Training value of laparoscopic colorectal videos on the World Wide Web: a pilot study on the educational quality of laparoscopic right hemicolectomy videos.

INTRODUCTION: Instructive laparoscopy videos with appropriate exposition could be ideal for initial training in laparoscopic surgery, but unfortunately there are no guidelines for annotating these videos or agreed methods to measure the educational content and the safety of the procedure presented. Aim of this study is to systematically search the World Wide Web to determine the availability of laparoscopic colorectal surgery videos and to objectively establish their potential training value. METHODS: A search for laparoscopic right hemicolectomy videos was performed on the three most used English language web search engines Google.com, Bing.com, and Yahoo.com; moreover, a survey among 25 local trainees was performed to identify additional websites for inclusion. All laparoscopic right hemicolectomy videos with an English language title were included. Videos of open surgery, single incision laparoscopic surgery, robotic, and hand-assisted surgery were excluded. The safety of the demonstrated procedure was assessed with a validated competency assessment tool specifically designed for laparoscopic colorectal surgery and data on the educational content of the video were extracted. RESULTS: Thirty-one websites were identified and 182 surgical videos were included. One hundred and seventy-three videos (95%) detailed the year of publication; this demonstrated a significant increase in the number of videos published per year from 2009. Characteristics of the patient were rarely presented, only 10 videos (5.4%) reported operating time and only 6 videos (3.2%) reported 30-day morbidity; 34 videos (18.6%) underwent a peer-review process prior to publication. Formal case presentation, the presence of audio narration, the use of diagrams, and snapshots and a step-by-step approach are all characteristics of peer-reviewed videos but no significant difference was found in the safety of the procedure. CONCLUSIONS: Laparoscopic videos can be a useful adjunct to operative training. There is a large and increasing amount of material available for free on the internet, but this is currently unregulated.

Synthesis and summary of patient-reported outcome measures to inform the development of a core outcome set in colorectal cancer surgery.

AIM: Patient-reported outcome (PRO) measures (PROMs) are standard measures in the assessment of colorectal cancer (CRC) treatment, but the range and complexity of available PROMs may be hindering the synthesis of evidence. This systematic review aimed to: (i) summarize PROMs in studies of CRC surgery and (ii) categorize PRO content to inform the future development of an agreed minimum 'core' outcome set to be measured in all trials. METHOD: All PROMs were identified from a systematic review of prospective CRC surgical studies. The type and frequency of PROMs in each study were summarized, and the number of items documented. All items were extracted and independently categorized by content by two researchers into 'health domains', and discrepancies were discussed with a patient and expert. Domain popularity and the distribution of items were summarized. RESULTS: Fifty-eight different PROMs were identified from the 104 included studies. There were 23 generic, four cancer-specific, 11 disease-specific and 16 symptom-specific questionnaires, and three ad hoc measures. The most frequently used PROM was the EORTC QLQ-C30 (50 studies), and most PROMs (n = 40, 69%) were used in only one study. Detailed examination of the 50 available measures identified 917 items, which were categorized into 51 domains. The domains comprising the most items were 'anxiety' (n = 85, 9.2%), 'fatigue' (n = 67, 7.3%) and 'physical function' (n = 63, 6.9%). No domains were included in all PROMs. CONCLUSION: There is major heterogeneity of PRO measurement and a wide variation in content assessed in the PROMs available for CRC. A core outcome set will improve PRO outcome measurement and reporting in CRC trials.

Clinical validity of consultant technical skills assessment in the English National Training Programme for Laparoscopic Colorectal Surgery.

