Peri-operative chemotherapy versus preoperative chemoradiotherapy in treatment of gastro-oesophageal junctional adenocarcinomas: A 10-year cohort study.

BACKGROUND: Gastro-oesophageal junctional (GOJ) cancers have been, more latterly, considered a distinct tumor entity with characteristic genetic profiles. The optimal multimodal therapy of advanced GOJ cancers remains debatable. In this comparative study, we analyzed the outcomes of peri-operative chemotherapy (CT) versus pre-operative chemoradiotherapy (CRT) in treatment of advanced GOJ adenocarcinomas. METHODS: This study included patients with locally advanced but resectable GOJ adenocarcinomas who underwent surgical resection after oncological therapy between 2010 till 2019 at our institution. Follow up to May 2021 was completed. The outcomes between CT and CRT groups were retrospectively analyzed. The long-term follow up data was obtained via direct contact with the patients during oncological clinics, cross-checked with hospital/national patients' electronic databases. RESULTS: 107 patients had GOJ cancers; 90 (84%) patients met our inclusion criteria. Perioperative chemotherapy was administrated in 65 (72%) patients. Overall median survival rate was 2.2 years in CRT-group compared to 2.4 years in CT-group (p-value 0.29), with comparable recurrence rates (48% vs 36% respectively). R0-resections were higher in CRT-group (84%) compared to CT-group (71%), yet insignificant p-value 0.197. Preoperative chemoradiotherapy achieved higher complete pathological response (28% vs 6%, p-value 0.009) and negative lymph nodes rates (64% vs 37%, p-value 0.014) compared to CT-group. Short-term outcomes (postoperative complications, morbidity rates and length of hospital stay) were similar across both groups. CONCLUSION: Preoperative chemoradiotherapy was associated with higher complete pathological response and negative lymph nodes rates for GOJ adenocarcinomas compared to peri-operative chemotherapy, without an increase in postoperative complications or morbidity rates. However, it wasn't associated with improved overall or disease-free survival rates.

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.

Undermining and bullying in surgical training: A review and recommendations by the Association of Surgeons in Training.

The 2012 General Medical Council National Trainees' Survey found that 13% of UK trainees had experienced undermining or bullying in the workplace. The Association of Surgeons in Training subsequently released a position statement raising concerns stemming from these findings, including potential compromise to patient safety. This article considers the impact of such behaviour on the NHS, and makes recommendations for creating a positive learning environment within the NHS at national, organisational, and local levels. The paper also discusses the nature of issues within the UK, and pathways through which trainees can seek help.

Female gender and diabetes mellitus increase the risk of recurrence after laparoscopic incisional hernia repair.

BACKGROUND: Laparoscopic hernia repair is used widely for the repair of incisional hernias. Few case studies have focussed on purely 'incisional' hernias. This multicentre series represents a collaborative effort and employed statistical analyses to provide insight into the factors predisposing to recurrence of incisional hernia after laparoscopic repair. A specific hypothesis (ie, laterality of hernias as well as proximity to the xyphoid process and pubic symphysis predisposes to recurrence) was also tested. METHODS: This was a retrospective study of all laparoscopic incisional hernias undertaken in six centres from 1 January 2004 to 31 December 2010. It comprised a comprehensive review of case notes and a follow-up using a structured telephone questionnaire. Patient demographics, previous medical/surgical history, surgical procedure, postoperative recovery, and perceived effect on quality of life were recorded. Repairs undertaken for primary ventral hernias were excluded. A logistic regression analysis was then fitted with recurrence as the primary outcome. RESULTS: A total of 186 cases (91 females) were identified. Median follow-up was 42 months. Telephone interviews were answered by 115/186 (62%) of subjects. Logistic regression analyses suggested that only female sex (odds ratio (OR) 3.53; 95% confidence interval (CI) 1.39-8.97) and diabetes mellitus (3.54; 1-12.56) significantly increased the risk of recurrence. Position of the defect had no statistical effect. CONCLUSIONS: These data suggest an increased risk of recurrence after laparoscopic incisional hernia repair in females and subjects with diabetes mellitus. These data will help inform surgeons and patients when considering laparoscopic management of incisional hernias. We recommend a centrally hosted, prospectively maintained national/international database to carry out additional research.

