Paul Neary

Immunonutrition: the role of taurine.

Taurine is a sulfonated beta amino acid derived from methionine and cysteine metabolism. It is present in high concentrations in most tissues and in particular in proinflammatory cells such as polymorphonuclear phagocytes. Initial investigation into the multifaceted properties of this non-toxic physiologic amino acid revealed a link between retinal dysfunction and dietary deficiency. Since then a role for this amino acid has been found in membrane stabilization, bile salt formation, antioxidation, calcium homeostasis, growth modulation, and osmoregulation. Our own group has demonstrated a key role for taurine in modulation of apoptosis in a variety of cell types. This review summarizes our current knowledge of taurine in nutrition, host proinflammatory cell homeostasis, therapeutic applications, and its potential immunoregulatory properties. It is our belief that taurine, similar to arginine and glutamine, is now more than worthy of critical clinical analysis.

Standardized Algorithms for Management of Anastomotic Leaks and Related Abdominal and Pelvic Abscesses After Colorectal Surgery

BackgroundThe risk factors and incidence of anastomotic leak following colorectal surgery are well reported in the literature. However, the management of the multiple clinical scenarios that may be encountered has not been standardized.MethodsThe medical literature from 1973 to 2007 was reviewed using PubMed for papers relating to anastomotic leaks and abdominal abscess, with a specific emphasis on predisposing factors, prevention strategies, and treatment approaches. A six-round modified Delphi research method was utilized to find consensus among a group of expert colorectal surgeons and interventional radiologists regarding standardized management algorithms for anastomotic leaks.ResultsManagement scenarios were divided into those for intraperitoneal anastomoses, extraperitoneal (low pelvic) anastomoses, and anastomoses with proximal diverting stomas. Management options were then based on the clinical presentation and radiographic findings and organized into three interconnected algorithms.ConclusionsThis process was a useful first step toward establishing guidelines for the management of anastomotic leak.

Is the skillset obtained in surgical simulation transferable to the operating theatre

BACKGROUND Simulated surgical training offers a safe and accessible way of learning surgical procedures outside the operating room. Training programs have been developed using simulated laboratories to train surgical trainees to proficiency outside the operating room. Despite the global enthusiasm among educators to enhance training through simulation-based learning, it remains to be elucidated whether the skill set obtained is transferrable to the operating room. METHODS Using standardized search methods, the authors searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Web-Based Knowledge, as well as the reference lists of relevant articles, and retrieved all published randomized controlled trials. RESULTS Sixteen randomized controlled trials involving 309 participants were identified to be suitable for qualitative analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The mean Consolidated Standards of Reporting Trials score was 16 (range, 12-22). The studies showed considerable clinical and methodologic diversity. Operative time improved consistently in all trials after training and was the only objective parameter measurable in the live setting. Studies that used the Objective Structured Assessment of Technical Skills as their primary outcome showed improved scores in 80% of trials, and studies that used performance indicators to assess participants all showed improved scores after simulation training in all of the trials, with 88% showing statistical significance. CONCLUSIONS The current literature consistently demonstrates the positive impact of simulation on operative time and predefined performance scores. However, these reproducible measures alone are insufficient to demonstrate transferability of skills from the laboratory to the operating room. The authors advocate a multimodal assessment, including metrics, the Objective Structured Assessment of Technical Skills, and critical step completion. This may provide a more complete assessment of operative performance. Only then can it be concluded that simulation skills are transferable to the live operative setting.

A comparison of human cadaver and augmented reality simulator models for straight laparoscopic colorectal skills acquisition training.

