Elective Laparoscopic Cholecystectomy as an Entrustable Professional Activity (EPA) for General Surgical Trainees in Australia.

INTRODUCTION: To evaluate the operation time and surgical outcomes of elective laparoscopic cholecystectomy performed by surgical trainees at different levels of training at Eastern health and hence, to establish the efficacy and safety of elective laparoscopic cholecystectomy as an Entrustable Professional Activity for surgical trainees in general surgery. OBJECTIVE: Elective laparoscopic cholecystectomies performed at our institution between January 2018 and January 2019 were included. Analyses were divided among three groups - consultants (C), fellows (F) and registrars (R). Standard technique with critical view of safety was used. RESULTS: A total of 592 patients was included, with a mean age of 54 ± 63 years old. The average operation time was 84 ± 51 minutes. Surgical education and training (SET) 2 trainees took significantly longer when compared to their SET3 and above counterparts as a primary operator (SET2: 131 ± 32 min, Reference; SET3: 78 ± 21 min, p = 0.003; SET4: 80 ± 33 min, p = 0.004; SET5: 77 ± 28 min, p = 0.003; F: 93 ± 77 min, p = 0.036; C: 85 ± 59 min; p = 0.007). Consultant primary operators took an average of 15 minutes longer to complete the operation when assisted by a SET trainee compared to the non-SET registrars (p = 0.03). The overall complication rate was 3.2% and was not significantly different among all three groups (p = 0.17). No death was recorded during the study period. The readmission and return to theatre rates were 7.8% and 0.8% respectively and were not significantly different among the groups (p-values = 0.61 and 0.69). All conversion to open were performed by the consultant primary operator. CONCLUSIONS: Elective laparoscopic cholecystectomy can be safely performed by surgical trainees at all SET levels when under appropriate supervision, although junior surgical trainees that is SET 2 took longer to complete the procedure. This operation seems to have a steep, but relatively short, learning curve and it may be broken down into various components. These components, with the addition of time, may be suitable as an Entrustable Professional Activity tool for assessing the competency of early SET trainees.

Retroperitoneal liposarcoma in a nonagenarian.

Retroperitoneal liposarcomas are rare tumors arising from the soft tissue of the retroperitoneum and are of mesenchymal cell origin. They can reach a large size prior to causing symptoms and generally have a poor prognosis. We present the case of a 93-year-old lady presenting with a large retroperitoneal liposarcoma at the site of a previous colonic anastomosis for the adenocarcinoma treatment. It caused minimal symptoms initially, but surgical resection was undertaken when the tumor was found to be growing significantly in size. However, due to the tumor's location and its invasion into surrounding structures, the resection was not feasible and subsequently abandoned. A retroperitoneal liposarcoma arising from the site of a previous colonic resection has not been previously described. A review of the diagnosis and current management of these lesions is also given.

Compliance with follow-up for patients with stage 1 testicular germ cell tumour.

BACKGROUND: This study aimed to evaluate the compliance and loss-to-follow-up (LTFU) rate in patients with stage 1 testicular germ cell tumours (GCTs) on active surveillance protocol at a metropolitan health service in Melbourne, Australia. METHODS: Patients with stage 1 testicular GCTs diagnosed between 30 June 2012 and 30 June 2018 were identified. Compliance of surveillance programme was classified into three groups: 'adequate', 'missed appointment(s)' or 'LTFU'. The LTFU rate was assessed using Kaplan-Meier methodology. Log-rank test was used for univariate analyses. RESULTS: Forty-eight patients had stage 1 testicular GCTs during the 6-year period. Twenty-two (46%) of them were managed with active surveillance and 26 (54%) of them were given adjuvant therapy. Compliance with active surveillance was assessed as adequate in 12 (55%), missed appointment(s) in six (27%) and LFTU in four (18%). The LTFU rates in patients with active surveillance at 12, 24 and 36 months were 9%, 9% and 19%, respectively. The LTFU rate in patients with active surveillance was not significantly different from patients who received adjuvant therapy (hazard ratio 0.71 (95% confidence intervals 0.22, 2.30), P = 0.56). Three (14%) of the 22 patients managed with active surveillance had recurrence of disease, all of which occurred in the first 12 months, compared to two (8%) of the 26 patients who had adjuvant therapy. CONCLUSION: Active surveillance is a commonly utilized management option for stage 1 testicular GCTs, but has a LTFU rate of almost 20% that may limit its effectiveness. The recurrence rate was comparable to published literature.

