Analysis of Endoscopic Evaluation Reliability for Ulcerative Colitis in Histological Remission

The Mayo endoscopic subscore (MES) is a major endoscopic scoring system used to assign a status of mucosal inflammation and disease activity to patients with ulcerative colitis (UC). Using interobserver reliability (IOR), this study clarified the difficulties for endoscopic observers imposed by MES parameters used for the endoscopic evaluation of UC in histological remission. First, 42 endoscopists of four observer groups examined each MES parameter, which were evaluated from endoscopically obtained images of 100 cases as Grade 0 or 1 of the Nancy histological index of histopathological inflammation. Then, IOR was assessed using multiple κ statistics for each finding of MES. The results showed that IOR among all the observers was slight or fair for all the parameters, indicating a low IOR. The experts of the UC practice group had “moderate” or higher IOR for seven of the nine parameters, whereas “slight” or “fair” results were found for all parameters by the trainee group. The IOR for each MES parameter was calculated separately for the observer groups. All the groups showed “slight” or “fair” for “Erythema” and “Decreased vascular pattern”. Large differences between the endoscopists were found in the IOR for the MES parameters in UC in histological remission. Even among UC practice experts, the IOR was low for “Erythema” and “Decreased vascular pattern”.

EP.TH.1043Outcomes of liver resections by trainee surgeons versus consultant surgeon – a single centre experience

Introduction Liver resection is a most effective treatment for patients with operable primary or secondary cancer deposits. The role of trainee as a lead surgeon versus consultant surgeon performing liver resections and its impact on surgical outcomes had never been reported. Methods and Materials This study was aimed to assess the liver resection outcomes including operative time, acute kidney injury (AKI), bile leak, sepsis, mortality and hospital readmission within 3 months. A total of 320 liver resections from Addenbookes Hospital at Cambridge between 2015 to 2017 were included in this study. All liver resections were performed under supervision of the consultant surgeon who is either scrubbed or unscrubbed in theatre. Trainee surgeons have performed 116 of 320 as lead surgeon and the consultant surgeons performed the remaining 204. Results The mean operative time was 413±129 versus 383±118 (P = 0.41) minutes in trainee surgeons and consultant surgeons respectively. The incidence of postoperative AKI were similar in between the groups (5/116 versus 11/204;P=0.79). Although the bile leak was numerically high in the trainee group, did not reach statistical difference (13/116 versus 12/204;P=0.12); similar results noted in the incidence of sepsis too (3/116 versus 4/204;P=070). Mortality, hospital readmission at 3 months were (1/204 versus 1/116;P=1) and (2/116 versus 4/204;P=1) respectively. No significant difference was observed. Conclusion Liver resections performed by the trainee surgeons under supervision appeared to be safe without increasing the operative time, morbidity, mortality and hospital readmission at 90 days. Further multicentre prospective study with long-term follow up is recommended.

Learning Curve for the Acquisition of 20 Standard Two-Dimensional Images in Advanced Perioperative Transesophageal Echocardiography: A Prospective Observational Study

Background Learning to perform intraoperative transesophageal echocardiography takes time and practice. We aimed to determine the cumulative success rate in the first 20 intraoperative transesophageal echocardiography cases performed by trainee anesthesiologists with no transesophageal echocardiography experience. Methods This prospective observational study included nine anesthesiologists (four cardiovascular and thoracic anesthesia fellows and five short-course perioperative intraoperative transesophageal echocardiography trainees). Overall, 180 studies self-performed by the trainees were reviewed by certified reviewers. A study was considered successful when at least 15 qualified images were collected within 30 minutes. The cumulative success of each trainee was used as a surrogate of a basic two-dimensional intraoperative transesophageal echocardiography learning curve. Results The participants comprised three male and six female anesthesiologists aged 29–43 years with 2–13 years of work experience. Most studies (146/180, 81.11%) were completed within 30 minutes, and the cumulative success rate was 70–90% (average 82.78 ± 6.71%). The average cumulative success rate in the short-course group (85 ± 7.07%) was higher than that in the official cardiovascular and thoracic fellow trainee group (80 ± 7.07%). The recommended caseload for a 75–80% success rate was 14–18 cases (95% confidence interval, 0.675–0.969). Conclusions We recommended a 14–18 caseload for a target success rate of 75–80% in studies performed by trainees with no previous experience. Our findings will enable the development of programs to train anesthesiologists in intraoperative transesophageal echocardiography.