BACKGROUND The aim of this study was to compare the human cadaver model with an augmented reality simulator for straight laparoscopic colorectal skills acquisition. STUDY DESIGN Thirty-five sigmoid colectomies were performed on a cadaver (n = 7) or an augmented reality simulator (n = 28) during a laparoscopic training course. Prior laparoscopic colorectal experience was assessed. Objective structured technical skills assessment forms were completed by trainers and trainees independently. Groups were compared according to technical skills and events scores and satisfaction with training model. RESULTS Prior laparoscopic experience was similar in both groups. For trainers and trainees, technical skills scores were considerably better on the simulator than on the cadaver. For trainers, generic events score was also considerably better on the simulator than on the cadaver. The main generic event occurring on both models was errors in the use of retraction. The main specific event occurring on both models was bowel perforation. Global satisfaction was better for the cadaver than for the simulator model (p < 0.001). CONCLUSIONS The human cadaver model was more difficult but better appreciated than the simulator for laparoscopic sigmoid colectomy training. Simulator training followed by cadaver training can appropriately integrate simulators into the learning curve and maintain the benefits of both training methodologies.

Gossypiboma: a case report and review of the literature

IntroductionPost-operative complications in surgery may frequently be unavoidable. However, some complications result from human error, both in the intra-operative and post-operative period. One such complication, which is frequently underreported, is the retained swab, or gossypiboma.Case reportWe report a case from our hospital of a patient who presented with unexplained pyrexia, 4 years post-gynaecological surgery in another institution. A 67-year-old woman from overseas presented to our emergency department with a 2-day-history of pyrexia, collapse and confusion. Following a CT guided biopsy, which was inconclusive, she was scheduled for retroperitoneal biopsy. In theatre, a retained swab was discovered.ConclusionPrevention of gossypiboma is far better than cure. Strict adherence to swab counts, and the avoidance of change of staff during procedures is important in decreasing the incidence. Perhaps, with the increasing use of minimally invasive procedures, the incidence of gossypiboma will fall dramatically.

NOVEL METHOD FOR ASSESSMENT AND SELECTION OF TRAINEES FOR HIGHER SURGICAL TRAINING IN GENERAL SURGERY

The aim of the study was to select surgeons for a higher surgical training in general surgery programme at the Royal College of Surgeons in Ireland (RCSI) using an objective, transparent and fair assessment programme. Thirty‐two individuals applied for higher surgical training in general surgery in Ireland in 2006. Sixteen applicants were short‐listed for interview and further assessment. All applicants were required to report on their education performance at undergraduate level and their postgraduate professional development. Applicants were scored on their training record during basic surgical training, structures references, clinical experience, approved technical skills courses, validated logbook and consolidation sheet. Assessments of their research and academic surgery included, the award of a higher degree by thesis, and other surgically relevant degree’s or diplomas that had been obtained through part‐time studies and were awarded by educational establishments recognized by RCSI or the Irish Medical Council. Short‐listed applicants completed validated objective assessment simulations of surgical skills, an interview and assessment of their suitability for a career in surgery. The nine individuals who were selected for higher surgical training in general surgery consistently scored higher than those candidates who were not, in post‐graduate development (P < 0.001), surgical skills (P < 0.002), interview scores (P < 0.007) and suitability for a career in surgery (P < 0.002). All performance assessment elements except undergraduate education showed high internal reliability α = 0.89 and good statistical power (range 0.95–0.99). The statistical power of undergraduate education was 0.7. The objective assessment programme introduced by RCSI for selection of candidates for the programme in higher surgical training in general surgery reliably and consistently distinguished between candidates. Candidates selected for further training consistently outperformed those who were not in good concordance between measures. This common selection process for higher surgical training is now being rolled out for selection into higher surgical training across all surgical specialties in Ireland.

The impact of aptitude on the learning curve for laparoscopic suturing

BACKGROUND Within surgery, several specialties demand advanced technical skills, specifically in the minimally invasive environment. METHODS Two groups of 10 medical students were recruited on the basis of their aptitude (visual-spatial ability, depth perception, and psychomotor ability). All subjects were tested consecutively using the ProMIS III simulator until they reached proficiency performing laparoscopic suturing. Simulator metrics, critical error scores, observed structured assessment of technical skills scores, and Fundamentals of Laparoscopic Surgery scores were recorded. RESULTS Group A (high aptitude) achieved proficiency after a mean of 7 attempts (range, 4-10). In group B (low aptitude), 30% achieved proficiency after a mean of 14 attempts (range, 10-16). In group B, 40% demonstrated improvement but did not attain proficiency, and 30% failed to progress. CONCLUSIONS Distinct learning curves for laparoscopic suturing can be mapped on the basis of fundamental ability. High aptitude is directly related to earlier completion of the learning curve. A proportion of subjects with low aptitude are unable to reach proficiency despite repeated attempts.

