Laura Beyer-Berjot

A total laparoscopic approach reduces the infertility rate after ileal pouch-anal anastomosis: a 2-center study.

Objective: To assess the infertility rate after laparoscopic ileal pouch-anal anastomosis (IPAA). Background: Total proctocolectomy with IPAA is known to be associated with postoperative infertility in open surgery, which may be caused by pelvic adhesions affecting the fallopian tubes. However, fertility after laparoscopic IPAA has never been assessed. Methods: All patients who underwent a total laparoscopic IPAA between 2000 and 2011 and were aged 45 years or less at the time of operation and 18 years or more at the time of data collection were included. The patients answered a fertility questionnaire by telephone. All demographic and perioperative data were prospectively collected. The results were compared with those of controls undergoing laparoscopic appendectomy. Results: Sixty-three patients were included. The mean age at the time of surgery was 31 ± 9 years (range 14–44). IPAA was performed for ulcerative colitis in 73% of the cases and familial adenomatous polyposis in 17%. The mean follow-up after IPAA was 68 ± 33 months (range 6–136). Fifty-six patients answered the questionnaire (89%). Half of them already had a child before IPAA. Fifteen patients attempted pregnancy after IPAA, of which 11 (73%) were able to conceive, resulting in 10 ongoing pregnancies and 1 miscarriage. The global infertility rate was 27%. There was no difference in fertility over time compared with the 14 controls who attempted pregnancy during the same period (90% vs 86% at 36 months, P = 0.397). Conclusions: The infertility rate appears to be lower after laparoscopic IPAA than after open surgery.

Advanced training in laparoscopic abdominal surgery: a systematic review.

BACKGROUNDnSimulation has spread widely this last decade, especially in laparoscopic surgery, and training out of the operating room has proven its positive impact on basic skills during real laparoscopic procedures. Few articles dealing with advanced training in laparoscopic abdominal surgery, however, have been published. Such training may decrease learning curves in the operating room for junior surgeons with limited access to complex laparoscopic procedures as a primary operator.nnnMETHODSnTwo reviewers, using MEDLINE, EMBASE, and The Cochrane Library conducted a systematic research with combinations of the following keywords: (teaching OR education OR computer simulation) AND laparoscopy AND (gastric OR stomach OR colorectal OR colon OR rectum OR small bowel OR liver OR spleen OR pancreas OR advanced surgery OR advanced procedure OR complex procedure). Additional studies were searched in the reference lists of all included articles.nnnRESULTSnFifty-four original studies were retrieved. Their level of evidence was low: most of the studies were case series and one fifth were purely descriptive, but there were eight randomized trials. Pig models and video trainers as well as gastric and colorectal procedures were mainly assessed. The retrieved studies showed some encouraging trends in terms of trainee satisfaction with improvement after training, but the improvements were mainly on the training tool itself. Some tools have been proven to be construct-valid.nnnCONCLUSIONnHigher-quality studies are required to appraise educational value in this field.

Deliberate practice enhances quality of laparoscopic surgical performance in a randomized controlled trial: from arrested development to expert performance.

BackgroundThis study investigated whether deliberate practice leads to an increase in surgical quality in virtual reality (VR) laparoscopic cholecystectomies (LC). Previous research has suggested that sustained DP is effective in surgical training.MethodsFourteen residents were randomized into deliberate practice (nxa0=xa07) or control training (nxa0=xa07). Both groups performed ten sessions of two VR LCs. Each session, the DP group was assigned 30xa0min of DP activities in between LCs while the control group viewed educational videos or read journal articles. Performance was assessed on speed and dexterity; quality was rated with global (GRS) and procedure-specific (PSRS) rating scales. All participants then performed five porcine LCs.ResultsBoth groups improved over 20 VR LCs in time, dexterity, and global rating scales (all pxa0<xa00.05). After 20 LCs, there were no differences in speed or dexterity between groups. The DP group achieved higher quality of VR surgical performance than control for GRS (26 vs. 20, pxa0=xa00.001) and PSRS (18 vs. 15, pxa0=xa00.001). For VR cases, DP subjects plateaued at GRSxa0=xa025 after ten cases and control group at GRSxa0=xa020 after five cases. At completion of VR training, 100xa0% of the DP group reached target quality of performance (GRSxa0≥xa021) compared with 30xa0% in the control group. There were no significant differences for improvements in time or dexterity over five porcine LCs.ConclusionThis study suggests that DP leads to higher quality performance in VR LC than standard training alone. Standard training may leave individuals in a state of “arrested development” compared with DP.