Difficult biliary cannulation in ERCP procedures with or without trainee involvement: a comparison study

Aims 5-5-1 criteria have been proposed by the European Society of Gastrointestinal Endoscopy to define difficult ERCP cannulation. However, the criteria may be inappropriate for cannulation procedures with trainee involvement. Here we aimed to develop difficult cannulation criteria in trainee involved cannulation. Methods Patients undergoing biliary cannulation with (trainee group) or without trainee involvement (non-trainee group) were eligible. The procedures which might be too easy (e.g. fistula) or too difficult (e.g. altered anatomy) was excluded. The primary outcome was difficult cannulation, which was defined as the values of cannulation time, attempts, or inadvertent PD cannulation exceeding 75% percentile of each variable. Propensity score matching analysis was used. Results After PSM, there were 1596 patients in each group. The trainee group had longer median cannulation time [7.5 (2.2-15.3) min vs. 2.0 (0.6-5.2) min], more median attempts [5 (2-10) vs. 2 (1-4)] and median inadvertent PD cannulation [0 (0-2) vs. 0 (0-1)] compared with the non-trainee group (all p<0.001). 15-10-2 and 5-5-1 difficult cannulation criteria determined by exceeding 75% percentile of cannulation variables were proposed for trainee involved cannulation and were nearly confirmed for non-trainee involved cannulation, respectively. The proportion of difficult cannulation was 35.5% 95%CI [33.2%, 37.9%] and 31.8% 95%CI [29.5%, 34.2%] respectively (OR 1.18 95%CI [1.02-1.37]). The incidence of PEP (7.8% 95%CI [5.7%, 10.3%] vs. 9.8% 95%CI [7.4%, 12.8%]) in difficult patients were comparable. Conclusion By using 75% percentiles of cannulation-related variables as cutoff values, we proposed that 15-10-2 difficult cannulation criteria could be appropriate in trainee involved cannulation.

Complexity explained: The dialectical position between theory and practice. Theoretical group analytic concepts and clinical examples

I present below an attempt to understand complexity theory and the dialectical relationship between theory and group analytic practice. These are often concepts difficult to make sense of as they are rarely illuminated with clinical material for the reader or the trainee group analyst to comprehend. After the introduction of the Kantian and Hegelian dialectic and its use to understand group analytic concepts, I move on to the complexity theory and attempt to illustrate its significance with a clinical example from a small group analytic group. Cavafis’s celebrated poem ‘Ithaka’, is used as a metaphor for the utmost importance of the splendid interpersonal and transpersonal journey in group analysis with all its challenges and gains that this brings to the individual and to the group as a whole as the emphasis is on the process (journey) rather the destination (Ithaka).

Moving Violations: Pairing an Illegitimate Learning Hierarchy with Trainee Status Mobility for Acquiring New Skills When Traditional Expertise Erodes

We explore how members of a community of practice learn new tools and techniques when environmental shifts undermine existing expertise. In our 20-month comparative field study of medical assistants and patient-service representatives learning to use new digital technology in five primary care sites, we find that the traditional master-apprentice training model worked well when established practices were being conferred to trainees. When environmental change required introducing new tools and techniques with which the experienced members had no expertise, third-party managers selected newer members as trainers because managers judged them to be agile learners who were less committed to traditional hierarchies and more willing to deviate from traditional norms. This challenged community members’ existing status, which was based on the historical distinctions of long tenure and expertise in traditional tasks. In three sites, the introduction of this illegitimate learning hierarchy sparked status competition among trainees and trainers, and trainees collectively resisted learning new tools and techniques. In the other two sites, managers paired the new, illegitimate learning hierarchy with the opportunity for trainee status mobility by rotating the trainer role; here, trainees embraced learning in order to exit the lower-status trainee group and join the higher-status trainer group. Drawing on ideas of status group legitimacy and mobility, we suggest that managers’ pairing of an illegitimate learning hierarchy with the opportunity for trainee status mobility is a mechanism for enabling the situated learning of new techniques when traditional expertise erodes.

