issues, and to contribute to discussions regarding quality and safety improvement. However, there are a number of real and perceived barriers to trainees doing so. These include concerns about the impact on training assessments and career progression, and uncertainty about the appropriate route. METHODS: Paper-based survey of delegates attending the Association of Surgeons in Training (ASiT) conference (response rate 73%; 479/652). RESULTS: 288 (60%) of trainees reported previous concerns over practices and behaviour of colleagues that might pose risks to patient care including concerns over poor performance (n = 243; 84%), bullying (n = 45; 16%), alcohol and drug abuse (n = 15; 5%) and mental health problems (n = 8; 3%). However, 53% (n = 153) did not escalate these concerns. 178 (37%) of trainees also reported concerns over hospital policies, protocols or systems that might pose a risk to patient care, with 46% (n = 82) not escalating such concerns. Respondents highlighted fear of personal vilification or reprisal (n = 224; 47%), fear of impact on career (n = 206; 43%) and a lack of confidence in the process (n = 170; 36%) as barriers to whistleblowing. More senior trainees were significantly more likely to raise concerns than more junior grades (p < 0.0001). CONCLUSION: These results highlight worrying issues around reporting concerns, with trainees often "silent witnesses" to poor performance in healthcare. Adverse events must provide opportunities for learning to improve future outcomes. Herein, ASiT proposes 14 recommendations to improve protection for trainees in raising patient safety concerns. These include the creation of a positive workplace culture, promoting the active involvement of trainees in quality improvement discussions, with clear mechanisms for trainees to raise concerns.

Hughes Abdominal Repair Trial (HART) - Abdominal wall closure techniques to reduce the incidence of incisional hernias: study protocol for a randomised controlled trial.

BACKGROUND: Incisional hernias are common complications of midline closure following abdominal surgery and cause significant morbidity, impaired quality of life and increased health care costs. The 'Hughes Repair' combines a standard mass closure with a series of horizontal and two vertical mattress sutures within a single suture. This theoretically distributes the load along the incision length as well as across it. There is evidence to suggest that this technique is as effective as mesh repair for the operative management of incisional hernias; however, no trials have compared the Hughes Repair with standard mass closure for the prevention of incisional hernia formation following a midline incision. METHODS/DESIGN: This is a 1:1 randomised controlled trial comparing two suture techniques for the closure of the midline abdominal wound following surgery for colorectal cancer. Full ethical approval has been gained (Wales REC 3, MREC 12/WA/0374). Eight hundred patients will be randomised from approximately 20 general surgical units within the United Kingdom. Patients undergoing open or laparoscopic (more than a 5-cm midline incision) surgery for colorectal cancer, elective or emergency, are eligible. Patients under the age of 18 years, those having mesh inserted or undergoing musculofascial flap closure of the perineal defect in abdominoperineal wound closure, and those unable to give informed consent will be excluded. Patients will be randomised intraoperatively to either the Hughes Repair or standard mass closure. The primary outcome measure is the incidence of incisional hernias at 1 year as assessed by standardised clinical examination. The secondary outcomes include quality of life patient-reported outcome measures, cost-utility analysis, incidence of complete abdominal wound dehiscence and C-POSSUM scores. The incidence of incisional hernia at 1 year, assessed by computerised tomography, will form a tertiary outcome. DISCUSSION: A feasibility phase has been completed. The results of the study will be used to inform current and future practice and potentially reduce the risk of incisional hernia formation following midline incisions. TRIAL REGISTRATION NUMBER: ISRCTN 25616490 . Registered on 1 January 2012.

The Association of Surgeons in Training Conference: #ASiT2015 Glasgow.

