ABSTRACT
Introduction. The use of simulation in surgery has made it possible to shorten learning curves through deliberate practice. Although it has been incorporated long ago, there are still no clear recommendations to standardize its development and implementation. This manuscript aims to share recommendations based on our experience of more than twelve years of employing and improving a methodology in laparoscopic surgical simulation. Topics for Reflection. To transfer surgical skills to a trainee, we base our methodology on a three-pillar framework: The hardware and infrastructure (tools to train with), the training program itself (what to do), and the feedback (how to improve). Implementing a cost-effective program is feasible: the hardware does not need to be high fidelity to transfer skills, but the program needs to be validated. These pillars have evolved over time by incorporating technology: the on-site guidance from experts has changed to a remote and asynchronous modality by video recording the trainee's execution, and by enabling remote and asynchronous feedback. The feedback provider does not necessarily have to be an expert clinician in the subject, but a person previously trained to be a trainer. This allows for deliberate practice until mastery has been reached and learning curves are consolidated. Conclusions. Recommendations based on the experience of our center have been presented, explaining the framework of our strategy. Considering these suggestions, it is hoped that our simulation methodology can aid the development and implementation of effective simulationbased programs for other groups and institutions.
Introducción. El uso de la simulación en cirugía ha permitido acortar las curvas de aprendizaje mediante la práctica deliberada. A pesar de que se ha incorporado previamente, aún no existen recomendaciones claras para estandarizar su desarrollo e implementación. Este manuscrito pretende compartir recomendaciones basadas en nuestra experiencia, con más de doce años empleando y mejorando una metodología en la simulación quirúrgica laparoscópica. Temas de reflexión. Para transferir las habilidades quirúrgicas a un aprendiz, basamos nuestra metodología en un marco de tres pilares: El hardware y la infraestructura (herramientas con las que entrenar), el programa de entrenamiento (qué hacer), y la retroalimentación (cómo mejorar). La implementación de un programa rentable es factible: el hardware no necesita ser de alta fidelidad para transferir las habilidades, pero el programa necesita ser validado. Estos pilares han evolucionado a lo largo del tiempo incorporando tecnología: la presencia de expertos ha evolucionado a una modalidad remota y asincrónica mediante la grabación en vídeo de la ejecución del alumno, y permitiendo su retroalimentación. Aquel que entrega retroalimentación no tiene que ser necesariamente un clínico experto en la materia, sino una persona previamente formada como instructor. Esto permite una práctica deliberada hasta dominar la habilidad y establecer curvas de aprendizaje. Conclusiones. Se han presentado recomendaciones basadas en la experiencia de nuestro centro, explicando el marco de nuestra estrategia. Teniendo en cuenta estas sugerencias, se espera que nuestra metodología de simulación pueda ayudar al desarrollo e implementación de programas efectivos basados en la simulación a otros grupos e instituciones.
Introdução. O uso de simulação em cirurgia tornou possível encurtar as curvas de aprendizagem por meio da prática deliberada. Embora tenha sido incorporado anteriormente, ainda não há recomendações claras para padronizar seu desenvolvimento e implementação. Este manuscrito pretende compartilhar recomendações com base em nossa experiência, com mais de doze anos usando e aprimorando uma metodologia em simulação cirúrgica laparoscópica. Temas de reflexão. Para transferir habilidades cirúrgicas para um aprendiz, baseamos nossa metodologia em uma estrutura de três pilares: o hardware e a infraestrutura (ferramentas para treinar), o programa de treinamento (o que fazer) e feedback (como melhorar). A implementação de um programa rentável é viável: o hardware não precisa ser de alta fidelidade para transferir as habilidades, mas o programa precisa ser validado. Esses pilares evoluíram ao longo do tempo incorporando a tecnologia: a presença de especialistas evoluiu para uma modalidade remota e assíncrona por meio da gravação em vídeo do desempenho do aluno e permitindo seu feedback. Quem dá feedback não precisa ser necessariamente um clínico especialista na área, mas sim uma pessoa previamente treinada como instrutor. Isso permite a prática deliberada até que a habilidade seja dominada e estabeleça curvas de aprendizado. Conclusões. Foram apresentadas recomendações baseadas na experiência do nosso centro, explicando o enquadramento da nossa estratégia. Levando em consideração essas sugestões, espera-se que nossa metodologia de simulação possa ajudar outros grupos e instituições a desenvolver e implementar programas eficazes baseados em simulação.
Subject(s)
General Surgery , Laparoscopy , Simulation Exercise , Education, Medical , Feedback , Simulation TrainingABSTRACT
BACKGROUND: Gallbladder cancer (GBC) is the second leading cause of cancer death in women in Chile. Even after curative surgery, prognosis is grim. To evaluate acute and late toxicity and efficacy of adjuvant chemoradiation (CRT) after curatively resected GBC. MATERIALS AND METHODS: We retrospectively analyzed the cohort of patients diagnosed between January 1999 and December 2009, treated with adjuvant CRT at our institution. Treatment protocol considered external beam radiation (RT) (45–54 Gy) to tumor bed and regional lymph nodes with or without concurrent 5-fluorouracil (5-FU) (500 mg/m2/day by 120-hours continuous infusion on days 1–5 and 29–33). Data was obtained from medical records, mortality from death certificates. Survival was estimated by Kaplan– Meier curves. RESULTS: 46 patients with curatively resected GBC received adjuvant CRT. Median age was 57 years (range 33–76); 39 patients were female. After diagnosis, a second surgery was performed in 42 patients. Cholecystectomy with hepatic segmentectomy and lymphadenectomy was the curative surgery in 41 patients. All patients received RT with a planned dose of 45 Gy in 25 fractions, 11 patients received a boost to the tumor bed up to 54 Gy and 34 patients had concurrent 5-FU. Therapy was well tolerated. Five patients experienced grade 3 toxicities. No grade 4 or 5 toxicity was observed. No grade >2 late toxicity was observed. Three- and 5-year overall survival (OS) were 57% and 51%, respectively. CONCLUSIONS: Adjuvant chemoradiation is well tolerated and might impact favorably on survival in patients with curatively resected GBC.
Subject(s)
Adult , Aged , Chemoradiotherapy, Adjuvant , Chile , Cohort Studies , Female , Gallbladder Neoplasms/mortality , Gallbladder Neoplasms/therapy , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Proportional Hazards Models , Retrospective StudiesABSTRACT
Background: Survival rates after curative surgery for gastric cancer are disappointing. Therefore adjuvant therapeutic strategies are required. Aim: To analyze survival and side effects of treatment among gastric cancer patients treated with adjuvant chemo radiotherapy after curative resection of gastric adenocarcinoma. Material and methods: Retrospective review of medical records of 74 patients aged 20 to 74 years, treated with complete resection of gastric adenocarcinoma followed by adjuvant chemo radiation. Survival analysis was based on the records and information from the National Mortality Registry. Results: Five years survival fluctuated from 50 percent among patients in stage IB to 25 percent among those is stage IV. Significant acute toxicity was observed in 23 patients (31 percent). No patients died due to acute toxicity. Eleven patients (16.4 percent) developed significant late toxicity, with two possible deaths related to treatment. Conclusions: Postoperative chemo radiotherapy is feasible in our experience. Continues infusion of 5-fluoruracil is recommended to reduce toxicity.