Impact of the new fast track kidney allocation scheme for declined kidneys in the United Kingdom.

INTRODUCTION: A "new" fast track kidney allocation scheme (FTKAS) was implemented in the UK in 2012 for offering of previously declined kidneys. We evaluated the impact of the FTKAS in utilization of declined kidneys and outcome. METHODS: Adult renal transplant centers were surveyed. Overall utilization was evaluated using National Health Service Blood and Transplant (NHSBT) data. Outcome of FTKAS kidneys in our center was analyzed. RESULTS: Centers cited graft, patient outcome concerns, and inadequate logistical support for their non-FTKAS participation. In the first year of the scheme, 266 kidneys were offered through the FTKAS, 158 were transplanted in 10 centers (59%). In comparison, 166 kidneys were offered through previous system over five yr (2006-2011), and 65 were utilized in 59 transplants (39%). In our center, 42 kidneys were transplanted in 39 recipients. One-yr graft and patient survival were both 95%. Results were comparable to a matched group of kidney transplants during the same periods allocated via the standard scheme. CONCLUSIONS: The FTKAS has led to effective utilization of the declined kidneys with outcome comparable to kidneys allocated through the standard scheme. Non-participation based on outcome concerns is mostly subjective while logistical issues need to be addressed.

Minimally invasive surgery training using multiple port sites to improve performance.

BACKGROUND: Structural learning theory suggests that experiencing motor task variation enables the central nervous system to extract general rules regarding tasks with a similar structure - rules that can subsequently be applied to novel situations. Complex minimally invasive surgery (MIS) requires different port sites, but switching ports alters the limb movements required to produce the same endpoint control of the surgical instrument. The purpose of the present study was to determine if structural learning theory can be applied to MIS to inform training methods. METHODS: A tablet laptop running bespoke software was placed within a laparoscopic box trainer and connected to a monitor situated at eye level. Participants (right-handed, non-surgeons, mean age = 23.2 years) used a standard laparoscopic grasper to move between locations on the screen. There were two training groups: the M group (n = 10) who trained using multiple port sites, and the S group (n = 10) who trained using a single port site. A novel port site was used as a test of generalization. Performance metrics were a composite of speed and accuracy (SACF) and normalized jerk (NJ; a measure of movement 'smoothness'). RESULTS: The M group showed a statistically significant performance advantage over the S group at test, as indexed by improved SACF (p < 0.05) and NJ (p < 0.05). CONCLUSIONS: This study has demonstrated the potential benefits of incorporating a structural learning approach within MIS training. This may have practical applications when training junior surgeons and developing surgical simulation devices.

Implantable versus cuffed external central venous catheters for the management of children and adolescents with acute lymphoblastic leukaemia.

PURPOSE: The aim of this study was to determine if there is a difference between complications for totally implantable central venous catheters (ports) and tunnelled external central venous catheters (external CVCs) that result in early removal of the central venous catheter (CVC) in children and adolescents with acute lymphoblastic leukaemia (ALL). METHODS: All children hospitalised between November 1996 and December 2007 with ALL who had a CVC were included retrospectively. We analysed data regarding the patient's first CVC. RESULTS: We included 322 patients. 254 received a port and 68 received an external CVC. There were 102 CVC complications that required removal of the CVC prior to the completion of chemotherapy (65 in patients with ports, 37 in patients with external CVCs). Overall complications requiring CVC removal were significantly less likely to occur in the patient's with ports (p < 0.001). Ports were significantly less likely to require removal prior to the end of treatment overall (p < 0.001) and for specific complications such as infection (p < 0.001) and dislodgement (p = 0.001). However, when adjusted for disease severity there is no difference in premature CVC removal rates. CONCLUSION: When patients are risk-stratified for disease severity there is no difference in rates of CVC removal prior to completion of treatment.

The Use of Closure Devices for Aortic Stent-Graft Insertion: Outcomes Following a Paradigm Shift to Percutaneous Access in a Tertiary Vascular Center.