An immersive “simulation week” enhances clinical performance of incoming surgical interns improved performance persists at 6 months follow-up

BACKGROUNDnThe transition from student to intern can be challenging. The August or July effect describes increased errors and reduced patient safety during this transition. The study objectives were to develop, pilot, and evaluate clinical performance after an immersive simulation course for incoming interns.nnnMETHODSnGraduating students were recruited for a 1-week immersive simulation course. Controls received no simulation training. Primary outcome (at baseline, and 1 and 6 months) was clinical performance on Objective Structured Clinical Examinations (OSCE) of clinical procedures and surgical technical skills. Secondary outcomes were self-reported confidence and clinical procedure logbook data.nnnRESULTSnNineteen students were recruited. Sixteen completed the 6-month follow-up, 10 in the intervention group and 6 in the control group. No differences were demonstrated between interventions and controls at baseline (OSCE [median, 66 vs. 78; P = .181], technical skills [48 vs. 52.5; P = .381], and confidence [101 vs 96; P = .368]). Interventions outperformed controls at 1 month (OSCE [111 vs 82; P = .001], technical skills [78.5 vs 63; P = .030], and confidence [142 vs. 119; P < .001]), and 6 months (OSCE [107 vs. 93; P = .007], technical skills [92.5 vs. 69; P = .044], and confidence [148 vs. 129; P = .022]). No differences were observed in numbers of clinical procedures performed at 1 (P = .958), 4 (P = .093), or 6 months (P = .713).nnnCONCLUSIONnThe immersive simulation course objectively improved subjects clinical skills, technical skills, and confidence. Despite similar clinical experience as controls, the intervention groups improved performance persisted at 6 months follow-up. This feasible and effective intervention to ease transition from student to intern could reduce errors and enhance patient safety.

Laparoscopic Approach Is feasible in Crohn’s Complex Enterovisceral Fistulas: A Case-Match Review

BACKGROUND: Complex enterovisceral fistulas are internal fistulas joining a “diseased” organ to any intra-abdominal “victim” organ, with the exception of ileoileal fistulas. Few publications have addressed laparoscopic surgery for complex fistulas in Crohn’s disease. OBJECTIVE: The aim of this study was to evaluate the feasibility of such an approach. DESIGN: This study is a retrospective, case-match review. SETTINGS: This study was conducted at a tertiary academic hospital. PATIENTS: All patients who underwent a laparoscopic ileocecal resection for complex enterovisceral fistulas between January 2004 and August 2011 were included. They were matched to a control group undergoing operation for nonfistulizing Crohn’s disease according to age, sex, nutritional state, preoperative use of steroids, and type of resection performed. Matching was performed blind to the peri- and postoperative results of each patient. MAIN OUTCOME MEASURES: The 2 groups were compared in terms of operative time, conversion to open surgery, morbidity and mortality rates, and length of stay. RESULTS: Eleven patients presenting with 13 complex fistulas were included and matched with 22 controls. Group 1 contained 5 ileosigmoid fistulas (38%), 3 ileotransverse fistulas (23%), 3 ileovesical fistulas (23%), 1 colocolic fistula (8%), and 1 ileosalpingeal fistula (8%). There were no significant differences between the groups in terms of operative time (120 (range, 75–270) vs 120 (range, 50–160) minutes, p = 0.65), conversion to open surgery (9% vs 0%, p = 0.33), stoma creation (9% vs 14%, p = 1), global postoperative morbidity (18% vs 32%, p = 0.68), and major complications (Dindo III: 0% vs 9%, p = 0.54; Dindo IV: 0% vs 0%, p = 1), as well as in terms of length of stay (8 (range, 7–32) vs 9 (range, 5–17) days, p = 0.72). No patients died. LIMITATIONS: This is a retrospective review with a small sample size. CONCLUSION: A laparoscopic approach for complex fistulas is feasible in Crohn’s disease, with outcomes similar to those reported for nonfistulizing forms.