Mentorship in surgical training: current status and a needs assessment for future mentoring programs in surgery.

AIMS: Mentoring has been used extensively in the business world to enhance performance and maximise potential. Despite this, there is currently a paucity of literature describing mentoring for surgical trainees. This study examined the current extent of mentoring and investigated future needs to support this. METHODS: An electronic, 47-item, self-administered questionnaire survey was distributed via national and regional surgical mailing lists and websites through the Association of Surgeons in Training and Specialty Associations in the UK and Republic of Ireland. RESULTS: Overall, 565 fully completed responses were received from trainees in all specialties, grades and training regions. A total of 48.7 % of respondents reported that they have a surgical mentor, with no significant gender difference (p = 0.65). Of respondents, 52.5 % considered their educational supervisor and 45.5 % their current consultant as mentors. Modal duration of mentoring relationships was 1-2 years (24.4 %). A total of 90.2 % of mentors were in the same specialty, 60.7 % in the same hospital, and 88.7 % in the same training region. Mentors covered clinical and professional matters (99.3 %) versus pastoral and non-clinical matters (41.1 %). Mentoring was commonly face to face or via email and not documented (64.7 %). Of the 51.3 % without a mentor, 89.7 % would like a clinical mentor and 51.0 % a pastoral mentor (p < 0.001). Priority mentoring areas included career progression (94.9 %), research (75.2 %), clinical skills (66.9 %) and clinical confidence (58.4 %). A total of 94.3 % would be willing to act as a peer mentor. Only 8.7 % had received mentoring training; 83 % wish to undertake this. CONCLUSIONS: Less than half of surgical trainees identified a mentor. The majority want mentoring on professional topics during their training and would additionally be willing to peer-mentor colleagues, although few have received training for this. Despite an identified need, there is currently no structure for organising this and little national provision for mentoring.

Delay to surgery does not influence the pathological outcome of acute appendicitis.

INTRODUCTION: Emergency surgery is performed on patients with appendicitis in the belief that inflammation of the appendix may progress to necrosis and perforation. Many cases of appendicitis, however, resolve with conservative treatment, and necrotic appendicitis may represent a different disease rather than the end result of inflammation of the appendix. We wished to explore the relationship between the interval to surgery after admission to hospital with appendicitis and the proportion of patients developing necrosis. METHODS: Appendicectomy operations performed between 2005 and 2010 were reviewed. End points included age, sex, interval from admission to surgery, and final pathological diagnosis. RESULTS: A total of 2403 evaluable patients were identified (1266 females). Necrotic appendicitis occurred more commonly in children (17.5%) and the elderly (25.4%) compared with adults (10.5%). The median interval to surgery of patients with normal histology (17.1 h) was longer than the time to removal of inflamed (13 h) or necrotic (13.5 h) appendices (p < 0.001).The ratio of necrotic to inflamed appendicitis in the entire cohort was 0.24. Multivariate analysis reveals that necrosis of the appendix is more common in children and the elderly and that the proportion of patients with necrosis does not change with increasing interval to surgery. DISCUSSION: Our observations show that appendicitis is not more likely to lead to perforation if a short delay prior to surgery is allowed. In addition, our findings add weight to the increasing volume of data showing that necrosis of the appendix is a disease different from simple inflammation.

Developing future surgical workforce structures: a review of post-training non-Consultant grade specialist roles and the results of a national trainee survey from the Association of Surgeons in Training.

