The Effect of an Interval Training on Skill Retention of High-Complex Low-Volume Minimal Invasive Pediatric Surgery Skills: A Pilot Study.

Background: Current training programs for complex pediatric minimal invasive surgery (MIS) are usually bulk training, consisting of 1- or 2-day courses. The aim of this study was to examine the effects of bulk training versus interval training on the preservation of high-complex, low-volume MIS skills. Materials and Methods: Medical students, without prior surgical experience, were randomly assigned to either a bulk or interval training program for complex MIS (congenital diaphragmatic hernia [CDH] and esophageal atresia [EA] repair). Both groups trained for 5 hours; the bulk group twice within 3 days and the interval groups five times in 3 weeks. Skills retention was assessed at 2 weeks, 6 weeks, and 6 months posttraining, using a composite score (0%-100%) based on the objective parameters tracked by SurgTrac. Results: Seventeen students completed the training sessions (bulk n = 9, interval n = 8) and were assessed accordingly. Retention of the skills for EA repair was significantly better for the interval training group than for the bulk group at 6 weeks (P = .004). However, at 6 months, both groups scored significantly worse than after the training sessions for EA repair (bulk 60 versus 67, P = .176; interval 63 versus 74, P = .028) and CDH repair (bulk 32 versus 67, P = .018; interval 47 versus 62, P = .176). Conclusion: This pilot study suggests superior retention of complex pediatric MIS skills after interval training, during a longer period of time, than bulk training. However, after 6 months, both groups scored significantly worse than after their training, indicating the need for continuous training.

Significance of the board-certified surgeon systems and clinical practice guideline adherence to surgical treatment of esophageal cancer in Japan: a questionnaire survey of departments registered in the National Clinical Database.

BACKGROUND: It remains unknown how much institutional medical structure and process of implementation of clinical practice guidelines for esophageal cancers can improve quality of surgical outcome in Japan. METHODS: A web-based questionnaire survey was performed for departments registered in the National Clinical Database in Japan from October 2014 to January 2015. Quality indicators (QIs) including structure and process indicators (clinical practice guideline adherence) were evaluated on the risk-adjusted odds ratio for operative mortality (AOR) of the patients using registered cases in the database who underwent esophagectomy and reconstruction in 2013 and 2014. RESULTS: Among 916 departments which registered at least one esophagectomy case during the study period, 454 departments (49.6%) responded to the questionnaire. Analyses of 6661 cases revealed that two structure QIs (certification of training hospitals by Japan Esophageal Society and presence of board-certified esophageal surgeons) were associated with significantly lower AOR (p < 0.001 and p = 0.005, respectively). One highly recommended process QI regarding preoperative chemotherapy had strong tendency to associate with lower AOR (p = 0.053). In two process QIs, the answer "performed at the doctor's discretion" showed a significant negative impact on prognosis, suggesting importance of institutional uniformity. CONCLUSIONS: The medical institutional structure of board-certified training sites for esophageal surgeons and of participation of board-certified esophageal surgeons improves surgical outcome in Japan. Establishment of appropriate QIs and their uniform implementation would be crucial for future quality improvement of medical care in esophagectomy.

Subspecialization may improve an esophageal atresia service but has not addressed declining trainee experience.

BACKGROUND: Subspecialization defined pediatric surgery using Alder Hey innovations in neonatal surgical units (Rickham) and anesthesia (Jackson-Rees). In neonatal surgery, United Kingdom subspecialization for cloacal extrophy and biliary atresia acknowledges their dependence on multidisciplinary management and the desirability of caseload for training. We phased in regional subspecialization for esophageal atresia (EA) repair and replacement surgery while trainee numbers increased nationally to reduce hours. We examined EA outcomes and training during subspecialization. METHODS: We analyzed EA cases (1999-2009) treated at Alder Hey Children's Hospital in two 5-year cohorts, the first early phase of incomplete subspecialization and the later near-total or "comprehensive" subspecialization phase. These periods approximated those before and after trainee numbers rose sharply to reduce working hours. RESULTS: Of 119 cases, 60 in the early cohort shared similar characteristics with the 59 in the later cohort. Near-complete subspecialization was achieved in the second 5 years with 97% of cases performed under a surgeon with an EA specialty interest; in the earlier cohort, 25% of surgeries were undertaken by surgeons without EA subspecialty interest. With near-complete subspecialization, pediatric intensive care unit stay fell from 5 (4-11) to 4 (2-7) days (median (IQR); P = .005), and approaches such as the Bianchi axillary repair and Bax single-stage jejunal interposition were introduced; hospital stay went from 25 (12-63) to 17 (13-28) days (P = .27), and deaths, from 6 to 3 children (P = .49). Mortality was 7.6% (9/119) compared with 14% (19/134) in our previous institutional series (χ(2) = 2.8, P = .09), and neonatal mortality fell from 6% to 0 (P = .008). Near doubling of trainee numbers accompanied an approximately 3-fold fall in repairs per trainee over the study. CONCLUSION: Near-complete subspecialization for EA coincided with reduced pediatric intensive care unit stay, successful introduction of cosmetic axillary approaches, and extension of our replacement service to offer all interposition types. It has not reversed the steep decline in trainee experience of EA that has been associated with the greater numbers of trainees that have been employed to reduce working hours.

[Benign esophageal disorders. Gastroesophageal reflux disease, diffuse esophageal spasm, achalasia]. / Benigne Erkrankungen des Ösophagus. Refluxkrankheit, diffuser Ösophagusspasmus, Achalasie.

Gastroesophageal reflux disease (GERD) is the most frequent benign disorder of the upper gastrointestinal (GI) tract and other defined disease entities, such as achalasia and diffuse esophageal spasm, also belong to this group. In addition to surgical therapy, medicinal therapy also has an important role in all 3 of these disorders. Therefore, it is very important to follow precise indication criteria based on diagnostic evaluation and patient selection as well as to use an optimal operative technique.The therapeutic spectrum for achalasia varies from Botox injections and endoscopic dilatation to laparoscopic myotomy which achieves a success rate up to 90%.Patients with diffuse spasm suffer from severe dysphagia, thoracic pain and burning sensations and even respiratory problems. Surgical therapy consists of thoracoscopic long myotomy and in selective cases with persisting pain even esophagectomy and gastric pull-up.Therapeutic options for GERD predominantly involve conservative medicinal therapy with proton pump inhibitors and selective laparoscopic antireflux procedures. Minimally invasive techniques have led to a higher acceptance of surgical therapy. The two major procedures most frequently used are total Nissen fundoplication and posterior partial Toupet fundoplication.