Educational value of a novel telestration device for surgical coaching-a randomized controlled trial.

INTRODUCTION: Communication is fundamental to effective surgical coaching. This can be challenging for training during image-guided procedures where coaches and trainees need to articulate technical details on a monitor. Telestration devices that annotate on monitors remotely could potentially overcome these limitations and enhance the coaching experience. This study aims to evaluate the value of a novel telestration device in surgical coaching. METHODS: A randomized-controlled trial was designed. All participants watched a video demonstrating the task followed by a baseline performance assessment and randomization into either control group (conventional verbal coaching without telestration) or telestration group (verbal coaching with telestration). Coaching for a simulated laparoscopic small bowel anastomosis on a dry lab model was done by a faculty surgeon. Following the coaching session, participants underwent a post-coaching performance assessment of the same task. Assessments were recorded and rated by blinded reviewers using a modified Global Rating Scale of the Objective Structured Assessment of Technical Skills (OSATS). Coaching sessions were also recorded and compared in terms of mentoring moments; guidance misinterpretations, questions/clarifications by trainees, and task completion time. A 5-point Likert scale was administered to obtain feedback. RESULTS: Twenty-four residents participated (control group 13, telestration group 11). Improvements in some elements of the OSATS scale were noted in the Telestration arm but there was no statistical significance in the overall score between the two groups. Mentoring moments were more in the telestration Group. Amongst the telestration Group, 55% felt comfortable that they could perform this task independently, compared to only 8% amongst the control group and 82% would recommend the use of telestration tools here. CONCLUSION: There is demonstrated educational value of this novel telestration device mainly in the non-technical aspects of the interaction by enhancing the coaching experience with improvement in communication and greater mentoring moments between coach and trainee.

High-level analytical potential-energy-surface-based dynamics of the OH- + CH3CH2Cl SN2 and E2 reactions in full (24) dimensions.

We develop a coupled-cluster full-dimensional global potential energy surface (PES) for the OH- + CH3CH2Cl reactive system, using the Robosurfer program package, which automatically samples configurations along PES-based trajectories as well as performs ab initio computations with Molpro and fitting with the monomial symmetrization approach. The analytical PES accurately describes both the bimolecular nucleophilic substitution (SN2) and elimination (E2) channels leading to the Cl- + CH3CH2OH and Cl- + H2O + C2H4 products, respectively, and allows efficient quasi-classical trajectory (QCT) simulations. QCT computations on the new PES provide accurate statistically-converged integral and differential cross sections for the OH- + CH3CH2Cl reaction, revealing the competing dynamics and mechanisms of the SN2 and E2 (anti, syn, ß-α transfer) channels as well as various additional pathways leading to induced inversion of the CH3CH2Cl reactant, H-exchange between the reactants, H2O⋯Cl- complex formation, and H2O + CH3CHCl- products via proton abstraction.

What is the educational value and clinical utility of artificial intelligence for intraoperative and postoperative video analysis? A survey of surgeons and trainees.

INTRODUCTION: Surgical complications often occur due to lapses in judgment and decision-making. Advances in artificial intelligence (AI) have made it possible to train algorithms that identify anatomy and interpret the surgical field. These algorithms can potentially be used for intraoperative decision-support and postoperative video analysis and feedback. Despite the very early success of proof-of-concept algorithms, it remains unknown whether this innovation meets the needs of end-users or how best to deploy it. This study explores users' opinion on the value, usability and design for adapting AI in operating rooms. METHODS: A device-agnostic web-accessible software was developed to provide AI inference either (1) intraoperatively on a live video stream (synchronous mode), or (2) on an uploaded video or image file (asynchronous mode) postoperatively for feedback. A validated AI model (GoNoGoNet), which identifies safe and dangerous zones of dissection during laparoscopic cholecystectomy, was used as the use case. Surgeons and trainees performing laparoscopic cholecystectomy interacted with the AI platform and completed a 5-point Likert scale survey to evaluate the educational value, usability and design of the platform. RESULTS: Twenty participants (11 surgeons and 9 trainees) evaluated the platform intraoperatively (n = 10) and postoperatively (n = 11). The majority agreed or strongly agreed that AI is an effective adjunct to surgical training (81%; neutral = 10%), effective for providing real-time feedback (70%; neutral = 20%), postoperative feedback (73%; neutral = 27%), and capable of improving surgeon confidence (67%; neutral = 29%). Only 40% (neutral = 50%) and 57% (neutral = 43%) believe that the tool is effective in improving intraoperative decisions and performance, or beneficial for patient care, respectively. Overall, 38% (neutral = 43%) reported they would use this platform consistently if available. The majority agreed or strongly agreed that the platform was easy to use (81%; neutral = 14%) and has acceptable resolution (62%; neutral = 24%), while 30% (neutral = 20%) reported that it disrupted the OR workflow, and 20% (neutral = 0%) reported significant time lag. All respondents reported that such a system should be available "on-demand" to turn on/off at their discretion. CONCLUSIONS: Most found AI to be a useful tool for providing support and feedback to surgeons, despite several implementation obstacles. The study findings will inform the future design and usability of this technology in order to optimize its clinical impact and adoption by end-users.

