Tarig Abdelrahman

Operative Experience vs. Competence: A Curriculum Concordance and Learning Curve Analysis

OBJECTIVE Certification of completion of training in general surgery requires proof of competence of index operations by means of 3, level-4 consultant-validated procedural-based assessments. The aim of this study was to examine the relationship between index operative experience and competence. DESIGN Higher surgical trainee procedural-based assessments were compared with e-logbooks to determine the relationship between index operative experience and achievement of a third level 4 competence (L4C) related to the indicative procedures of emergency laparotomy (EL, target 100), Hartmann procedure (5), appendicectomy (80), segmental colectomy (20), laparoscopic cholecystectomy (50), and inguinal hernia (80). SETTING All trainees are from a single UK Deanery. PARTICIPANTS Consecutive 69 national training number higher surgical trainees were appointed to a single UK Deanery between 2007 and 2014. RESULTS EL L4C was achieved at a median of 76 (15-136) cases, Hartmann procedure L4C at 17 (7-27) cases (p = 0.009 vs. EL), appendicectomy L4C at 107 (20-206) cases, segmental colectomy L4C at 52 (15-131) cases, laparoscopic cholecystectomy L4C at 72 (40-197) cases, and inguinal hernia L4C at 64 (17-132) cases. CONCLUSIONS The learning curve and caseload required to demonstrate L4C related to specific procedure varied over 4-fold, from 0.76 to 3.4 times the national indicative target number guidance. Certification of completion of training operative logbook number targets should be reconsidered to better reflect the competencies demanded by the curriculum.

Hirsch Index Value and Variability Related to General Surgery in a UK Deanery

OBJECTIVES The Hirsch Index (h-index) is often used to assess research impact, and on average a social science senior lecturer will have an h-index of 2.29, yet its validity within the context of UK General Surgery (GS) is unknown. The aim of this study was to calculate the h-indices of a cohort of GS consultants in a UK Deanery to assess its relative validity. DESIGN Individual h-indices and total publication (TP) counts were obtained for GS consultants via the Scopus and Web of Science (WoS) Internet search engines. Assessment of construct validity and reliability of these 2 measures of the h-index was undertaken. SETTING All hospitals in a single UK National Health Service Deanery were included (14 general hospitals). PARTICIPANTS All 136 GS consultants from the Deanery were included. RESULTS Median h-index (Scopus) was 5 (0-52) and TP 15 (0-369), and strong correlation was found between h-index and TP (ρ = 0.932, p < 0.001), with the intraclass correlation between Scopus and WoS h-index also significant (intraclass correlation coefficient = 0.973 [95% CI: 0.962-0.981], p < 0.001). Academic GS consultants had higher h-indices than nonacademic University Hospital and District General Hospital consultants (Scopus 12 vs 7 vs 4 [p < 0.001] and WoS 10.5 vs 7 vs 4 [p < 0.001]). h-Index was >2.29 in 57.4% of consultants. No subspecialty differences were apparent in median h-indices (p = 0.792) and TP (p = 0.903). CONCLUSIONS h-Index is a valid GS research productivity metric with over half of consultants performing at levels equivalent to social science Senior Lecturers.

Relative accuracy of emergency CT in adults with non- traumatic abdominal pain

OBJECTIVE CT examination prior to emergency laparotomy has become ubiquitous in contemporary clinical practice, but the relative accuracy of CT in this context has not been widely reported. The aim of this study was to determine the accuracy and strength of agreement between the perceived pre-operative CT diagnosis and operative findings. METHODS Data from patients undergoing pre-operative CT prior to emergency laparotomy from January 2013 to June 2014 in a large teaching hospital were analysed. The CT diagnosis was compared with operative findings using the χ(2) test and weighted kappa statistic (Kw). Results were further analysed related to the time of day the CT was reported, anatomical location and grade of the reporting radiologist. RESULTS 361 patients [median age 67 years (18-98 years); 180 males] underwent CT prior to emergency laparotomy. CT reports were deemed accurate in 318 (88.1%) cases and inaccurate in 43 (11.9%) cases, which resulted in 5 negative laparotomies in this latter cohort (11.6%, χ(2) 37.50, df 1; p < 0.0001). Accuracy and strength of agreement varied with anatomical location of the pathology; upper gastrointestinal (UGI) 75.5%, Kw 0.673 (0.531-0.815; p < 0.001); small bowel 89.9%, Kw 0.781 (0.687-0.875, p < 0.001); lower gastrointestinal (LGI) 90.4%, Kw 0.821 (0.749-0.893; p < 0.001). CT examinations reported within normal working hours had higher strength of agreement [Kw 0.832 (0.768-0.896), p < 0.001] than CTs reported out of hours [Kw 0.789 (0.721-0.857), p < 0.001], but there was no significant difference in overall accuracy (89.9 vs 86.0%; χ(2) 1.306, df 1, p = 0.253). Reporter seniority was not associated with improved diagnostic accuracy (χ(2) 1.825, df 1; p = 0.177). CONCLUSION CT agreement with emergency operative pathology was good to excellent, but the strength of agreement varied in relation to anatomical location of pathology. ADVANCES IN KNOWLEDGE Overall accuracy was 88.1% with good to excellent agreement between pre-operative CT and emergency laparotomy findings in adult patients with non-traumatic abdominal pain in the acute setting. Diagnostic accuracy of CT reporting varies with anatomical location of pathology.

