ANZ Journal of Surgery

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Syndicate content
Wiley Online Library : ANZ Journal of Surgery
Updated: 14 hours 14 min ago

Medicine in small doses

August 3, 2017 - 09:27

Issue information - JEB

August 3, 2017 - 09:27

25, 50 & 75 years ago

August 3, 2017 - 09:26

Implementing entrustable professional activities: the yellow brick road towards competency-based training?

August 3, 2017 - 09:26
Background

We describe implementation of competency-based postgraduate surgical training, using an entrustable professional activities (EPAs) programme. The programme aims to improve patient outcomes by optimizing supervision of surgical trainees, creating opportunities for additional teaching and feedback. The curriculum was designed to maximize feasibility for implementation within a colorectal surgical department.

Methods

The curriculum was developed using previously described methods by consensus between two consultants within the department. Seven EPAs were identified and described for each grade of trainee. A consultant within the teaching faculty or a delegate is required to assess each EPA and provide formal feedback until the trainee is given permission to act autonomously.

Results

It is hoped the programme can progress with minimal disruption to key stakeholders. We will record trainee assessment data anticipating that performance of trainees on other tasks in the future may provide some evidence of validity for the EPA assessments.

Conclusions

There are perceived benefits and problems evident in the EPA model at this early stage of implementation. The programme should result in an increase in the number of formative assessments and feedback opportunities for trainees. The assessment process is familiar to supervisors, which should facilitate implementation of the curriculum. There is concern that supervisors may require further training to ensure the assessment process is objective and reproducible. The EPA programme could make the process of delegating patient care to trainees more transparent, but we have not identified a method of widely disseminating trainee assessment data without the potential to prejudice trainees unfairly.

General surgery primary operator rates: a guide to achieving future competency

August 3, 2017 - 09:26
Background

Competency in surgical training is a topic of much recent discussion, with concern regarding the adequacy of current training schemes to achieve competency. Most programmes use caseload and primary operator rates to assess trainee progression. Some trainees still lack technical competence even when recommended procedural numbers are met. It is possible that current measures of individual's capabilities used in surgical education are outdated.

Methods

Logbook data of New South Wales general surgical trainees between 2010 and 2012 was obtained through General Surgeons Australia. The top 10 most common operations recorded in trainee logbooks were identified. Individual trainee data were grouped by the surgical education and training year and primary operator versus assistant experience. The data were analysed focusing on the primary operator rate, comparing between trainee levels to identify progression.

Results

A total of 183 319 operations were recorded in New South Wales general surgery trainee logbooks. A positive association was demonstrated between trainee seniority and primary operator rates for the most common procedures, indicating trainee's continual progression in experience as they advance. However, laparoscopic inguinal hernia repair, oversew of gastroduodenal ulcer, open cholecystectomy and right hemicolectomy showed poor primary operator rates among trainees regardless of trainee year, despite these operations being among the 10 most common.

Conclusion

General surgical trainees accumulate operative experience with progression through the surgical education and training programme, highlighting expected technical progression and competency of trainees for common procedures. For less common or more complicated procedures, the use of entrustable professional activities and accompanying simulation training could be used to achieve the necessary technical expertise.

Paediatric surgical services in remote northern Australia: an integrated model of care

August 1, 2017 - 09:51
Background

Surgical services for children in the Northern Territory of Australia are routinely performed by general surgeons with specific paediatric training, supported by paediatric surgeons. In Australasia, indications for appropriate transfer of elective routine surgery in children to tertiary paediatric surgical centres have been contentious. To transfer all elective paediatric cases from rural locations would have significant social and financial consequences for families and the health system. This study reviews clinical outcomes for elective surgery for two common conditions managed by an integrated service of general surgeons and visiting paediatric surgeons, and compares them with published outcomes from paediatric centres.

Method

A retrospective audit of children undergoing orchidopexy under the age of 5 years or inguinal herniotomy under the age of 1 year at the Royal Darwin Hospital and Darwin Private Hospital between January 2005 and 2016 was conducted.

Results

During the study period, 66 boys underwent 80 orchidopexies at a mean age of 22.3 months (±20.4 SD). A recurrence rate of 5.5%, severe atrophy rate of 1.3% and total atrophy rate of 5.5% were achieved. Sixty-three children underwent 65 inguinal herniotomies at a mean age of 2.5 months (±4.2). A testicular maldescention and atrophy rate of 1.8% and recurrence rate of 0% was achieved.

Conclusion

Children managed with this model of care had complication rates equivalent to or slightly higher than published gold standards. Considering the family disruption, cultural, financial implications and threat to compliance that transfer across vast distances entails, this model provides acceptable outcomes.

Impact of health utility after thrombotic complications following total hip and knee arthroplasty

August 1, 2017 - 09:51
Background

Medical complications and preexisting conditions frequently place the surgeon in the unenviable position of choosing between the serious and potentially life-threatening effects of thrombosis, or the issue of bleeding and surgical site complications. The aim of this research was to determine if health utility could be a consideration before choosing to therapeutically anticoagulate in the hip and knee arthroplasty patient.