BACKGROUND: The English National Training Programme for Laparoscopic Colorectal Surgery introduced a validated objective competency assessment tool to accredit surgeons before independent practice. The aim of this study was to determine whether this technical skills assessment predicted clinical outcomes. METHODS: Established consultants, training in laparoscopic colorectal surgery, were asked to submit two operative videos for evaluation by two blinded assessors using the competency assessment tool. A mark of 2·7 or above was considered a pass. Clinical and oncological outcomes were compared above and below this mark, including regression analysis. RESULTS: Eighty-five consultant surgeons submitted 171 videos. Of these, 44 (25·7 per cent) were in the fail group (score less than 2·7). This low scoring group had more postoperative morbidity (25 versus 8·7 per cent; P = 0·005), including surgical complications (18 versus 6·3 per cent; P = 0·020) and fewer lymph nodes harvested (median 13 versus 18; P = 0·004). A score of less than 2·7 was an independent predictor of surgical complication, lymph node yield and distal resection margin clearance. Consultants with higher scores had performed similar numbers of laparoscopic colorectal operations (median 37 versus 40; P = 0·373) but more structured training operations (18 versus 9; P < 0·001). CONCLUSION: An objective technical skills assessment provided a discriminatory tool with which to accredit laparoscopic colorectal surgeons.

Outreach training model for accredited colorectal specialists in laparoscopic colorectal surgery: feasibility and evaluation of challenges.

AIM: The aim of this study was to explore the feasibility and safety of an outreach model of laparoscopic colorectal training of accredited specialists in advanced laparoscopic techniques and to explore the challenges of this model from the perspective of a National Training Programme (NTP) trainer. METHOD: Prospective data were collected for unselected laparoscopic colorectal training procedures performed by five laparoscopic colorectal NTP trainees supervised by a single NTP trainer with an outreach model between 2009 and 2012. The operative and postoperative outcomes were compared with standard laparoscopic colorectal training procedures performed by six senior colorectal trainees under the supervision of the same NTP trainer within the same study period. The primary outcome was 30-day mortality. The Mann-Whitney test was used to compare continuous variables and the Chi squared or Fisher's exact tests were applied for the analysis of categorical variables. The level of statistical significance was set at P < 0.05. RESULTS: During the study period 179 elective laparoscopic colorectal procedures were performed. This included 54 cases performed by NTP trainees and 125 cases performed by the supervised trainees. There were no significant differences in age, gender, body mass index, American Society of Anesthesiologists grade, pathology and procedure type between both groups. Seventy-eight per cent of the patients operated on by the NTP trainees had had no previous abdominal surgery, compared with 50% in the supervised trainees' group (P = 0.0005). There were no significant differences in 30-day mortality or the operative and postoperative outcome between both groups. There were, however, difficulties in training an already established consultant in his or her own hospital and these were overcome by certain adjustments to the programme. CONCLUSION: Outreach laparoscopic training of colorectal surgeons is a feasible and safe model of training accredited specialists and does not compromise patient care. The challenges encountered can be overcome with optimum training and preparation.

Contemporary use of social media by consultant colorectal surgeons.

AIM: There is evidence of significant growth in the engagement of UK health-care professionals with 'open' social media platforms, such as Twitter and LinkedIn. Social media communication provides many opportunities and benefits for medical education and interaction with patients and colleagues. This study was undertaken to evaluate the uptake of public social media membership and the characteristics of use of such media channels amongst contemporary UK consultant colorectal surgeons. METHOD: Colorectal surgeons were identified from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) national registry of colorectal mortality outcomes and were cross-referenced with the General Medical Council (GMC) register. Individuals were identified by manual searching on a number of social media platforms. Matching accounts were then examined to confirm ownership and to evaluate key markers of use. RESULTS: Six-hundred and eighteen individual consultant colorectal surgeons from 142 health authorities were studied (79.5% were ACPGBI members and 90.8% were male). Two-hundred and twenty-nine (37.1%) had LinkedIn profiles (37.7% male surgeons, 29.8% female surgeons; P = 0.2530). LinkedIn membership was significantly higher in ACPGBI members (P < 0.001) and in those with GMC registration before 1997 vs after this date (39% before 1997 vs 30% after 1997; P = 0.03). LinkedIn members had a mean of 62 connections (median = 22), and 19 (3.1%) surgeons had Twitter profiles with a mean of 82 (median = 16; range: 0-914) followers and their accounts were followed by a mean of 87 (median = 27; range: 0-642) persons. CONCLUSION: UK consultant colorectal surgeons are less engaged with social media than reported studies from other health-care professional groups. Further education and appropriate guidance on usage may encourage uptake and confidence, particularly in younger consultants.