The optimal workforce model for surgery has been much debated historically; in particular, whether there should be a recognised role for those successfully completing training employed as non-Consultant grade specialists. This role has been termed the 'sub-consultant' grade. This paper discusses historical and future career structures in surgery, draws international comparisons, and presents the results of a national trainee survey examining the post-Certificate of Completion of Training (CCT) non-consultant specialist grade. Junior doctors in surgical training (i.e. pre-CCT) were invited to participate in an electronic, 38-item, self-administered national training survey. Of 1710 questionnaires submitted, 1365 were appropriately completed and included in the analysis. Regarding the question 'Do you feel that there is a role in the surgical workforce for a post-CCT non-consultant specialist ("sub-consultant") grade in surgery?', 56.0% felt there was no role, 31.1% felt there was a role and 12.8% were uncertain. Only 12.6% of respondents would consider applying for such a post, while 72.4% would not and 15.0% were uncertain. Paediatric (23.3%), general (15.7%) and neurosurgery (11.6%) were the specialties with the highest proportions of trainees prepared to consider applying for such a role. For both questions, there was a significant gender difference in responses (p < 0.0001, Chi-square test) with female trainees more likely to consider applying. Overall 50.8% of respondents felt that the introduction of a post-CCT non-consultant specialist grade would impact positively upon service provision, however, only 21.6% felt it would have a positive impact on patient care, 13.9% a positive impact on surgical training, 11.1% a positive impact on the surgical profession and just 7.9% a positive impact on their surgical career. This survey indicates that the introduction of a 'sub-consultant' grade for surgeons who have completed training would be unpopular, with the majority believing it would be to the detriment of both patient care and surgical training. Changes to surgical career structures must be made in the interests of patient safety and quality, and on this basis ASiT supports the continued provision of primarily Consultant-delivered care.

Medical talc increases the incidence of seroma formation following onlay repair of major abdominal wall hernias.

PURPOSE: Seroma is a well established complication of the repair of major abdominal wall hernias, occasionally requiring aspiration and reoperation. Medical talc seromadesis (MTS) has been described in the literature. The aim of this study was to determine the effect of MTS on seroma formation after onlay repair of incisional hernia. METHODS: A retrospective review of a prospective database was conducted for 5 months from April 2011, when 21 consecutive patients received MTS. Outcomes were compared with a published and validated series from the same unit. RESULTS: There were no differences in basic demographics and co-morbidities between the two groups. The mean BMI was 34 for the MTS group. The incidence of recurrent incisional hernia prior to surgery was greater in MTS (9/21 vs. 36/116, p = 0.39). The mean area of fascial defect measured intra-operatively and mesh used to cover the incisional hernia defect was 170 and 309 cm(2) for the MTS group. The mean operating time was 152 min and a mean of 10 g of medical talc was used for seromadesis. The seroma rate increased from 11/116 (9.5 %) to 16/21 (76 %) (p = 0.001) as did the rate of superficial wound infection 10/116 (8.6 %) to 9/21 (43 %) (p = 0.03) in the MTS group. There was no difference in the length of in-hospital stay between the two groups. CONCLUSIONS: The application of medical talc increased the rate of seroma formation and superficial wound infection in patients undergoing open 'onlay' repair of major abdominal wall hernia.

Clinical fellowships in surgical training: analysis of a national pan-specialty workforce survey.

BACKGROUND: Fellowship posts are increasingly common and offer targeted opportunities for training and personal development. Despite international demand, there is little objective information quantifying this effect or the motivations behind undertaking such a post. The present study investigated surgical trainees' fellowship aims and intentions. METHODS: An electronic, 38-item, self-administered questionnaire survey was distributed in the United Kingdom via national and regional surgical mailing lists and websites via the Association of Surgeons in Training, Royal Surgical Colleges, and Specialty Associations. RESULTS: In all, 1,581 fully completed surveys were received, and 1,365 were included in the analysis. These represented trainees in core or higher training programs or research from all specialties and training regions: 66 % were male; the mean age was 32 years; 77.6 % intended to or had already completed a fellowship. Plastic surgery (95.2 %) and cardiothoracic (88.6 %) trainees were most likely to undertake a fellowship, with pediatrics (51.2 %), and urology (54.3 %) the least likely. Fellowship uptake increased with seniority (p < 0.01) and was positively correlated (p = 0.016, r = 0.767) with increasing belief that fellowships are necessary to the attainment of clinical competence, agreed by 73.1 %. Fellowship aims were ranked in descending order of importance as attaining competence, increasing confidence, and attaining subspecialist skills. CONCLUSIONS: Over three-quarters of trainees have or will undertake a clinical fellowship, varying with gender, specialty, and seniority. Competence, confidence, and subspecialty skills development are the main aims. The findings will influence workforce planning, and perceptions that current training does not deliver sufficient levels of competence and confidence merit further investigation.

Introduction, availability and role of simulation in surgical education and training: review of current evidence and recommendations from the Association of Surgeons in Training.