Surgical gender gap: a curriculum concordance and career vector perspective

Introduction Women’s participation in medicine has increased dramatically during the last 50 years, yet Office for National Statistics data (2016) regarding annual pay continue to show an unequivocal 34% deficit in female doctors’ remuneration compared with their male counterparts. This study aimed to identify whether there are measurable differences in the training, career vectors and profiles of higher general surgical trainees (HSTs), related to gender. Method The Deanery roster supplemented with Intercollegiate Surgical Curriculum Programme and Scopus data was used to identify the profiles of 101 consecutive HSTs (38 women, 63 men, single UK deanery). Primary outcome measures were training programme attrition rate, time to completion of training and achievement of third level 4 competence (3L4C) in indicative operations. Secondary outcomes were publication number, citations and Hirsch Indices (HIs). Results Attrition rates were similar irrespective of gender (female n=3 (7.9%) vs male n=6 (9.5%), p=0.871). Training duration was on average 16 months longer in women (94 (72–134) months) than men (78 (72–112), p=0.002). Operative learning curve trajectories were similar; median operations required to achieve 3L4C was 380 (f) versus 410 (m, p=1.00). Academic profiles of men were stronger than women, specifically higher degrees; men (n=31, 83.8%), women (n=6, 16.2%, p=0.001); median (range) publication number 8 (0–57) versus 3 (0–38, p=0.003), citations 43 (0–1600) versus 9 (0–774, p=0.001), and HI 3 (0–26) versus 2 (0–12, p=0.002). Conclusion A complex variable gender gap was apparent related to time in training and academic profile, but not training attrition or operative learning curve trajectory.

FRCS first pass variance: deanery and specialty contrariety

Background FRCS exit examination success may be interpreted as a surrogate marker for UK Deanery-related training quality. The aim of this study was to evaluate relative FRCS examination pass rates related to Deanery and Surgical Specialty. Methods Joint Committee on Surgical Training-published examination first attempt pass rates were scrutinised for type I higher surgical trainees and outcomes compared related to Deanery and Surgical Specialty. Results Of 9363 FRCS first attempts, 3974 were successful (42.4%). Median and mean pass rates related to Deanery were 42.1% and 30.7%, respectively, and ranged from 26.7% to 45.6%. Median (range) pass rates by specialty were urology 76.3% (60%–100%), trauma and orthopaedic surgery 74.7% (58.2%–100%), general surgery 70.0% (63.1%–86%), ENT 62.5% (50%–100%), cardiothoracic surgery 50.0% (25%–100%), oral and maxillofacial surgery 50% (40.0%–100%), neurosurgery 50% (22.7%–100%), plastic surgery 47.6% (30.0%–100%) and paediatric surgery 25% (16.7%–100%). Significant variance was observed across all specialties and deaneries (p=0.001). Conclusion As much as threefold variance exists related to FRCS examination first attempt success, trainees should be aware of this spectrum when preferencing deaneries during national selection.

Outcomes after laparoscopic anti-reflux surgery related to obesity: A systematic review and meta-analysis