Methods

The quantitative risks and effectiveness of treatment options for venous thromboembolism, atrial fibrillation, acute coronary syndromes, ischaemic stroke and mechanical heart valves were evaluated from previously published data. Previously calculated health utility values were obtained from published studies for both thrombotic events and anticoagulant-related complications at the site of arthroplasty. An impact score was generated through a multiplication of 1 − utility with the rate of the event occurring.

Results

Impact scores associated with revision surgery and deep infection at the arthroplasty site following anticoagulation are higher compared to impact scores in subsets of non-treated venous thromboembolism, low CHADS2 (congestive heart failure, hypertension, age >75, diabetes (1 point each), stroke/transient ischaemic attack (2 points)) atrial fibrillation and potentially some acute coronary syndrome patients. Some anticoagulation strategies in mechanical heart valves are of definite overall patient value due to the significant complications otherwise.

Conclusion

Objective calculation of both the benefit and risks of anticoagulation in the post-operative patient is significantly altered by including the effect on patient's quality of life utility value. Therapeutic anticoagulation in some common situations is probable to be of more detriment than benefit when considering health utility.

Factors related to recurrence of idiopathic granulomatous mastitis: what do we learn from a multicentre study?

July 27, 2017 - 19:35
Background

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory disease of the breast with unknown aetiology. Its treatment is controversial and the recurrence rate is high. The objectives of this study were to examine the demographic, sociocultural and clinical characteristics observed among a large cohort of IGM patients from Turkey and to identify factors related to the recurrence of IGM.

Methods

The study was designed as a multicentre retrospective study including 22 breast centres in Turkey. A total of 720 IGM patients are included in the study. Patient data were obtained from the patient's files and electronic records based on the study protocol. Patients’ demographic, clinical, radiological, treatment and recurrence of IGM related characteristics were recorded.

Results

Our results revealed a statistically significant association between IGM recurrence and history of pregnancy, breastfeeding, breast infection and smoking (P < 0.05). Having a chronic systematic disease, oral contraceptive, analgesic and herbal medicine consumptions, treatment choice, education, place of birth and current residence were not found to be associated with IGM recurrence (P > 0.05).

Conclusion

Our findings show that history of pregnancy, breastfeeding, breast infection and smoking were the risk factors for IGM recurrence. As current treatment methods did not affect IGM recurrence, recurrence-related factors, such as breast infection and smoking, should be considered to eliminate while focusing on less invasive local treatment research.

Long-term effectiveness of the preoperative smoking cessation programme at Western Health

July 22, 2017 - 14:41
Background

Smoking is associated with adverse effects in the perioperative period, including elevated risk of death. The perioperative period provides an opportunity to engage with patients who are smokers to encourage smoking cessation, often referred to as a ‘teachable moment’. We developed a smoking intervention model for the pre-admission clinic (PAC) at Western Health, Victoria, Australia. This case series aimed to assess the impact of the smoking intervention model, which is standard of care, on the participant's smoking habits over four time points.

Methods

We enrolled 50 consecutive participants for elective surgery who were smokers and had attended PAC at Western Health, Footscray. All smokers were offered a standard intervention package to address their smoking. Participants underwent a brief interview to elicit their current smoking behaviour on their day of surgery, 3 and 12 months post-operatively.

Results

We found a reduction at each time point post-intervention in the average number of cigarettes smoked per day by all participants with a 43% reduction at 12 months compared with PAC. We found that the number of participants who had quit increased at each time point, with 29% abstinent at 12 months post-operatively. At 12 months, we found 71% of participants had either quit or reduced the number of cigarettes smoked compared with the amount reported at PAC.

Conclusion

This study adds to the evidence that a simple intervention preoperatively can contribute to long-term changes in smoking behaviour.

Hartmann's reversal: a comparative study between laparoscopic and open approaches

July 21, 2017 - 17:05
Background

A reversal of Hartmann's procedure can be performed using either a laparoscopic or open approach. However, laparoscopic reversal (LR) of Hartmann's procedure is challenging. This study was designed to compare the results between open and laparoscopic approaches.

Methods

This was a retrospective study of prospectively collected data. We analysed 29 patients who received Hartmann's reversal at Korea University Anam Hospital between April 2007 and September 2014. All patients underwent either LR (n = 17) or open reversal (OR, n = 12).

Results

Patient characteristics were similar between the LR and OR groups. There was also no difference in mean operation time (212.5 versus 251.8 min), diversion ileostomy, length of hospital stay, postoperative analgesic days, time to diet resumption (3.9 versus 6.2 days) or complication rate. Although the time to resuming a solid diet was not different between the two groups (P = 0.053), bowel movement occurred faster in LR patients (LR versus OR, 1.8 versus 2.8 days, P = 0.020). Patients in the LR group also had less blood loss during surgery (114.1 versus 594.2 mL, P = 0.026). There were no mortalities in this study.

Conclusion

LR of Hartmann's procedure resulted in faster bowel function recovery than the open method. Laparoscopic approaches are feasible even for patients who received an open Hartmann's procedure.