The utility of simulation in surgical training is now well-established, with proven validity and demonstrable transfer of skills to the clinical setting. Through a reduction in the technical learning curve, simulation can prepare surgeons for actual practice and in doing so it has the potential to improve both patient safety and service efficiency. More broadly, multi-disciplinary simulation of the theatre environment can aid development of non-technical skills and assist in preparing theatre teams for infrequently encountered scenarios such as surgical emergencies. The role of simulation in the formal training curriculum is less well-established, and availability of facilities for this is currently unknown. This paper reviews the contemporary evidence supporting simulation in surgical training and reports trainee access to such capabilities. Our national surgical trainee survey with 1130 complete responses indicated only 41.2% had access to skills simulator facilities. Of those with access, 16.3% had availability out-of-hours and only 54.0% had local access (i.e. current work place). These results highlight the paucity in current provision of surgical skills simulator facilities, and availability (or awareness of availability) varies widely between region, grade and specialty. Based on these findings and current best-evidence, the Association of Surgeons in Training propose 22 action-points for the introduction, availability and role of simulation in surgical training. Adoption of these should guide trainers, trainees and training bodies alike to ensure equitable provision of appropriate equipment, time and resources to allow the full integration of simulation into the surgical curriculum.

Relationships between structural and functional measures of nutritional status in a normally nourished population.

BACKGROUND AND AIMS: Both anthropometric and functional measurements have been used in nutritional assessment and monitoring. Hand dynamometry is a predictor of surgical outcome and peak expiratory flow rate has been used as an index of respiratory muscle function. This study aims to measure in normal subjects the relationship between anthropometric measurements, voluntary muscle strength by hand grip dynamometry and respiratory muscle function by peak expiratory flow rate. METHODS: Ninety-eight subjects (46 male, 52 female) with a mean age of 45.9 years were studied. Hand grip strength was measured in the dominant and non-dominant hands with a portable strain-gauge dynamometer. Peak expiratory flow rate was measured using a mini-Wright peak flow meter. Three readings were taken, each 1 min apart, and the average recorded. Midarm muscle circumference (MAMC) was derived from triceps skin fold thickness and midarm circumference (MAC) using standard anthropometric techniques. Statistical relationships were measured with Pearson's coefficient of correlation. RESULTS: In both sexes there was significant correlation between hand grip strength in the dominant and non-dominant hands and peak expiratory flow rate (P<0.001). In men, there was a positive correlation between MAMC, hand grip strength (P<0.001) and peak expiratory flow rate (P<0.001). In women muscle function correlated with height (P<0.001) but not MAMC (P>0.05). CONCLUSIONS: In normal subjects bedside tests of skeletal and respiratory muscle function correlated with each other in both sexes, and with muscle mass in men but not in women.

A practical posture for hand grip dynamometry in the clinical setting.

BACKGROUND & AIMS: The optimal testing position for hand grip strength, which is a useful functional measure of nutritional status, is open to debate. We therefore examined the systematic difference between different postures in order to establish a methodology that is clinically relevant, easy to perform and reproducible. METHODS: Grip strength was measured in the dominant and non-dominant hands with a strain gauge dynamometer in three positions: lying at 30 degrees in bed with elbows supported, seated in an armchair with elbows supported and in a chair with elbows unsupported. The average of three readings made in each position, each 1 min apart, was recorded. RESULTS: 55 normally nourished subjects (26 male) were studied. Mean (95% CI) grip strengths measured in the dominant hand with the subject in bed, sitting in an armchair and sitting in a chair were 45.7 (42.3-49.2), 46.3 (42.9-49.8) and 48.5 (45.4-51.7) kg, respectively for males. Corresponding values for females were 29.4 (27.0-31.8), 29.3 (26.8-31.9) and 31.6 (28.8-34.3) kg. There was no significant difference (Student t-paired test) between measurements made in bed and on an armchair (P = 0.49), but the measurements made in a chair were significantly higher than those made in bed (P = 0.001) and in an armchair (P = 0.004). No statistical difference was present, comparing the three separate measurements in each position (Student t-paired test). CONCLUSIONS: Measurement of grip strength using hand dynamometry is reproducible and consistent. As all patients are not able to sit in a chair with elbows unsupported, in clinical practice it is more practicable to perform hand dynamometry with the elbows supported in a bed or armchair.