The objective of this study was to investigate the effect of prehabilitation on survival after colorectal cancer surgery.
Preoperative multimodal exercise and nutritional programs (prehabilitation) ...improve functional capacity and recovery following colorectal surgery. Exercise may also affect cancer outcomes by mediating the systemic inflammatory response. The effect of prehabilitation on cancer outcomes is unknown.
Pooled data from 3 prehabilitation trials (2 randomized controlled trials, 1 cohort) in patients undergoing elective, biopsy-proven, primary non-metastatic colorectal cancer surgery from 2009 to 2014 within an enhanced recovery program were analyzed. Patients were grouped into +prehab or-prehab. The primary outcomes were 5-year disease-free (DFS) and overall survival (OS). DFS and OS were analyzed using Kaplan-Meier curves and multiple Cox regression.
A total of 202 patients were included (+prehab 104, -prehab 98). Median prehabilitation duration was 29 days (interquartile range 20-40). Patient and tumor characteristics were well-balanced (33% stage III). Postoperative complications and time to adjuvant chemotherapy were similar. Mean duration of follow-up was 60.3 months (standard deviation 26.2). DFS was similar for the combined group of stage I-III patients (P = 0.244). For stage III patients, prehabilitation was associated with improved DFS (73.4% vs 50.9%, P = 0.044). There were no differences in OS (P = 0.226). Prehabilitation independently predicted improved DFS (hazard ratio 0.45; 95% confidence interval, 0.21-0.93), adjusting for stage and other confounders. Prehabilitation did not independently predict OS.
In this report, prehabilitation is associated with improved 5-year DFS in stage III colorectal cancer. This finding should be confirmed in future trials.
Abstract Background The purpose of this study was to assess whether training to proficiency with the Fundamentals of Laparoscopic Surgery (FLS) simulator would result in improved performance in the ...operating room (OR). Methods Nineteen junior residents underwent baseline FLS testing and were assessed in the OR using a validated global rating scale (GOALS) during elective laparoscopic cholecystectomy. Those with GOALS scores ≤15 were randomly assigned to training (n = 9) or control (n = 8) groups. An FLS proficiency-based curriculum was used in the training group. Scoring on FLS and in the OR was repeated after the study period. Evaluators were blinded to randomization status. Results Sixteen residents completed the study. There were no differences in baseline simulator (49.1 ± 17 vs 39.5 ± 16, P = .27) or OR scores (11.3 ± 2.0 vs 12.0 ± 1.8; P = .47). After training, simulator scores were higher in the trained group (95.1 ± 4 vs 60.5 ± 23, P = .004). OR performance improved in the control group by 1.8 to 13.8 ± 2.2 ( P = .04), whereas the trained group improved by 6.1 to 17.4 ± 1.9 ( P = .0005 vs control; P < .0001 vs baseline). Conclusions This study clearly demonstrates the educational value of FLS simulator training in surgical residency curricula.
Introduction
The incidence of incisional hernia(IH) may be affected by the choice of specimen extraction incision. The objective of this study was to perform a systematic review and meta-analysis ...comparing the incidence of IH after midline and off-midline incisions in patients undergoing laparoscopic colorectal surgery.
Methods
A systematic search was performed according to PRISMA guidelines to identify all comparative studies from January 1991–August 2016 on the incidence of IH after midline and off-midline(transverse or Pfannenstiel) incisions in patients undergoing laparoscopic colorectal surgery. Case series and studies reporting the IH after stoma site extraction, SILS, or NOTES were excluded. The MINORS instrument was used for quality assessment for observational studies. Weighted estimates were calculated using a random-effects model.
Results
A total of 17 articles were identified and included for meta-analysis, 16 of which were observational studies and 1 was an RCT. The mean MINORS score for observational studies was 12.9 (SD 3.2, range 7–17). Sample sizes in the midline (mean 185, range 20–995) and off-midline(mean 184, range 20–903) groups were similar. Follow-up ranged from 17.3 to 42 months. The pooled incidence of IH was 10.6% (338/3177) in midline, 3.7% (48/1314) in transverse, and 0.9% (9/956) in Pfannenstiel incisions. IH was significantly higher in the midline compared to off-midline groups (weighted OR 4.1, 95% CI 2.0–8.3,
I
2
= 79.7%,
p
for heterogeneity <0.001). Midline incisions were also at higher risk of IH versus transverse (weighted OR 3.0, 95% CI 1.4–6.7,
I
2
= 72.7%,
p
for heterogeneity <0.001) and Pfannenstiel (weighted OR 8.6, 95% CI 3.0–24.6,
I
2
= 43.5%,
p
for heterogeneity = 0.101) incisions. There was no publication bias according the funnel plot or statistically (Egger’s
p
= 0.336).
Conclusions
Midline incisions for specimen extraction in laparoscopic colorectal surgery are at significantly higher risk of IH compared to off-midline (transverse or Pfannenstiel) incisions, but these data are of poor quality and heterogeneous.