Development and evaluation of a cadaveric training curriculum for low rectal cancer surgery in the English LOREC National Development Programme.

AIM: The National Development Programme for Low Rectal Cancer in England (LOREC) was commissioned in response to wide variation in the outcome of patients with low rectal cancer. One of the aims of LOREC was to enhance surgical techniques in managing low rectal cancer. This study reports on the development and evaluation of a novel national technical skills cadaveric training curriculum in extralevator abdominoperineal excision. METHOD: Three sites were commissioned for the cadaveric workshops, each delivering the same training curriculum. Training was undertaken in pairs using a fresh-frozen cadaveric model under the supervision of expert mentors. Global assessment score (GAS) forms were developed to promote reflective learning. Feedback on the impact of the workshop was obtained from a sample of delegates at the end of the course, and also after 3-23 months via an online questionnaire. RESULTS: Overall 112 consultant colorectal surgeons attended one of 15 cadaveric technical skills training workshops. Seventy-six per cent of delegates reported easy identification of anatomy in the cadaveric model; 67% found tissue planes easy to interpret. Ninety-six per cent of delegates felt the workshop would influence their future practice; 96% reported increased awareness of important anatomy. Only 2% of delegates wished to pursue supplementary formal training from LOREC. CONCLUSION: Fresh-frozen cadavers could provide an effective training model for low rectal surgery. A structured 1-day cadaveric workshop has facilitated the dissemination of technical skills for management of low rectal cancer. Attending the cadaveric workshop enhanced delegates' confidence in performing this procedure.

A systematic review of outcome reporting in colorectal cancer surgery.

AIM: Evaluation of surgery for colorectal cancer (CRC) is necessary to inform clinical decision-making and healthcare policy. The standards of outcome reporting after CRC surgery have not previously been considered. METHOD: Systematic literature searches identified randomized and nonrandomized prospective studies reporting clinical outcomes of CRC surgery. Outcomes were listed verbatim, categorized into broad groups (outcome domains) and examined for a definition (an appropriate textual explanation or a supporting citation). Outcome reporting was considered inconsistent if results of the outcome specified in the methods were not reported. Outcome reporting was compared between randomized and nonrandomized studies. RESULTS: Of 5644 abstracts, 194 articles (34 randomized and 160 nonrandomized studies) were included reporting 766 different clinical outcomes, categorized into seven domains. A mean of 14 ± 8 individual outcomes were reported per study. 'Anastomotic leak', 'overall survival' and 'wound infection' were the three most frequently reported outcomes in 72, 60 and 44 (37.1%, 30.9% and 22.7%) studies, respectively, and no single outcome was reported in every publication. Outcome definitions were significantly more often provided in randomized studies than in nonrandomized studies (19.0% vs 14.9%, P = 0.015). One-hundred and twenty-seven (65.5%) papers reported results of all outcomes specified in the methods (randomized studies, n = 21, 61.5%; nonrandomized studies, n = 106, 66.2%; P = 0.617). CONCLUSION: Outcome reporting in CRC surgery lacks consistency and method. Improved standards of outcome measurement are recommended to permit data synthesis and transparent cross-study comparisons.

'Trainee' evaluation of the English National Training Programme for laparoscopic colorectal surgery.