Surgical training: design of a virtual care pathway approach.

BACKGROUNDnBoth intra- and perioperative care are essential for patients safety. Training for intraoperative technical skills on simulators and for perioperative care in virtual patients have independently demonstrated educational value, but no training combining these 2 approaches has been designed yet. The aim of this study was to design a pathway approach for training in general surgery. A common disease requiring essential skills was chosen, namely, acute appendicitis.nnnMETHODSnPreoperative care training was created using virtual patients presenting with acute right iliac fossa (RIF) pain. A competency-based curriculum for laparoscopic appendectomy (LAPP) was designed on a virtual reality simulator: Novices (<10 LAPP) and experienced surgeons (>100 LAPP) were enrolled to perform 2 virtual LAPP for assessment of validity evidence; novices performed 8 further LAPP for analysis of a learning curve. Finally, postoperative virtual patients were reviewed after LAPP.nnnRESULTSnFour preoperative patient scenarios were designed with different presentations of RIF; not all required operative management. Comments were provided through case progression to allow autonomous practice. Ten novices and 10 experienced surgeons were enrolled for intraoperative training. Time taken (median values) of novices versus experienced surgeons (285 vs 259xa0seconds; Pxa0=xa0.026) and performance score (67% vs 99%; Pxa0<xa0.0001) demonstrated evidence for validity, whereas path length did not (916 vs 673xa0cm; Pxa0=xa0.113). Proficiency benchmark criteria were defined for measures with validity evidence. Two postoperative virtual patients were created with an uneventful or complicated outcome.nnnCONCLUSIONnA virtual care pathway approach has been designed for acute appendicitis, enabling trainees to follow simulated patients from admission to discharge.

A Randomized Controlled Trial to Assess the Effects of Competition on the Development of Laparoscopic Surgical Skills.

BACKGROUNDnSerious games have demonstrated efficacy in improving participation in surgical training activities, but studies have not yet demonstrated the effect of serious gaming on performance. This study investigated whether competitive training (CT) affects laparoscopic surgical performance.nnnMETHODSnA total of 20 novices were recruited, and 18 (2 dropouts) were randomized into control or CT groups to perform 10 virtual reality laparoscopic cholecystectomies (LCs). Competitiveness of each participant was assessed. The CT group members were informed they were competing to outperform one another for a prize; performance ranking was shown before each session. The control group did not compete. Performance was assessed on time, movements, and instrument path length. Quality of performance was assessed with a global rating scale score.nnnRESULTSnThere were no significant intergroup differences in baseline skill or measured competitiveness. Time and global rating scale score, at final LC, were not significantly different between groups; however, the CT group was significantly more dexterous than control and had significantly lower variance in number of movements and instrument path length at the final LC (p = 0.019). Contentiousness was inversely related to time in the CT group.nnnCONCLUSIONnThis was the first randomized controlled trial to investigate if CT can enhance performance in laparoscopic surgery. CT may lead to improved dexterity in laparoscopic surgery but yields otherwise similar performance to that of standard training in novices. Competition may have different effects on novices vs experienced surgeons, and subsequent research should investigate CT in experienced surgeons as well.