Optimising surgical training: use of feedback to reduce errors during a simulated surgical procedure

Objective To assess the effect of proximate or immediate feedback during an intensive training session. The authors hypothesised that provision of feedback during a training session would improve performance and learning curves. Methods Twenty-eight trainee surgeons participated in the study between September and December 2008. They were consecutively assigned to group 1 (n=16, no feedback) or group 2 (n=12, feedback) All the participants performed five hand-assisted laparoscopic colectomy procedures on the ProMIS surgical simulator. Efficiency of instrument use (instrument path length and smoothness) and predefined intraoperative error scores were assessed. Facilitators assisted their performance and answered questions when asked. Group 1 participants were given no extra assistance, but group 2 participants received standardised feedback and the chance to review errors after every procedure. Data were analysed using SPSS V.15. Mann–Whitney U tests were used to compare mean performance results, and analysis of variance was used to calculate within-subject improvement. Results Group 1 achieved better results for instrument path length (23 874 mm vs 39 086 mm, p=0.001) and instrument smoothness (2015 vs 2567, p=0.045) However, group 2 (feedback) performed significantly better with regard to error scores (14 vs 4.42, p=0.000). In addition, they demonstrated a smoother learning curve. Inter-rater reliability for the error scores was 0.97. Conclusion The provision of standardised proximate feedback was associated with significantly fewer errors and an improved learning curve. Reducing errors in the skills lab environment should lead to safer clinical performance. This may help to make training more efficient and improve patient safety.

Laparoscopic colectomy is cheaper than conventional open resection

Objective  International randomized trials have endorsed the routine use of laparoscopic techniques in colorectal surgery. The authors hypothesize that the overall care pathway in minimal access resection was cheaper than conventional open resection.

Dynamic magnetic resonance imaging of the pelvic floor in patients with idiopathic combined fecal and urinary incontinence

The etiologies of combined fecal and urinary incontinence may be interrelated but remain poorly understood. A potential variable in this process is global pelvic floor dysfunction. The aim of this study was to prospectively assess the use of phased-array, body coil dynamic MRI in identifying pelvic floor abnormalities in patients with combined incontinence symptoms. Symptomatic patients were compared to asymptomatic control subjects and were selected from those referred to the pelvic physiology laboratory with complaints of combined urinary and fecal incontinence. All patients underwent standard urodynamic studies and anorectal physiologic assessment. Colonoscopy and endoanal ultrasonography were also performed. A standardized protocol was used for dynamic MRI, and the parameters were measured using workstation software (callipers, compass, and densitometer). In the incontinent group there was a significant difference, when compared to control subjects, in the angle of the levator ani muscle arch of the levator plate complex (3.0 ± 5 degrees vs. 14 ± 10 degrees; P = 0.004), the width of the levator hiatus (58.3 ± 8 mm vs. 46.5 ± 8 mm; P = 0.001), the area and tissue density of the levator ani muscle (19.5 ±1 mm2 vs. 26.9 ±1 mm2; P = 0.001, and 157.3 ± 47 pixels vs. 126.1 ± 23 pixels; P ± 0.025, respectively), and in the length of the external anal sphincter (20.0 ± 5 mm vs. 26.6 ± 13 mm; P = 0.03). Body coil dynamic MRI is a noninvasive and well-tolerated imaging modality. Our data show that it can identify changes in pelvic muscle morphology in patients with disorders of incontinence, and this may help in planning better management strategies.