AIM: The aim of this study was to review trainees' opinions of the training they had received through the National Training Programme (NTP). METHOD: An online questionnaire was distributed to NTP trainees who had completed five or more training episodes within the programme. Demographic data were collected. Opinion was given using a five-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, 5 = strongly agree). Percentages, mean values and SD were presented. ANOVA and Mann-Whitney U-tests were used to examine the impact of different factors on ratings and the difference between ratings, respectively. RESULTS: Fifty-four registered trainees fulfilled the inclusion criteria, and 37 (69% response rate) completed the questionnaire. Teaching sessions were organized using an inreach (11%), in-house (11%), outreach (27%) or combination (51%) system of training. Trainees felt that their trainers seldom cancelled sessions (93%), that it was easy to organize (92%) and consent (100%) the patient, and that their hospital was supportive of training (97%). Trainees stated that overall their trainers were excellent at training (Likert scale = 4.71 ± 0.46) and that they received regular feedback (87%). The only variable to have a significant impact on the level of NTP approval was whether the trainee was able to choose his or her trainer (supportive of NTP, chose trainer P = 0.050; critical of NTP, chose trainer P = 0.020). CONCLUSION: The large majority of trainees was highly satisfied with the training received in this innovative programme, irrespective of region or training structure used, thus demonstrating acceptability of the programme in its current form.

Single port laparoscopic right colonic resection using a 'vessel-first' approach.

AIM: Single port laparoscopic colorectal surgery (SPLC), performed through a single incision of ≤ 3 cm, has been shown to be feasible. This study aimed to assess its safety and efficacy when used as the method of choice for right hemicolectomy. METHOD: A prospective study was carried out of patients undergoing right hemicolectomy using a single port laparoscopic technique. They were compared with a historical series of patients undergoing right hemicolectomy using a multiport laparoscopic technique. Between December 2009 and September 2010, single port surgery replaced conventional laparoscopic colorectal surgery (LCS) for radical medial to lateral right hemicolectomy performed by a single surgeon. Histology, length of hospital stay, complications, conversions and readmissions were recorded. RESULTS: Fourteen patients were treated using single port laparoscopic surgery (SPLC): 10 for carcinoma (Dukes A1, B6, C3) and four for Crohn's disease. Twelve patients were treated using multiport laparoscopic colorectal surgery (LCS): eight for carcinoma (Dukes B4, C3, Carcinoid 1), three for Crohn's disease and one for adenoma. The median (interquartile range) operative time for the SPLC group was 120 (90-135) min and for the LCS group was 135 (116-150) min. The median (interquartile range) length of hospital stay was 3.5 (2.0-5.0) days for the SPLC group and for the LCS group was 4.0 (3.8-7.0) days. The median (interquartile range) number of lymph nodes removed for SPLC patients was 14.5 (9.8-19.5) and for the LCS patients was 14.5 (13.0-19.5). There were no conversions, no complications and no readmissions in either group. CONCLUSION: These data confirm the feasibility of the technique. Furthermore they suggest that it is safe and efficacious.

The National Training Programme for Laparoscopic Colorectal Surgery in England: a new training paradigm.

AIM: The National Training Programme in laparoscopic colorectal surgery was set up in 2008 to introduce laparoscopic colorectal surgery nationwide in a safe and structured way. METHOD: Over 150 consultant surgeons were enrolled; they received regular and supervised hands on training, and the operative outcome and the structured sign-off process were monitored continuously. RESULTS: Over 1000 training cases have been recorded with clinical outcomes comparable to established experts; 1/3 elective colorectal resections in England are performed laparoscopically. CONCLUSION: This successful and novel training model may be a training paradigm for other surgical and interventional specialities.

Pancreatic cyst in a cat.

CASE HISTORY: A 5-year-old neutered male Cornish Rex cat was presented for evaluation with a history of vomiting over the previous 5 days. CLINICAL FINDINGS: An abdominal mass was palpated, which was shown to be cystic by ultrasound examination. Exploratory surgery revealed this to be associated with the pancreas and it was duly resected. Histopathology was performed on the cystic mass. DIAGNOSIS: Pancreatic cyst with associated chronic active inflammation. CLINICAL RELEVANCE: This is the first report of a true pancreatic cyst in a cat.

Nasal infection with Scedosporium apiospermum in a dog.