Enhanced recovery simulation in colorectal surgery: design of virtual online patients

BackgroundThe aim of the present study was to design virtual patients (VP) involving enhanced recovery programs (ERP) in colorectal surgery, in order to train surgical residents in peri-operative care. Indeed, ERP have changed perioperative care and improved patients outcomes in colorectal surgery. Training, using online VP with different pre- and post-operative cases, may increase implementation of ERP.MethodsPre- and post-operative cases were built in the virtual world of Second Life™ according to a linear string design method. All pre- and post-operative cases were storyboarded by a colorectal surgeon in accordance with guidelines in both ERP and colorectal surgery, and reviewed by an expert in colorectal surgery.ResultsFour pre-operative and five post-operative cases of VP undergoing colorectal surgery were designed, including both simple and complex cases. Comments were provided through case progression to allow autonomic practice (such as “prescribed”, “this is not useful” or “the consultant does not agree with your decision”). Pre-operative cases involved knowledge in colorectal diseases and ERP such as pre-operative counseling, medical review, absence of bowel preparation in colonic surgery, absence of fasting, minimal length incision, and discharge plan. Post-operative cases involved uneventful and complicated outcomes in order to train in both simple implementation of ERP (absence of nasogastric tube, epidural analgesia, early use of oral analgesia, perioperative nutrition, early mobilization) and decision making for more complex cases.ConclusionVirtual colorectal patients have been developed to train in ERP through pre- and post-operative cases. Such patients could be included in a whole pathway care training involving technical and non-technical skills.

Does faecal diversion prevent morbidity after ileocecal resection for Crohn's disease? Retrospective series of 80 cases.

After ileocecal resection for Crohns disease, a temporary faecal diversion is indicated in high‐risk patients. The impact of a temporary stoma on post‐operative morbidity has been poorly assessed so far. The aim was to analyse post‐operative morbidity of temporary faecal diversion after ileocecal resection for Crohns disease.

Anti-tnf Therapy Is Associated With an Increased Risk of Postoperative Morbidity After Surgery for Ileocolonic Crohn Disease: Results of a Prospective Nationwide Cohort

Objective: To determine the risk factors of morbidity after surgery for ileocolonic Crohn disease (CD). Summary Background Data: The risk factors of morbidity after surgery for CD, particularly the role of anti-TNF therapy, remain controversial and have not been evaluated in a large prospective cohort study. Methods: From 2013 to 2015, data on 592 consecutive patients who underwent surgery for CD in 19 French specialty centers were collected prospectively. Possible relationships between anti-TNF and postoperative overall morbidity were tested by univariate and multivariate analyses. Because treatment by anti-TNF is possibly dependent on the characteristics of the patients and disease, a propensity score was calculated and introduced in the analyses using adjustment of the inverse probability of treatment-weighted method. Results: Postoperative mortality, overall and intra-abdominal septic morbidity rates in the entire cohort were 0%, 29.7%, and 8.4%, respectively; 143 (24.1%) patients had received anti-TNF <3 months prior to surgery. In the multivariate analysis, anti-TNF <3 months prior to surgery was identified as an independent risk factor of the overall postoperative morbidity (odds-ratio [OR] =1.99; confidence interval [CI] 95% = 1.17–3.39, P = 0.011), with preoperative hemoglobin <10u200ag/dL (OR = 4.77; CI 95% = 1.32–17.35, P = 0.017), operative time >180u200amin (OR = 2.71; CI 95% = 1.54–4.78, P < 0.001) and recurrent CD (OR = 1.99; CI 95% = 1.13–3.36, P = 0.017). After calculating the propensity score and adjustment according to the inverse probability of treatment-weighted method, anti-TNF <3 months prior to surgery remained associated with a higher risk of overall (OR = 2.98; CI 95% = 2.04–4.35, P <0.0001) and intra-abdominal septic postoperative morbidities (OR = 2.22; CI 95% = 1.22–4.04, P = 0.009). Conclusions: Preoperative anti-TNF therapy is associated with a higher risk of morbidity after surgery for ileocolonic CD. This information should be considered in the surgical management of these patients, particularly with regard to the preoperative preparation and indication of temporary defunctioning stoma.