BACKGROUND: This retrospective case series aims to evaluate the efficacy of the Perclose ProGlide system for postoperative hemostasis following aortic stent-graft insertion. MATERIAL AND METHODS: A prospectively maintained database of patients with a minimum follow-up of 12 months following percutaneous aortic procedures was interrogated. Preprocedural computed tomography (CT) scans were reviewed to assess existing stenosis in the common femoral artery (CFA). Arteries with an estimated stenosis of greater than 25% on visual inspection underwent quantification using multiplanar and curved planar reformation. The preoperative and 1-year follow-up CTs of these patients were assessed for change in stenosis. Analysis was performed by 2 independent reviewers, with senior authors reviewing any discrepancies. RESULTS: One hundred forty-two endovascular aortic aneurysm repairs (EVARs) were performed. The ProGlide system was used in 235 arteries, yielding a high success rate in obtaining postprocedural hemostasis (94%). There were 13 postprocedural access-related complications, including 5 patients requiring surgical closure due to inadequate seal. Two patients required thrombectomy due to distal embolization. One patient required CFA endarterectomy at 6 months for the treatment of preexisting short distance claudication. Vessel analysis was performed in 31 arteries. Mean preoperative stenosis was 32% (range: 20%-57%). Mean postoperative stenosis was 32% (21%-57%). No significant change in degree of stenosis was detected (defined as a 5% change). CONCLUSIONS: The ProGlide system yielded a high success rate in obtaining postoperative hemostasis with low rate of conversion to surgical closure and low complication rates. There was no evidence of worsening vessel stenosis in arteries with preprocedural stenotic disease. LEVEL OF EVIDENCE: Level 4, Case Series.

Laparoscopic Motor Learning and Workspace Exploration.

BACKGROUND: Laparoscopic surgery requires operators to learn novel complex movement patterns. However, our understanding of how best to train surgeons' motor skills is inadequate, and research is needed to determine optimal laparoscopic training regimes. This difficulty is confounded by variables inherent in surgical practice, for example, the increasing prevalence of morbidly obese patients presents additional challenges related to restriction of movement because of abdominal wall resistance and reduced intra-abdominal space. The aim of this study was to assess learning of a surgery-related task in constrained and unconstrained conditions using a novel system linking a commercially available robotic arm with specialised software creating the novel kinematic assessment tool (Omni-KAT). METHODS: We created an experimental tool that records motor performance by linking a commercially available robotic arm with specialized software that presents visual stimuli and objectively measures movement outcome (kinematics). Participants were given the task of generating aiming movements along a horizontal plane to move a visual cursor on a vertical screen. One group received training that constrained movements to the correct plane, whereas the other group was unconstrained and could explore the entire "action space." RESULTS: The tool successfully generated the requisite force fields and precisely recorded the aiming movements. Consistent with predictions from structural learning theory, the unconstrained group produced better performance after training as indexed by movement duration (p < 0.05). CONCLUSION: The data showed improved performance for participants who explored the entire action space, highlighting the importance of learning the full dynamics of laparoscopic instruments. These findings, alongside the development of the Omni-KAT, open up exciting prospects for better understanding of the learning processes behind surgical training and investigate ways in which learning can be optimized.

The Problem with Big Data: Operating on Smaller Datasets to Bridge the Implementation Gap.

Big datasets have the potential to revolutionize public health. However, there is a mismatch between the political and scientific optimism surrounding big data and the public's perception of its benefit. We suggest a systematic and concerted emphasis on developing models derived from smaller datasets to illustrate to the public how big data can produce tangible benefits in the long term. In order to highlight the immediate value of a small data approach, we produced a proof-of-concept model predicting hospital length of stay. The results demonstrate that existing small datasets can be used to create models that generate a reasonable prediction, facilitating health-care delivery. We propose that greater attention (and funding) needs to be directed toward the utilization of existing information resources in parallel with current efforts to create and exploit "big data."

The learning curve of robot-assisted laparoscopic fundoplication in children: a prospective evaluation and CUSUM analysis.

