Gearing up for milestones in surgery: Will simulation play a role?

BACKGROUND: The Consortium of American College of Surgeons-Accredited Education Institutes was created to promote patient safety through the use of simulation, develop new education and technologies, identify best practices, and encourage research and collaboration. METHODS: During the 7th Annual Meeting of the Consortium, leaders from a variety of specialties discussed how simulation is playing a role in the assessment of resident performance within the context of the Milestones of the Accreditation Council for Graduate Medical Education as part of the Next Accreditation System. CONCLUSION: This report presents experiences from several viewpoints and supports the utility of simulation for this purpose.

Ethical considerations regarding the implementation of new technologies and techniques in surgery.

Ethical considerations relevant to the implementation of new surgical technologies and techniques are explored and discussed in practical terms in this statement, including (1) How is the safety of a new technology or technique ensured?; (2) What are the timing and process by which a new technology or technique is implemented at a hospital?; (3) How are patients informed before undergoing a new technology or technique?; (4) How are surgeons trained and credentialed in a new technology or technique?; (5) How are the outcomes of a new technology or technique tracked and evaluated?; and (6) How are the responsibilities to individual patients and society at large balanced? The following discussion is presented with the intent to encourage thought and dialogue about ethical considerations relevant to the implementation of new technologies and new techniques in surgery.

Fundamentals of Endoscopic Surgery cognitive examination: development and validity evidence.

BACKGROUND: Flexible endoscopy is an integral part of surgical care. Exposure to endoscopic procedures varies greatly in surgical training. The Society of American Gastrointestinal and Endoscopic Surgeons has developed the Fundamentals of Endoscopic Surgery (FES), which serves to teach and assess the fundamental knowledge and skills required to practice flexible endoscopy of the gastrointestinal tract. This report describes the validity evidence in the development of the FES cognitive examination. METHODS: Core areas in the practice of gastrointestinal endoscopy were identified through facilitated expert focus groups to establish validity evidence for the test content. Test items then were developed based on the content areas. Prospective enrollment of participants at various levels of training and experience was used for beta testing. Two FES cognitive test versions then were developed based on beta testing data. The Angoff and contrasting group methods were used to determine the passing score. Validity evidence was established through correlation of experience level with examination score. RESULTS: A total of 220 test items were developed in accordance with the defined test blueprint and formulated into two versions of 120 questions each. The versions were administered randomly to 363 participants. The correlation between test scores and training level was high (r = 0.69), with similar results noted for contrasting groups based on endoscopic rotation and endoscopic procedural experience. Items then were selected for two test forms of 75 items each, and a passing score was established. CONCLUSIONS: The FES cognitive examination is the first test with validity evidence to assess the basic knowledge needed to perform flexible endoscopy. Combined with the hands-on skills examination, this assessment tool is a key component for FES certification.

Changes in self-perceived abilities among male and female medical students after the first year of clinical training.

BACKGROUND: It is known that male and female medical students have different experiences in their clinical training. AIMS: To assess whether male and female medical students change in their self-rated work habits and interpersonal habits during the first year of clinical training. METHOD: Longitudinal study of self- and peer-assessment among 224 medical students in 3 consecutive classes at a private US medical school. Students rated themselves on global work habits (WH) and interpersonal attributes (IA). Students also rated and were rated by 6-12 peers on the same scale. RESULTS: In the second year of medical school, there were no differences between men and women in quartiles of self-assessed WH or IA. At the end of the third year, however, women were more likely to be in the lower quartiles of self-assessed WH (X(2) = 6.77; p = 0.03), as well as the highest quartiles of self-assessed IA (X(2) = 11.36; p = 0.003). In both years, women rated their own WH skills significantly lower than they rated their peers, while men rated themselves similarly to peers. There were no sex differences in self-assessed IA. CONCLUSIONS: Although second-year male and female medical students appear similar to one another in terms of self-assessed WH and IA, by the end of the third year women rate themselves relatively lower in WH, while men rate themselves relatively lower in IA.

Gastrectomy as a remedial operation for failed fundoplication.