BACKGROUND Laparoscopic Anti-Reflux Surgery (LARS) is an established alternative treatment to pharmacological therapy for patients with Gastro Osophageal Reflux Disease (GORD), yet its safety and efficacy in obese patients is controversial. A systematic review and meta-analysis was performed to compare LARS related to obesity. METHODS Embase, MEDLINE and the Cochrane Library (January 1970 to July 2017) were searched for studies reporting clinical outcomes of LARS in patient cohorts stratified by Body Mass Index (BMI). Data was grouped according to BMI, <30 kg/m2 (non-obese) and ≥30 kg/m2 (obese). Primary outcome measures were reflux recurrence, operative morbidity, re-intervention (redo surgery and endoscopic dilatation), conversion to open surgery, and early return to theatre. Results were pooled in meta-analyses as Odds Ratios (OR). RESULTS Thirteen eligible observational studies comparing LARS in non-obese (n = 6246) and obese (n = 1753) patients were identified. Recurrence of reflux was significantly lower in the non-obese cohort (OR 0.28, 95% C.I. 0.13 to 0.61, p = 0.001), however no significant differences were observed in rates of operative morbidity (OR 0.82, 0.54 to 1.23, p = 0.33), redo surgery (OR 0.94, 0.51 to 1.72, p = 0.84), endoscopic dilatation (OR 0.98, 0.45 to 2.17, p = 0.97), conversion to open surgery (OR 0.96, 0.50 to 1.85, P = 0.90), or early return to theatre (OR 0.77, 0.43 to 1.38, p = 0.39). CONCLUSIONS LARS can be performed safely in obese patients, but risks higher GORD recurrence. Clinicians and patients should be aware that obesity may adversely affect LARS outcome and careful consideration be given in the consent process inherent within the optimal management of GORD.

Prognostic Significance of Serum Inflammatory Markers in Gastric Cancer

Background The aim of this study was to assess the relative prognostic value of biomarkers to measure the systemic inflammatory response (SIR) and improve prognostic modeling in a cohort of patients undergoing potentially curative surgery for gastric adenocarcinoma. The hypothesis was that a single SIR biomarker would be associated with the most prognostic value.

PWE-419 Value and variability of the hirsch index within the context of gastrointestinal surgery in a single uk deanery

Introduction The Hirsch Index (HI) is often used by academic institutions to assess research impact, and on average across all disciplines a full social science professor will have a HI of 4.9 and a Senior Lecturer 2.2. Nevertheless its validity within the context of Gastrointestinal Surgery (GIS) is unknown and the aim of this study was to calculate HI for a cohort of GIS consultant trainers in a single UK Deanery to assess its relative validity. Method Contemporary 75 GIS consultant trainers were identified and individual HIs and Total Publication (TP) counts obtained via the Internet search engines, Scopus and Web of Science (WoS). Results Median HI (Scopus) was 5 (0–34) and TP 13 (0–152). Median HI vs. TP by subspecialty were: Hepatobiliary 6.5 vs. 17, Oesophagogastric 6.5 vs. 16, and Colorectal 4 vs. 12 (HI p = 0.792, TP p = 0.903). Both academic and university hospital consultants had higher HIs when compared with peers (11 vs. 4 p = 0.001 and 10 vs. 4 p < 0.001). HI was greater than 4.9 in 52% and 2.2 in 73%. Correlation between HI and TP was strong (rho = 0.929, p < 0.001) with the Intraclass Correlation Coefficient between Scopus and WoS HI also highly significant [ICC 0.969 (95% CI 0.951 to 0.981), p < 0.001] Conclusion Almost three quarters (73%) of GIS consultants had HIs equivalent to Senior Lecturer level or above, and the academic targets within the 2013 JCST Certificate of Completion of Training Curriculum appear achievable during training. Disclosure of interest None Declared.

AGA AbstractsSu1919 Prognostic Significance of T (LNR) M in Staging Esophageal Cancer Incorporating Pathological Lymph Node Ratio (LNR)

incorporating LNR into a novel TNM staging system. Methods: Consecutive 359 patients undergoing gastrectomy for cancer were studied. Patients originally classified and staged using TNM6 were retrospectively re-staged using TNM7, and LNR was calculated and scores subclassified as 0 (node negative), 1 (0.01-0.24), 2 (0.25-0.49) and 3 (>0.50). Results: TNM7 reclassification resulted in stage migration in 20.3% of patients (20% downstaged, 0.3% upstaged) when compared with TNM6. T(LNR)M reclassification resulted in stage migration in 20.9% of patients (11% downstaged and 9.9% upstaged) compared with TNM7. Five-year survival for stages I, II and III was 51%, 30% and 16% using TNM6, compared with 51%, 36% and 13%, respectively, using TNM7. Univariable analysis revealed that pT, TNM6 pN, TNM7 pN, LNR, TNM6 stage group, TNM7 stage group and T(LNR)M prognostic group were all associated with survival (p<0.001). Multivariable analysis revealed that only T(LNR)M prognostic group was independently and significantly associated with survival (HR 1.38 95% CI 1.25-1.53, p<0.001). T(LNR)M had a progressively poorer prognosis; stage 1 (HR 2.12 95% CI 1.35-3.32, p<0.001) and stage 2 (HR 3.65, 95% CI 2.31-5.79, p<0.001) Conclusion: T(LNR)M is a better prognostic tool than both TNM6 and TNM7 staging systems and represents an important advance in staging gastric cancer.