Peter H. Cosman

A systematic review of skills transfer after surgical simulation training.

Objective:To determine whether skills acquired by simulation-based training transfer to the operative setting. Summary Background Data:The fundamental assumption of simulation-based training is that skills acquired in simulated settings are directly transferable to the operating room, yet little evidence has focused on correlating simulated performance with actual surgical performance. Methods:A systematic search strategy was used to retrieve relevant studies. Inclusion of articles was determined using a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Only studies that reported on the use of simulation-based training for surgical skills training, and the transferability of these skills to the operative setting, were included. Results:Ten randomized controlled trials and 1 nonrandomized comparative study were included in this review. In most cases, simulation-based training was in addition to normal training programs. Only 1 study compared simulation-based training with patient-based training. For laparoscopic cholecystectomy and colonoscopy/sigmoidoscopy, participants who received simulation-based training before undergoing patient-based assessment performed better than their counterparts who did not receive previous simulation training, but improvement was not demonstrated for all measured parameters. Conclusions:Skills acquired by simulation-based training seem to be transferable to the operative setting. The studies included in this review were of variable quality and did not use comparable simulation-based training methodologies, which limited the strength of the conclusions. More studies are required to strengthen the evidence base and to provide the evidence needed to determine the extent to which simulation should become a part of surgical training programs.

Margin Clearance and Outcome in Resected Pancreatic Cancer

PURPOSE Current adjuvant therapies for pancreatic cancer (PC) are inconsistently used and only modestly effective. Because a high proportion of patients who undergo resection for PC likely harbor occult metastatic disease, any adjuvant trials assessing therapies such as radiotherapy directed at locoregional disease are significantly underpowered. Stratification based on the probability (and volume) of residual locoregional disease could play an important role in the design of future clinical trials assessing adjuvant radiotherapy. PATIENTS AND METHODS We assessed the relationships between margin involvement, the proximity to operative resection margins and outcome in a cohort of 365 patients who underwent operative resection for PC. RESULTS Microscopic involvement of a resection margin by tumor was associated with a poor prognosis. Stratifying the minimum clearance of resection margins by 0.5-mm increments demonstrated that although median survival was no different to clear margins based on these definitions, it was not until the resection margin was clear by more than 1.5 mm that optimal long-term survival was achieved. CONCLUSION These data demonstrate that a margin clearance of more than 1.5 mm is important for long-term survival in a subgroup of patients. More aggressive therapeutic approaches that target locoregional disease such as radiotherapy may be beneficial in patients with close surgical margins. Stratification of patients for entry onto future clinical trials based on this criterion may identify those patients who benefit from adjuvant radiotherapy.

Superior Mesenteric Artery Syndrome: Diagnosis and Treatment Strategies

IntroductionSuperior mesenteric artery (SMA) syndrome is an unusual cause of vomiting and weight loss resulting from the compression of the third part of the duodenum by the SMA. Various medical and psychiatric conditions may result in the initial rapid weight loss which causes narrowing of the aortomesenteric angle. The vomiting and obstructive syndrome is then self-perpetuated regardless of the initiating factors. The young age and nonspecific symptoms often lead to a delay in diagnosis.DiscussionA series of eight cases is presented reviewing the presentation, investigations, surgical treatment by division of duodenum and duodenojejunostomy, and outcomes.ConclusionSMA syndrome is a well-described entity which must be considered as a cause of vomiting associated with significant weight loss in young adults. Surgical treatment should be allied with psychological assessment to treat any underlying psychosocial abnormality.

Virtual reality simulators: Current status in acquisition and assessment of surgical skills

Medical technology is currently evolving so rapidly that its impact cannot be analysed. Robotics and telesurgery loom on the horizon, and the technology used to drive these advances has serendipitous side‐effects for the education and training arena. The graphical and haptic interfaces used to provide remote feedback to the operator – by passing control to a computer – may be used to generate simulations of the operative environment that are useful for training candidates in surgical procedures. One additional advantage is that the metrics calculated inherently in the controlling software in order to run the simulation may be used to provide performance feedback to individual trainees and mentors. New interfaces will be required to undergo evaluation of the simulation fidelity before being deemed acceptable. The potential benefits fall into one of two general categories: those benefits related to skill acquisition, and those related to skill assessment. The educational value of the simulation will require assessment, and comparison to currently available methods of training in any given procedure. It is also necessary to determine – by repeated trials – whether a given simulation actually measures the performance parameters it purports to measure. This trains the spotlight on what constitutes good surgical skill, and how it is to be objectively measured. Early results suggest that virtual reality simulators have an important role to play in this aspect of surgical training.

Synoptic reporting improves histopathological assessment of pancreatic resection specimens

Aim: We examined whether introduction of a standardised pancreatic cancer minimum data set improved the reporting of key pathological features across multiple institutions. Methods: From seven different pathology departments that are members of the New South Wales Pancreatic Cancer Network, 109 free text reports and 68 synoptic reports were compared. Results: AJCC stage could not be inferred from 44% of free text reports, whereas stage was reported in all 68 synoptic reports. In the free text reports 28 different names were used to designate margins. All margins were reported in only 12 (11%) of the free text reports compared with 64 (94%) of the synoptic reports (p = 0.0011). The presence or absence of lymphovascular or perineural invasion was reported in 72 (66%) and 92 (84%) of free text reports, respectively. In contrast, lymphovascular space and perineural invasion were reported in all synoptic reports (p = 0.0011 and p = 0.0058). Conclusion: We conclude that synoptic reporting of pancreatic resections without any other intervention increases the information contained within histopathology reports. Therefore, the introduction of minimal data set synoptic reports is a simple and feasible mechanism to immediately improve reporting for pancreatectomy specimens.