The decision for, and choice of, a remedial antireflux procedure after a failed fundoplication is a challenging clinical problem. Success depends upon many factors including the primary symptom responsible for failure, the severity of underlying anatomic and physiologic defects, and the number and type of previous remedial attempts. Satisfactory outcomes after reoperative fundoplication have been reported to be as low as 50%. Consequently, the ideal treatment option is not clear. The purpose of this study was to evaluate the outcome of gastrectomy as a remedial antireflux procedure for patients with a failed fundoplication. The study population consisted of 37 patients who underwent either gastrectomy (n = 12) with Roux-en-Y reconstruction or refundoplication (n = 25) between 1997-2005. Average age, M/F ratio, and preoperative BMI were not significantly different between the two groups. Outcome measures included perioperative morbidity, relief of primary and secondary symptoms, and the patients' overall assessment of outcome. Mean follow up was 3.5 and 3.3 years in the gastrectomy and refundoplication groups, respectively (p = 0.43). Gastrectomy patients had a higher prevalence of endoscopic complications of GERD (58% vs 4%, p = 0.006) and of multiple prior fundoplications than those having refundoplication (75% vs 24%, p = 0.004). Mean symptom severity scores were improved significantly by both gastrectomy and refundoplication, but were not significantly different from each other. Complete relief of the primary symptom was significantly greater after gastrectomy (89% vs 50%, p = 0.044). Overall patient satisfaction was similar in both groups (p = 0.22). In-hospital morbidity was higher after gastrectomy than after refundoplication (67% vs 20%, p = 0.007) and new onset dumping developed in two gastrectomy patients. In select patients with severe gastroesophageal reflux disease (GERD) and multiple previous fundoplications, primary symptom resolution occurs significantly more often after gastrectomy than after repeat fundoplication. Gastrectomy, however, is associated with higher morbidity. Gastrectomy is an acceptable treatment option for recurrent symptoms particularly when another attempt at fundoplication is ill advised, such as in the setting of multiple prior fundoplications or failed Collis gastroplasty.

Cognitive task analysis for teaching technical skills in an inanimate surgical skills laboratory.

BACKGROUND: The teaching of surgical skills is based mostly on the traditional "see one, do one, teach one" resident-to-resident method. Surgical skills laboratories provide a new environment for teaching skills but their effectiveness has not been adequately tested. Cognitive task analysis is an innovative method to teach skills, used successfully in nonmedical fields. The objective of this study is to evaluate the effectiveness of a 3-hour surgical skills laboratory course on central venous catheterization (CVC), taught by the principles of cognitive task analysis to surgical interns. METHODS: Upon arrival to the Department of Surgery, 26 new interns were randomized to either receive a surgical skills laboratory course on CVC ("course" group, n = 12) or not ("traditional" group, n = 14). The course consisted mostly of hands-on training on inanimate CVC models. All interns took a 15-item multiple-choice question test on CVC at the beginning of the study. Within two and a half months all interns performed CVC on critically ill patients. The outcome measures were cognitive knowledge and technical-skill competence on CVC. These outcomes were assessed by a 14-item checklist evaluating the interns while performing CVC on a patient and by the 15-item multiple-choice-question test, which was repeated at that time. RESULTS: There were no differences between the two groups in the background characteristics of the interns or the patients having CVC. The scores at the initial multiple-choice test were similar (course: 7.33 +/- 1.07, traditional: 8 +/- 2.15, P = 0.944). However, the course interns scored significantly higher in the repeat test compared with the traditional interns (11 +/- 1.86 versus 8.64 +/- 1.82, P = 0.03). Also, the course interns achieved a higher score on the 14-item checklist (12.6 +/- 1.1 versus 7.5 +/- 2.2, P <0.001). They required fewer attempts to find the vein (3.3 +/- 2.2 versus 6.4 +/- 4.2, P = 0.046) and showed a trend toward less time to complete the procedure (15.4 +/- 9.5 versus 20.6 +/- 9.1 minutes, P = 0.149). CONCLUSIONS: A surgical skills laboratory course on CVC, taught by the principles of cognitive task analysis and using inanimate models, improves the knowledge and technical skills of new surgical interns on this task.

Surgical management of hypertensive lower esophageal sphincter with dysphagia or chest pain.