Retroperitoneal liposarcoma in a nonagenarian

Retroperitoneal liposarcomas are rare tumors arising from the soft tissue of the retroperitoneum and are of mesenchymal cell origin. They can reach a large size prior to causing symptoms and generally have a poor prognosis. We present the case of a 93-year-old lady presenting with a large retroperitoneal liposarcoma at the site of a previous colonic anastomosis for the adenocarcinoma treatment. It caused minimal symptoms initially, but surgical resection was undertaken when the tumor was found to be growing significantly in size. However, due to the tumor's location and its invasion into surrounding structures, the resection was not feasible and subsequently abandoned. A retroperitoneal liposarcoma arising from the site of a previous colonic resection has not been previously described. A review of the diagnosis and current management of these lesions is also given.

Duplicated Inferior Vena Cava in a Patient With Ampullary Adenocarcinoma: A Case Report and Literature Review of Anatomical Variations.

Duplicated inferior vena cava (IVC) is a rare anatomical anomaly as a result of failed regression of the left supracardinal vein during the embryonic stage. This anatomical variation has certain surgical implications and could lead to potential catastrophe perioperatively. We hereby report a case of a 54 years old male in whom a whipple procedure was performed with type 1 duplicated IVC for ampullary adenocarcinoma. Review of current literature of such anatomical anomaly will also be discussed. This venous anomaly must be kept in mind in all surgical procedures involving the retroperitoneum to minimise the risk of incomplete lymph node dissection and life-threatening bleeding, and to guide management for deep vein thrombosis in the post-operative setting.

Should bariatric surgery be offered for hepatocellular adenomas in obese patients?

BACKGROUND: Obesity and metabolic syndrome are increasingly recognized as risk factors for development of hepatocellular adenoma (HCA). The implications of weight loss on HCA regression has not been previously reviewed. OBJECTIVES: To analyze the effects of surgical and nonsurgical weight loss on HCA. SETTING: University Tertiary Hospital. METHODS: Literature review of full-text articles from PubMed and Scopus on patients with HCA who underwent surgical or nonsurgical weight loss was performed. Only English language articles were included and editorial comments were excluded. Wilcoxon signed rank test was used for paired data analysis. Spearman correlation was used for correlation between percent excess weight loss (%EWL) and number and size of HCA lesions. RESULTS: Out of 4 studies, 7 patients were included in this review, all of whom were female. The median preintervention body mass index was 41 kg/m2 compared with the postintervention body mass index of 28 kg/m2 (P = .002). The %EWL following intervention positively correlated to reduction in number of HCA lesions (%) postintervention, with a Spearman correlation of .78 (P = .04). Similarly, %EWL postintervention was positively correlated, though not statistically significant, to reduction in lesion size (%), with a Spearman correlation of .46 (P = .29). All patients who were candidates for liver resection preintervention based on lesion size > 5 cm avoided liver resection postintervention following surgical and nonsurgical weight loss. CONCLUSIONS: Effective long-term weight loss by surgical and nonsurgical methods result in regression of HCAs. Weight loss could avoid major liver resections or decrease the morbidity associated with liver surgery. Bariatric surgery should be considered as an option for management of surgically challenging HCAs in carefully selected obese patients. Multicenter long-term trials, while adjusting for cofounding factors, are required to determine the effects of surgical compared with nonsurgical weight loss on maintenance of HCA regression.