Since advanced technologies were introduced into surgical education, a variety of new programs have been developed. However, a comprehensive review of digital education in general thoracic surgery ...has not been performed. This narrative review was conducted was to identify the current applications of digital education in general thoracic surgery.
A literature search was performed using keywords related to general thoracic surgery and digital education, including e-learning and virtual simulation, up to September 2021. Studies published in English investigating the effect of digital education in general thoracic surgery were included.
Thirteen studies met the criteria. The settings were in undergraduate (n = 6) and postgraduate education (residency) (n = 5) and mixed audience with other disciplines (n = 2). Theoretical knowledge (n = 5), technical skills (n = 4), and both knowledge and technical skills (n = 4) were the stated educational objectives for the studies. The didactic materials were transferred to hardware, software, or online platforms and delivered with multimedia materials. Technical skills training for bronchoscopy and chest tube insertion (n = 5) were offered using virtual reality and computer-based simulations. Subjective evaluation was done in 10 studies. Although after the digital education training there was observed improvement in knowledge or skills in 8 studies, studies were not designed to test for superiority compared with controls through randomized controlled studies.
This review summarizes the current applications of digital education in general thoracic surgery and helps establish the needs for future studies in this field.
AI is becoming ubiquitous, revolutionizing many aspects of our lives. In surgery, it is still a promise. AI has the potential to improve surgeon performance and impact patient care, from ...post-operative debrief to real-time decision support. But, how much data is needed by an AI-based system to learn surgical context with high fidelity? To answer this question, we leveraged a large-scale, diverse, cholecystectomy video dataset. We assessed surgical workflow recognition and report a deep learning system, that not only detects surgical phases, but does so with high accuracy and is able to generalize to new settings and unseen medical centers. Our findings provide a solid foundation for translating AI applications from research to practice, ushering in a new era of surgical intelligence.
Fundamentals of Laparoscopic Surgery (FLS) is a program of SAGES and the American College of Surgeons designed to teach and evaluate the knowledge, judgment, and skills fundamental to laparoscopic ...surgery, independent of the surgical specialty. It has undergone rigorous evaluation to ensure that the evaluation component meets appropriate standards to ensure the reliability and validity of the test. The manual skills component is based on the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) program. This component has been shown to meet standards for reliability (interrater, test–retest, and internal consistency) required for a high-stakes examination. Content, face, construct, and criterion validity have also been established through a series of experimental studies. FLS presents a comprehensive learning package that is inexpensive and of proven value for teaching minimally invasive surgery. Its unique contribution is the included validated assessment to ensure that those taking the program have demonstrated the requisite knowledge and skills fundamental to performing laparoscopic surgery.
Introduction
Patients, clinicians and researchers seek an easy, reproducible and valid measure of postoperative recovery. The six-minute walk test (6MWT) is a low-cost measure of physical function, ...which is a relevant dimension of recovery. The aim of the present study was to contribute further evidence for the validity of the 6MWT as a measure of postoperative recovery after colorectal surgery.
Methods
This study involved a sample of 174 patients enrolled in three previous randomized controlled trials. Construct validity was assessed by testing the hypotheses that the distance walked in 6 min (6MWD) at 4 weeks after surgery is greater (1) in younger versus older patients, (2) in patients with higher preoperative physical status versus lower, (3) after laparoscopic versus open surgery, (4) in patients without postoperative complications versus with postoperative complications; and that 6MWD (5) correlates cross-sectionally with self-reported physical activity as measured with a questionnaire (CHAMPS). Statistical analysis was performed using linear regression and Spearman’s correlation. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was used to guide the formulation of hypotheses and reporting of results.
Results
One hundred and fifty-one patients who completed the 6MWT at 4 weeks after surgery were included in the analysis. All hypotheses tested for construct validity were supported by the data. Older age, poorer physical status, open surgery and occurrence of postoperative complications were associated with clinically relevant reduction in 6MWD (>19 m). There was a moderate positive correlation between 6MWD and patient-reported physical activity (
r
= 0.46).
Conclusions
This study contributes further evidence for the construct validity of the 6MWT as a measure of postoperative recovery after colorectal surgery. Results from this study support the use of the 6MWT as an outcome measure in studies evaluating interventions aimed to improve postoperative recovery.
Background
Complete mesocolic excision (CME) is advocated based on oncologic superiority, but not commonly performed in North America. Many data are case series with few comparative studies. Our aim ...was to perform a systematic review comparing outcomes between CME and non-CME colectomy.
Methods
A systematic review was performed according to PRISMA guidelines of MEDLINE, EMBASE, HealthStar, Web of Science, and Cochrane Library. Studies were included if they compared conventional resection (non-CME) to CME for colon cancer. Quality was assessed using methodological index for non-randomized studies (MINORS). The main outcome measures were short-term morbidity and oncologic outcomes. Weighted pooled means and proportions with 95% CI were calculated using a random-effects model when appropriate.