Hypertensive lower esophageal sphincter (LES) is an uncommon manometric abnormality found in patients with dysphagia and chest pain, and is sometimes associated with gastroesophageal reflux disease (GERD). Preventing reflux by performing a fundoplication raises concerns about inducing or increasing dysphagia. The role of myotomy in isolated hypertensive LES is also unclear. The aim of this study was to determine the outcome of surgical therapy for isolated hypertensive LES and for hypertensive LES associated with GERD. Sixteen patients (5 males and 11 females), ranging in age from 39 to 89 years, with hypertensive LES (>26 mm Hg; i.e., >95th percentile of our control population) who had surgical therapy between 1996 and 1999 were reviewed. Patients with a diagnosis of achalasia and diffuse esophageal spasm were excluded. All patients had dysphagia or chest pain. Eight of 16 patients had symptoms of GERD, four had a type III hiatal hernia, and four had isolated hypertensive LES pain. Patients with hypertensive LES and GERD or type III hiatal hernia had a Nissen fundoplication, and those with isolated hypertensive LES had a myotomy of the LES with partial fundoplication. Outcome was assessed as follows: excellent if the patient was asymptomatic; good if symptoms were present but no treatment was required; fair if symptoms were present and required treatment; and poor if symptoms were unimproved or worsened. All patients were contacted by telephone for symptom assessment at a median of 3.6 years (range 3 to 6.1 years) after surgery. Patients with hypertensive LES and GERD or type III hiatal hernia had significantly lower LES pressure than those with isolated hypertensive LES (29.9 vs. 47.4 mm Hg; P=0.013). Dysphagia and chest pain were relieved in all patients at long-term follow up. Outcome was excellent in 10 of 16, good in 3 of 16, and fair in 3 of 16. All patients but one were satisfied with their outcome. Patients with hypertensive LES are a heterogeneous group in regard to symptoms and etiology. Treatment of patients with hypertensive LES should be individualized. A Nissen fundoplication for hypertensive LES with GERD or type III hiatal hernia relieves dysphagia and chest pain suggesting reflux as an etiology. A myotomy with partial fundoplication for isolated hypertensive LES relieves dysphagia and chest pain suggesting a primary sphincter dysfunction.

Increasing esophageal length: a comparison of laparoscopic versus transthoracic esophageal mobilization with and without vagal trunk division in pigs.

BACKGROUND: New laparoscopic techniques allow both mediastinal mobilization and performance of a Collis gastroplasty when necessary, and the utility of a transthoracic approach is questioned. The aim of this study was to compare the increase in esophageal length achievable with laparoscopic and transthoracic esophageal mobilization in pigs, and to assess the impact of vagal trunk division on esophageal length. STUDY DESIGN: Baseline esophageal length was obtained in 20 farm pigs by measuring the distance between a stitch placed in the esophagus to a K-wire placed in a vertebral body. Subsequently, laparoscopic and then transthoracic mediastinal mobilization of the esophagus were performed in 15 pigs and the length gain after each procedure recorded. In 7 of 15 animals, the vagal nerve trunks were divided after esophageal mobilization and the increase in esophageal length measured. In five animals, vagal trunk division was performed without earlier esophageal mobilization. RESULTS: Esophageal length gain after laparoscopic mobilization (median 4 mm) was significantly less than that after transthoracic mobilization (median 12 mm, p < 0.0001). Unilateral vagal nerve transection resulted in a median 2.5 mm of esophageal length gain compared with a median of 6.25 mm with division of both vagal trunks. Maximal esophageal lengthening (median 18.5 mm) occurred with a combination of esophageal mobilization and bilateral vagal trunk division. CONCLUSIONS: Esophageal length gain after transthoracic mobilization in normal pigs is significant, and would likely be even greater in patients with gastroesophageal reflux disease with concomitant mediastinal inflammation. Transthoracic mobilization alone likely will allow successful reduction of the gastroesophageal junction below the diaphragm in many patients who might otherwise require a Collis gastroplasty.

Absence of gastroesophageal reflux disease in a majority of patients taking acid suppression medications after Nissen fundoplication.

Recent studies have shown that many patients use acid suppression medications after antireflux surgery. The aim of this study was to determine the frequency of gastroesophageal reflux disease in a cohort of surgically treated patients with postoperative symptoms and a high prevalence of acid suppression medication use. The study group consisted of 86 patients who had symptoms following Nissen fundoplication that were sufficient to merit evaluation with 24-hour distal esophageal pH monitoring. All completed a detailed symptom questionnaire. The mean postoperative follow-up period was 28 months (median 18 months). Thirty-seven patients (43%) were taking acid suppression medications after fundoplication. Only 23% (20 of 86) of all the patients and only 24% (9 of 37) of those taking acid suppression medications had abnormal esophageal acid exposure on the 24-hour pH study. Heartburn and regurgitation were the only symptoms that were significantly associated with an abnormal pH study. Endoscopic assessment of the fundoplication was the most significant factor associated with an abnormal pH study. Multivariable logistic regression analysis showed that patients with a disrupted, abnormally positioned fundoplication had a 52.6 times increased risk of abnormal esophageal acid exposure. Most patients who use acid suppression medications after antireflux surgery do not have abnormal esophageal acid exposure, and the use of these medications is thus often inappropriate. Because of the limited predictive power of symptoms, objective evidence of reflux disease should be obtained before prescribing acid suppression medication for patients who have undergone antireflux surgery.