418 SYSTEMATIC REVIEW OF LEARNING CURVES IN MINIMALLY INVASIVE PARAESOPHAGEAL HERNIA REPAIR: IS THERE ENOUGH EVIDENCE FOR MENTORSHIP IN SURGICAL RESIDENCY?

Laparoscopic repair remains the approach of choice for the surgical management of symptomatic paraesophageal hernia (PEH), although robotic techniques are becoming increasingly popular. The learning curve for minimally invasive PEH repair can be variable and little is known of its potential impact upon surgical residents’ training. The aim of this review is to appraise current literature on learning curves in PEH repair and its impact on training and mentorship of surgical residents. Methods Literature searches were performed in three databases: MEDLINE (1980-2020), EMBASE and the Cochrane Library. Search results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data quality was assessed in accordance with the Newcastle-Ottawa Scale for cohort studies. Results A total of 6 studies were identified; 4 laparoscopic and 2 robotic assisted with 2678 patients assessed in total. One study used a cumulative sum (CUSUM) analysis to define learning with the remainder of studies using between 3 and 11 parameters. 2 studies evaluated trainees’ performance in performing laparoscopic PEH repair when mentored by surgeons who had achieved competence on the learning curve. Both studies reported equivalent clinical outcomes for laparoscopic PEH repair performed by trainees versus consultants, although one study suggested 5-year outcomes were inferior in the trainee group despite mentorship. Conclusion Despite being commonly performed, little is known about the learning curves for minimally invasive PEH repair. Furthermore, whether prior laparoscopic experience confers any advantage to performing robotic PEH repair is not known at present. Further data to help evaluate the learning curve for those performing PEH is required in order to enhance training and permit quicker attainment of competency.

Differences in the Exposure of the Lumbar Nerve Root Between Experts and Novices: Results From a Realistic Simulation Pilot Study With Force Sensors

Study Design: Nonrandomized prospective trial. Objective: Several studies could demonstrate “learning curves” in almost every single surgical procedure for unexperienced surgeons. This is in sharp contrast to the rising quality requirements in public health care to provide surgical training at patients “expense.” The aim of this study was to visualize, measure, and set a baseline of the pressure load on the spinal nerve root during a simulated microdiscectomy on a standardized and validated model (RealSpine) under the influence of the level of surgical experience and individual skills. Methods: Five highly experienced spine surgeons and 5 trainees without considerable surgical experience were selected to perform a standardized microsurgical discectomy on a validated RealSpine simulator. Force-torque sensors were integrated in this simulator to measure the load on the nerve root. The forces were recorded every 125 ms. Results: We could identify cumulative for the total intervention as well as for defined single surgical steps of this procedure and as well in between the single subjects a significant higher tension and contusion forces on the nerve for the trainee group (Δp contusion 83-765 Nċs and Δp tension 159-1131 Nċs for the trainees. Δp contusion 16-171 Nċs and Δp tension 27-146 Nċs for the experts). Conclusion: We could measure a difference between unexperienced and experienced surgeons regarding the manipulations of the nerve root during a standardized simulated microdiscectomy. This possibility could be the starting point for a new and innovative surgical education to improve outcome without negative side effects of “learning curves.”

Safety of tympanoplasty and ossiculoplasty performed by otorhinolaryngology trainees

ObjectiveThis study aimed to examine the impact of trainee involvement in performing tympanoplasty or tympano-ossiculoplasty on outcomes.MethodsA retrospective analysis was performed of a prospective database of all patients undergoing tympanoplasty and tympano-ossiculoplasty in a single centre during a three-year period. Patients were divided into three primary surgeon groups: consultants, fellows and residents. The outcomes of operative time, surgical complications, length of hospital stay, and air–bone gap improvement were compared among the groups.ResultsThe study included 398 tympanoplasty and tympano-ossiculoplasty surgical procedures, 71 per cent of which were performed by junior trainees (residents). The junior trainee group was associated with a significantly longer surgical time, without adverse impact on outcomes.ConclusionTrainee participation in tympanoplasty and tympano-ossiculoplasty surgery was associated with longer surgical time, but did not negatively affect the peri-operative course or hearing outcome. Therefore, resident involvement in these types of surgery is safe.