CASE HISTORY: A 2-year-old female Siberian Husky was presented with a 6-month history of sneezing and mucous discharge from the right nostril. CLINICAL FINDINGS: Reduced airflow through the right nostril was evident. Radiographs showed subtle loss of detail of turbinates within the right nasal chamber. Rhinoscopy revealed swollen and erythematous turbinates and a white mass within the caudal aspect of the right nasal cavity. Histopathologically, there was a heavy mixed inflammatory infiltrate in the submuscosa of the right turbinate, and the presence of fungal hyphae and spores in the white mass. A heavy growth of Scedosporium apiospermum was cultured from the mass. DIAGNOSIS: Chronic rhinitis of the right nasal cavity and infection with S. apiospermum. CLINICAL RELEVANCE: This is the first reported case of S. apiospermum isolated from the nasal cavity of a dog in New Zealand. Fungal culture is necessary to differentiate this fungus from Aspergillus spp.

Metastatic adenocarcinoma masquerading as a solitary nerve sheath tumour.

We present a case of a solitary metastasis of an adenocarcinoma to a dorsal root ganglion (DRG) following a disease free interval of 12 years after resection of a Duke's C carcinoma. The presentation of this unusually placed metastasis was associated with a 3-year complex pain syndrome and radiological appearances consistent with benign disease. The case highlights the importance of not dismissing unusual lesions as innocent in the presence of a history of malignant disease.

The poor quality of information about laparoscopy on the World Wide Web as indexed by popular search engines.

BACKGROUND: This study was undertaken to determine the quality of information on the Internet regarding laparoscopy. METHODS: Four popular World Wide Web search engines were used with the key word "laparoscopy." Advertisements, patient- or physician-directed information, and controversial material were noted. RESULTS: A total of 14,030 Web pages were found, but only 104 were unique Web sites. The majority of the sites were duplicate pages, subpages within a main Web page, or dead links. Twenty-eight of the 104 pages had a medical product for sale, 26 were patient-directed, 23 were written by a physician or group of physicians, and six represented corporations. The remaining 21 were "miscellaneous." The 46 pages containing educational material were critically reviewed. At least one of the senior authors found that 32 of the pages contained controversial or misleading statements. All of the three senior authors (LKN, NAO, GAF) independently agreed that 17 of the 46 pages contained controversial information. CONCLUSION: The World Wide Web is not a reliable source for patient or physician information about laparoscopy. Authenticating medical information on the World Wide Web is a difficult task, and no government or surgical society has taken the lead in regulating what is presented as fact on the World Wide Web.

Minisatellite instability is found in colorectal tumours with mismatch repair deficiency.

Microsatellite instability (MSI) in colorectal tumours is demonstrated by PCR amplification of several different microsatellite loci. Minisatellites, which are repeats of longer sequences also found throughout the genome, may also be affected by tumorigenesis. Certain minisatellite alleles contain 2 types of similar repeat unit that are randomly interspersed. The interspersion pattern can be analysed by mapping variant repeat units along an amplified allele, minisatellite variant repeat unit mapping PCR (MVR-PCR). We have applied microsatellite analysis with 10 markers and MVR-PCR for locus D7S21 to 33 cases of colorectal neoplasia, 27 sporadic and 6 from patients suspected of having hereditary non-polyposis colorectal cancer (HNPCC). Of the 27 sporadic cases, 3 were MSI-high on microsatellite analysis and one MSI-low. Instability with MVR-PCR was observed, but only in the MSI-high cases. Four of the HNPCC patients had mismatch repair (MMR) gene mutations in either hMLH1 or hMSH2. All 4 had DNA instability by MVR-PCR, but only two of these had MSI (one high, one low). The other 2 of the 6 patients with suspected HNPCC were negative to mutation analysis. One had features strongly suggestive of HNPCC and was unstable by both microsatellite analysis (MSI-high) and by MVR-PCR. The other tumour, from an Amsterdam criteria positive kindred, did not demonstrate instability by any technique. Thus MVR-PCR detects DNA instability in MSI-high sporadic tumours and in those associated with HNPCC where MSI is observed. Further, in some MMR mutation positive cases MSI was not seen but instability was observed by MVR-PCR. MVR-PCR may be a valuable adjunct to the detection of MMR deficiency in colorectal tumours and it may allow new insights into the nature of DNA instability in this condition.