The Association of Surgeons in Training (ASiT) is a professional body and registered charity working to promote excellence in surgical training for the benefit of junior doctors and patients alike. ASiT is in-dependent of the National Health Service (NHS), Surgical Royal Colleges, and specialty associations and represents trainees in all ten surgical specialties. ASiT was delighted to welcome a number of distinguished guests and speakers to Glasgow for #ASiT2015. The theme of 'The Future of Surgery' delved into challenges surgical training faces, exciting developments into using technology to help patients, a glance at the past with the development of the Glasgow Coma Score and whether mortality truly is the future of measured outcomes. More than £3500 of prizes was awarded by the incoming President, Miss. Rhiannon Harries to the highest scoring papers presented selected from over 1000 abstracts submitted.

Defining our destiny: trainee working group consensus statement on the future of emergency surgery training in the United Kingdom.

The United Kingdom National Health Service treats both elective and emergency patients and seeks to provide high quality care, free at the point of delivery. Equal numbers of emergency and elective general surgical procedures are performed, yet surgical training prioritisation and organisation of NHS institutions is predicated upon elective care. The increasing ratio of emergency general surgery consultant posts compared to traditional sub-specialities has yet to be addressed. How should the capability gap be bridged to equip motivated, skilled surgeons of the future to deliver a high standard of emergency surgical care? The aim was to address both training requirements for the acquisition of necessary emergency general surgery skills, and the formation of job plans for trainee and consultant posts to meet the current and future requirements of the NHS. Twenty nine trainees and a consultant emergency general surgeon convened as a Working Group at The Association of Surgeons in Training Conference, 2015, to generate a united consensus statement to the training requirement and delivery of emergency general surgery provision by future general surgeons. Unscheduled general surgical care provision, emergency general surgery, trauma competence, training to meet NHS requirements, consultant job planning and future training challenges arose as key themes. Recommendations have been made from these themes in light of published evidence. Careful workforce planning, education, training and fellowship opportunities will provide well-trained enthusiastic individuals to meet public and societal need.

To admit or not to admit on the morning of surgery patients' perspectives on day of surgery admission.

Patient experience of day of surgery admission (DOSA) has not been studied in depth. Over a one-month period a questionnaire was given to consecutive patients prior to their surgery to obtain their perspective on the desirability of DOSA and to examine whether other factors influenced this decision. 149 patients participated; across all age groups there was a statistically significant difference in preferring DOSA (p = 0.01).

Spontaneous resolution of an inferior epigastric artery pseudoaneurysm secondary to surgical drain placement.

We report the case of a 73-year-old woman who was found to have an inferior epigastric artery pseudoaneurysm caused by surgical drain placement during a laparotomy for an appendix abscess. She presented with pain around the drain site two months following surgery and intravenous contrast computed tomography (CT) revealed a right inferior epigastric artery pseudoaneurysm. A decision was made to manage this expectantly as she remained stable with no other complications. Following a period of nine months of observation, repeat intravenous contrast CT showed evidence of spontaneous regression and thrombosis of the pseudoaneurysm. She remains well and her symptoms have now resolved.

Neck/shoulder pain is more strongly related to depressed mood in adolescent girls than in boys.

A cross-sectional study of 1258, 14 year old girls and boys used self-report and physical examination measures to assess neck/shoulder pain in the last month, depressed mood, physical fitness, body composition, self-efficacy, global self-worth, family functioning and social advantage. The data was used to compare the relationship between depressed mood and neck/shoulder pain (NSP) in adolescent girls and boys. The prevalence of NSP in girls (34%, 211/621) was significantly greater than in boys (21%, 134/637; p < .001). After controlling for covariates, girls with medium (OR = 4.28; CI = 2.31-7.92; p < .001) and high depressed mood (OR = 8.63; CI = 4.39-16.98; p < .001) were significantly more likely to report NSP than girls with low depressed mood. Depressed mood was also a significant correlate of NSP in boys after controlling for covariates, although the association was substantially weaker (OR = 2.44; CI = 1.29-4.61; p < .001). After controlling for relevant biological, psychological and social covariates, depressed mood was a significant correlate of NSP in both sexes; but the association between depressed mood and NSP was significantly stronger for girls than for boys.