Results
Out of 825 unique citations, 23 studies underwent full-text reviews and 14 met inclusion criteria. Mean MINORS score was 13.3 (range 11–15). The mean sample size in CME group was 1166 (range 45–3756) and 945 (range 40–3425) in non-CME. Four papers reported plane of dissection, with CME plane achieved in 85.8% (95% CI 79.8–91.7). Mean OR time in CME group was 167 min (163–171) and 138 min (135–142) in conventional group. Perioperative morbidity was reported in six studies, with pooled overall complications of 22.5% (95% CI 18.4–26.6) for CME and 19.6 (95% CI 13.6–25.5) for non-CME. Anastomotic leak occurred in 6.0% (95% CI 2.2–9.7) of CME resections versus 6.0% (95% CI 4.1–7.9) in non-CME. CME had more lymph nodes, longer distance to high tie, and specimen length in all studies. Nine studies compared long-term oncologic outcomes and only three reported statistically significant higher disease-free or overall survival in favor of CME. Local recurrence was lower after CME in two of four studies.
Conclusions
The quality of evidence is limited and does not consistently support the superiority of CME. Better data are needed before CME can be recommended as the standard of care for colon cancer resections.
Background
Telesimulation helps overcome limitations in time and local expertise by eliminating the need for the learner and educator to be physically co-located, especially important during ...COVID-19. We investigated whether teaching advanced laparoscopic suturing (ALS) through telesimulation is feasible, effective, and leads to improved suturing in the operating room (OR).
Methods
In this prospective feasibility study, three previously developed 3D-printed ALS tasks were used: needle handling (NH), suturing under tension (UT), and continuous suturing (CS). General surgery residents (PGY4-5) underwent 1-month of telesimulation training, during which an expert educator at one site remotely trained residents at the other site over 2–3 teaching sessions. Trainees were assessed in the three tasks and in the OR at three time points: baseline(A1), control period(A2), and post-intervention(A3) and completed questionnaires regarding educational value and usability of telesimulation. Paired
t
-test was used to compare scores between the three assessment points.
Results
Six residents were included. Scores for UT improved significantly post-intervention A3(568 ± 60) when compared to baseline A1(416 ± 133) (
p
< 0.019). Similarly, scores for CS improved significantly post-intervention A3(756 ± 113) vs. baseline A1(539 ± 211) (
p
< 0.02). For intraoperative assessments, scores improved significantly post-intervention A3(21 ± 3) when compared to both A1(17 ± 4) (
p
< 0.018) and A2(18 ± 4) (
p
< 0.0008). All residents agreed that tasks were relevant to practice, helped improve technical competence, and adequately measured suturing skill. All residents found telesimulation easy to use, had strong educational value, and want the system to be incorporated into their training.
Conclusion
The use of telesimulation for remotely training residents using ALS tasks was feasible and effective. Residents found value in training using the tasks and telesimulation system, and improved ALS skills in the OR. As the pandemic has caused a major structural shift in resident education, telesimulation can be an effective alternative to on-site simulation programs. Future research should focus on how telesimulation can be effectively incorporated into training programs.
Background Although the “learning curve” is commonly analyzed by splitting the data into arbitrary chunks of experience, this does not allow for precise estimation of where the curve plateaus or the ...rate at which learning is achieved. Our objective was to describe a simple way to characterize the learning curve for a fundamental laparoscopic task. Methods Sixteen medical students performed 40 repetitions of the Fundamentals of Laparoscopic Surgery (FLS) pegboard task and were scored using validated metrics. A learning curve was plotted and nonlinear regression was used to fit an inverse curve (Y = a − b/X), yielding an estimate of a (asymptote) and b (slope) for each subject. Two values were derived from these estimates: “learning plateau,” defined as the theoretical best score achievable (when X = ∞, Y = a) and the “learning rate,” defined as the number of trials required to reach 90% of potential (Y = 0.9a when X = 10∗b/a). Analysis of variance (ANOVA) was used to compare subjects reporting an interest in a surgical career ( n = 4) to those not interested ( n = 4) or undecided ( n = 8). Data expressed as mean values ± standard deviations. Results The raw starting score was 48 ± 24, increasing to 94 ± 8 for the 40th trial. The curve-fitting estimated “learning plateau” was 90 ± 10 (range, 61–99), whereas the “learning rate,” or the number of trials to 90% of potential, was 6 ± 2 (range, 2–11). Subjects not interested in a surgical career had lower starting scores and learning plateau and slower learning rate compared with subjects interested in surgery or undecided (ANOVA; P < .05). Conclusion Fitting an inverse curve allowed for estimation of learning plateau and learning speed for this fundamental laparoscopic task. These parameters allowed for comparisons to be made within subgroups of subjects and may have utility as an outcome for educational interventions designed to impact the learning curve.
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