BACKGROUND: Fundoplication is a leading application of robotic surgery in children, yet the learning curve for this procedure (RF) remains ill-defined. This study aims to identify various learning curve transition points, using cumulative summation (CUSUM) analysis. METHODS: A prospective database was examined to identify RF cases undertaken during 2006-2014. Time-based surgical process outcomes were evaluated, as well as clinical outcomes. RESULTS: A total of 57 RF cases were included. Statistically significant transitions beyond the learning phase were observed at cases 42, 34 and 37 for docking, console and total operating room times, respectively. A steep early learning phase for docking time was overcome after 12 cases. There were three Clavien-Dindo grade ≥ 3 complications, with two patients requiring redo fundoplication. CONCLUSIONS: We identified numerous well-defined learning curve trends to affirm that experience confers significant temporal improvements. Our findings highlight the value of the CUSUM method for learning curve evaluation.

Learning curve evaluation using cumulative summation analysis-a clinical example of pediatric robot-assisted laparoscopic pyeloplasty.

BACKGROUND: The cumulative summation (CUSUM) method for learning curve analysis remains under-utilized in the surgical literature in general, and is described in only a small number of publications within the field of pediatric surgery. This study introduces the CUSUM analysis technique and applies it to evaluate the learning curve for pediatric robot-assisted laparoscopic pyeloplasty (RP). METHODS: Clinical data were prospectively recorded for consecutive pediatric RP cases performed by a single-surgeon. CUSUM charts and tests were generated for set-up time, docking time, console time, operating time, total operating room time, and postoperative complications. Conversions and avoidable operating room delay were separately evaluated with respect to case experience. Comparisons between case experience and time-based outcomes were assessed using the Student's t-test and ANOVA for bi-phasic and multi-phasic learning curves respectively. Comparison between case experience and complication frequency was assessed using the Kruskal-Wallis test. RESULTS: A total of 90 RP cases were evaluated. The learning curve transitioned beyond the learning phase at cases 10, 15, 42, 57, and 58 for set-up time, docking time, console time, operating time, and total operating room time respectively. All comparisons of mean operating times between the learning phase and subsequent phases were statistically significant (P=<0.001-0.01). No significant difference was observed between case experience and frequency of post-operative complications (P=0.125), although the CUSUM chart demonstrated a directional change in slope for the last 12 cases in which there were high proportions of re-do cases and patients <6 months of age. CONCLUSIONS: The CUSUM method has a valuable role for learning curve evaluation and outcome quality monitoring. In applying this statistical technique to the largest reported single surgeon series of pediatric RP, we demonstrate numerous distinctly shaped learning curves and well-defined learning phase transition points.

Simplified fast-track laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The surgical management of complex or morbid obesity is increasing exponentially. Laparoscopic procedures are being increasingly utilized due to their similar efficacy but shorter hospital stay and faster convalescence when compared with open surgery. Despite this, many patients remain in hospital for a number of days after laparoscopic obesity surgery due to concerns about potential sequelae. We present the results of our simplified fast-track service, designed to enable discharge of all patients on postoperative day one following laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: All patients operated on by a single surgeon during a 3-year period underwent fast-track management and were included. Our simplified fast-track service has three components; it is applicable to all patients, patients are counselled regarding fast-track discharge and the only routine postoperative investigations are full blood count and serum C-reactive protein (CRP). CRP was investigated as a prognosticator for complications following LRYGB. RESULTS: One hundred twelve patients underwent a LRYGB during the study period (35 male, median age 44 [18-73], median BMI 49.4 [36.5-75.0]). Ninety-eight patients (87.5 %) were discharged the day after LRYGB. Five patients developed postoperative complications (three major, two minor). One patient required readmission following discharge on postoperative day 1. A CRP greater than 100 mg/L on postoperative day 1 was found to predict major complications with 100 % sensitivity and 95 % specificity with a diagnostic accuracy of 0.98. CONCLUSION: Our simplified fast-track LRYGB service allows the vast majority of patients to be safely and successfully discharged on postoperative day 1.