Anantha Madhavan

A Critical Evaluation of the Intercollegiate Surgical Curriculum and Comparison With its Predecessor the “Calman” Curriculum

BACKGROUND The increasing need for doctors to be accountable and an emphasis on competency have led to the evolution of medical curricula. The Intercollegiate Surgical Curriculum Project succeeded the Calman curriculum for surgical training in 2007 in the UK. It sought to provide an integrated curriculum based upon a website platform. The aim of this review is to examine the changes to the curriculum and effect on surgical training. METHODS A comparison was made of the Calman Curriculum and the ISCP and how they met training needs. RESULTS The new curriculum is multifaceted, providing a more prescriptive detail on what trainees should achieve and when, as well as allowing portfolio, learning agreements, and work-based assessments to be maintained on an easily accessed website. The increasing emphasis on work-based assessments has been one of the major components, with an aim of providing evidence of competence. However, there is dissatisfaction amongst trainees with this component which lacks convincing validity. CONCLUSION This new curriculum significantly differs from its predecessor which was essentially just a syllabus. It needs to continuously evolve to meet the needs of trainees whose training environment is ever changing.

Case‐based discussions: UK surgical trainee perceptions

An increasing emphasis on accountability led to the development of the Intercollegiate Surgical Curriculum Project (ISCP) in the UK. A major feature of ISCP was a focus on competence with the institution of formative assessments to aid learning and provide portfolio evidence. Case‐based discussions (CBDs) are one of the main formative assessments used at all stages of training. The aim of this study was to review the use of CBDs by surgical trainees to determine if and when they are useful, and whether they are perceived as being used correctly.

Surgical Management of Gastric Gastrointestinal Stromal Tumours: Comparison of Outcomes for Local and Radical Resection

Gastrointestinal stromal tumours (GISTs) most commonly originate from the stomach. Their treatment is dependent on size and whether they are symptomatic. Curative treatment requires surgery, which may be preceded by neoadjuvant imatinib if it is felt that this will aid in achieving clear (R0) resection margins. The aim of this study was to evaluate outcomes from patients that underwent a “local” organ-preserving operation, with those that required a more radical resection, and the influences on selecting a more radical resection. A retrospective review of patients undergoing surgery for symptomatic gastric GISTs from a single institution over 9 years was carried out. Patients were divided into three cohorts dependent on whether they had a “local” resection, “anatomical” resection, or “extended” resection. 71 patients were included. Overall, 5-year survival was 92%. Operating time, blood loss, and length of stay were significantly lower in the group undergoing local resection (p < 0.05). Tumour size was also smaller in the local group (median 4 cm versus 5 cm p < 0.05). Tumour location also influenced the type of surgery performed, with tumours at the cardia, gastroesophageal junction, and antrum all having “anatomical” resections. Lymphadenectomy did not appear to impact on outcomes. These findings indicate that local excision, where possible, does not impair oncological outcomes.

Are Contrast Swallows Necessary Immediately Postlaparoscopic Heller Cardiomyotomy

Laparoscopic cardiomyotomy is an effective treatment for achalasia. Intraoperative leak tests are carried out to exclude mucosal perforations, additionally some surgeon perform postoperative contrast swallows. The aim of the study was to identify whether postoperative contrast swallows were necessary in all patients who undergo laparoscopic cardiomyotomy. All patients who underwent a laparoscopic cardiomyotomy at a single center between 2004 and 2011 were identified. Median age was 55 (18 to 79), median body mass index 26 (17 to 37), and median length of stay was 1 day (1 to 4). A total of 54% of patients had previous pneumatic dilatations. One intraoperative mucosal perforation was identified and repaired. No leaks were seen on the postoperative swallow; however, 1 patient was readmitted with a contained leak, 8 days after surgery. Postoperative contrast swallow did not have any clinical impact. We suggest that they are only indicated if there is a clinical concern and that laparoscopic cardiomyotomy can be safely carried out as a day case procedure.

Novel technique for retraction of the gastroesophageal junction in laparoscopic antireflux surgery.

Laparoscopic antireflux surgery is a recognized procedure for patients diagnosed with gastroesophageal reflux disease whose symptoms are refractory to medical treatment. We describe a novel and cost-effective technique that aids in mobilization and retraction of the gastroesophageal junction before repair of the diaphragmatic crural defect. After hiatal dissection and creation of a posterior gastric wrap, an index suture (2-0 ethibond) is placed across the wrap. This is used to retract the gastroesophageal junction and expose the crura for repair and “required facilitate fixation of fundus to the crura (fundopexy).” This technique negates the requirement for further instruments thus reducing operative expenditure and offers minimal disruption to the tissue. We have performed over 350 operative procedures using this technique and recommend it as an alternative choice that is cost effective for retraction of the esophagogastric junction in antireflux surgery.