Lessons learned from laparoscopic gastric banding for morbid obesity.

BACKGROUND: Laparoscopic gastric banding is a minimally invasive bariatric operation that is increasing in popularity at many centers worldwide. Although this procedure is not yet approved in the United States, clinical trials are ongoing. METHODS: We report our results of a 3-year follow-up on 60 patients who underwent the laparoscopic gastric band procedure for the treatment of morbid obesity. The procedure was performed at the Wesley Obesity Clinic in Brisbane, Australia. RESULTS: At follow-up, 51 of the 60 patients (85%) still had the laparoscopic gastric band in place. All of the patients had a lower body weight after undergoing the procedure. The average weight loss was 39 kg (range 2 to 98 kg), representing a loss of 65% of average excess body weight. Twenty-five of 51 patients (49%) regained some weight after their initial loss, but the average amount was only 5 kg. The remaining 26 patients have remained at their lowest body weight recorded after the procedure or are continuing to lose weight. There was no operative mortality. Complications predominantly were caused by band slippage (21%), which has been nearly eliminated in recent practice (1 slip in the last 225 cases). Subsequent modifications in the technique to prevent band slippage included placing the band near the level of the esophagus, with minimal disruption of the posterior gastric attachments and diligent suturing of the band in place. CONCLUSIONS: We conclude that the laparoscopic gastric band is effective in short- and long-term weight loss. The high rate of reoperation for repositioning has been avoided in current practice.

Impact of previous surgery on time taken for incision and division of adhesions during laparotomy.

PURPOSE: Adhesions from previous surgery constitute a major problem in general surgery. Much is known of the consequences of adhesions in terms of morbidity, but there has been little documentation of the effect of previous surgery on the time taken to reoperate. METHODS: Information on incision time and division of adhesion time was recorded on 120 patients (89 elective cases and 31 emergencies) undergoing midline laparotomy under the care of a single colorectal surgeon. RESULTS: Fifty-one percent of elective and 71 percent of emergency cases had previously had abdominal surgery. Previous surgery prolonged the median incision time from 5 (range, 3-10) to 8 (range, 4-39) minutes (P < 0.001) and the median division of adhesion time from 0 (range, 0-30) to 15 (range, 0-12) minutes (P < 0.0001). CONCLUSIONS: Previous surgery significantly increases the operating time during subsequent surgery by a median of 18 minutes. This information may be of use in the planning of surgical workload and highlights the needs for cost-effective adhesion prevention strategies.

Non-operative management of breast masses diagnosed as fibroadenoma.

A 7-9-year study was undertaken in 99 female patients (median age 20 years), 56 of whom had single and 43 multiple fibroadenomas (total 279). Thirty-four women with 58 masses (21 per cent) were lost to follow-up. Twenty-eight women with 73 masses (26 per cent) subsequently underwent excision at a median of 10 (range 3-59) months for single and 38 (1-110) months for multiple fibroadenomas (P = 0.03), with histological confirmation in 71 and other benign disease in two cases. There was resolution of 107 masses (38 per cent of those entered into the study, 72 per cent of those not lost or excised), leaving 41 persisting masses (15 per cent of those entered into the study, 28 per cent of those not lost or excised). The actuarial probability of disappearance was 0.46 at 5 years and 0.69 at 9 years (Kaplan-Meier analysis). There was no difference in the rate of resolution when 56 single lesions were compared with 223 multiple lesions, or when 192 lesions measuring 2 cm or less in diameter were compared with 87 greater than 2 cm. Resolution was significantly more frequent in women aged 20 years or less than in those who were older (P < 0.01). Non-operative management remains a safe approach in selected women and should be followed by resolution of half of fibroadenomas at 5 years.

Phalangeal fractures resulting from finger wrestling.

Two cases of proximal phalangeal fracture following finger wrestling are described. The mechanism of the injury is discussed.