Expression of S100A2 Calcium-Binding Protein Predicts Response to Pancreatectomy for Pancreatic Cancer

BACKGROUND & AIMS Current methods of preoperative staging and predicting outcome following pancreatectomy for pancreatic cancer (PC) are inadequate. We evaluated the utility of multiple biomarkers from distinct biologic pathways as potential predictive markers of response to pancreatectomy and patient survival. METHODS We assessed the relationship of candidate biomarkers known, or suspected, to be aberrantly expressed in PC, with disease-specific survival and response to therapy in a cohort of 601 patients. RESULTS Of the 17 candidate biomarkers examined, only elevated expression of S100A2 was an independent predictor of survival in both the training (n = 162) and validation sets (n = 439; hazard ratio [HR], 2.19; 95% confidence interval [CI]: 1.48-3.25; P < .0001) when assessed in a multivariate model with clinical variables. Patients with high S100A2 expressing tumors had no survival benefit with pancreatectomy compared with those with locally advanced disease, whereas those without high S100A2 expression had a survival advantage of 10.6 months (19.4 vs 8.8 months, respectively) and a HR of 3.23 (95% CI: 2.39-4.33; P < .0001). Of significance, patients with S100A2-negative tumors had a significant survival benefit from pancreatectomy even in the presence of involved surgical margins (median, 15.7 months; P = .0007) or lymph node metastases (median, 17.4 months; P = .0002). CONCLUSIONS S100A2 expression is a good predictor of response to pancreatectomy for PC and suggests that high S100A2 expression may be a marker of a metastatic phenotype. Prospective measurement of S100A2 expression in diagnostic biopsy samples has potential clinical utility as a predictive marker of response to pancreatectomy and other therapies that target locoregional disease.

LEARNING THE SURGICAL CRAFT: A REVIEW OF SKILLS TRAINING OPTIONS

Surgical practice is undergoing fundamental changes, and this is having a significant effect on the training of surgeons. Learning the craft of surgery is threatened by reduced elective operative exposure and general service cuts within public teaching hospitals, safer working hour legislation and pressures to accelerate the training of young surgeons. Rapid technological changes mean that ‘old dogs’ have to teach ‘young dogs’ many new tricks in a relatively adverse environment. This review outlines the great variety of resources available for skills‐based training outside the operating room. These resources are ready to be used as a necessary adjunct to the training of competent surgeons in Australasia.

Expression of LMO4 and outcome in pancreatic ductal adenocarcinoma

Identification of a biomarker of prognosis and response to therapy that can be assessed preoperatively would significantly improve overall outcomes for patients with pancreatic cancer. In this study, patients whose tumours exhibited high LMO4 expression had a significant survival advantage following operative resection, whereas the survival of those patients whose tumours had low or no LMO4 expression was not significantly different when resection was compared with operative biopsy alone.

Real time intraoperative confocal laser microscopy-guided surgery.

Objective:To assess the potential utility of in vivo histologic surface and subsurface imaging in real-time using the Optiscan confocal laser microscope to detect diseased tissue at the time of surgery. Summary Background Data:The goal of surgical treatment of diseases such as cancer is complete microscopic resection of diseased tissue; however, current methods for the assessment of extent of disease at the time of surgery are inadequate. Methods:We assessed the potential of the Optiscan confocal laser microscope, a new device developed for real-time in vivo histologic surface and subsurface imaging during surgery. Results:Intravenous Fluorescein Sodium contrast enabled visualization of cellular and architectural morphology of intra-abdominal organs with magnification equivalent to light microscopy and enabled differentiation between normal organs and disease. Conclusions:Real time intraoperative confocal microscopy has significant potential application in detecting disease, and influencing decision-making at the time of surgery.

A novel approach to high definition, high-contrast video capture in abdominal surgery.

Objective:The aim of this study was to define the best available option for video capture of surgical procedures for educational and archival purposes, with a view to identifying methods of capturing high-quality footage and identifying common pitfalls. Summary Background Data:Several options exist for those who wish to record operative surgical techniques on video. While high-end equipment is an unnecessary expense for most surgical units, several techniques are readily available that do not require industrial-grade audiovisual recording facilities, but not all are suited to every surgical application. Methods:We surveyed and evaluated the available technology for video capture in surgery. Our evaluation included analyses of video resolution, depth of field, contrast, exposure, image stability, and frame composition, as well as considerations of cost, accessibility, utility, feasibility, and economies of scale. Results:Several video capture options were identified, and the strengths and shortcomings of each were catalogued. None of the commercially available options was deemed suitable for high-quality video capture of abdominal surgical procedures. A novel application of off-the-shelf technology was devised to address these issues. Conclusions:Excellent quality video capture of surgical procedures within deep body cavities is feasible using commonly available equipment and technology, with minimal technical difficulty.