The influence of fluorination on the dynamics of the F- + CH3CH2I reaction.

The competition between the bimolecular nucleophilic substitution (SN2) and base-induced elimination (E2) reaction and their intrinsic reactivity is of key interest in organic chemistry. To investigate the effect of suppressing the E2 pathway on SN2 reactivity, we compared the reactions F- + CH3CH2I and F- + CF3CH2I. Differential cross-sections have been measured in a crossed-beam setup combined with velocity map imaging, giving insight into the underlying mechanisms of the individual pathways. Additionally, we employed a selected-ion flow tube to obtain reaction rates and high-level ab initio computations to characterize the different reaction pathways and product channels. The fluorination of the ß-carbon not only suppresses the E2-reaction but opens up additional channels involving the abstraction of fluorine. The overall SN2 reactivity is reduced compared to the non-fluorinated iodoethane. This reduction is presumably due to the competition with the highly reactive channels forming FHF- and CF2CI-.

Dynamics of the Cl- + CH3I reaction on a high-level ab initio analytical potential energy surface.

We have developed a full-dimensional analytical ab initio potential energy surface (PES) for the Cl- + CH3I reaction using the Robosurfer program system. The energy points have been computed using a robust composite method defined as CCSD-F12b + BCCD(T) - BCCD with the aug-cc-pVTZ(-PP) basis set and have been fitted by the permutationally invariant polynomial approach. Quasi-classical trajectory simulations on the new PES reveal that two product channels are open in the collision energy (Ecoll) range of 1-80 kcal/mol, i.e., SN2 leading to I- + CH3Cl and iodine abstraction (above ∼45 kcal/mol) resulting in ICl- + CH3. Scattering angle, initial attack angle, product translational energy, and product internal energy distributions show that the SN2 reaction is indirect at low Ecoll and becomes direct-rebound-back-side (CH3-side) attack-type, as Ecoll increases. Iodine abstraction mainly proceeds with direct stripping mechanism with side-on/back-side attack preference. Comparison with crossed-beam experiments and previous direct dynamics simulations shows quantitative or qualitative agreement and also highlights possible theoretical and/or experimental issues motivating further research.

Protonation of serine: conformers, proton affinities and gas-phase basicities at the "gold standard" and beyond.

The potential energy surfaces (PESs) of serine and its protonated counterparts are investigated to determine the structures of the minima. A total of 95 neutral serine, 15 N-(amino-) and 46 O-(carbonyl-)protonated serine conformers are found. Their relative energies, geometries and harmonic vibrational frequencies are determined at the MP2/aug-cc-pVDZ level of theory. To obtain highly accurate thermodynamic values, further computations are performed: the ten conformers with the lowest relative energies from each molecule type (neutral, N- and O-protonated) are further optimized using the explicitly correlated CCSD(T)-F12a/cc-pVDZ-F12 method (for neutral serine, harmonic vibrational frequencies were also computed). In addition, auxiliary corrections were determined: basis-set effects up to CCSD(T)-F12b/cc-pVQZ-F12, electron correlation effects up to CCSDT(Q), core correlation and second-order Douglas-Kroll relativistic effects along with zero-point energy contributions. Two important thermodynamic parameters (at 298.15 K), proton affinity (PA)/gas-phase basicity (GB) are calculated considering the two different protonation sites: 218.05 ± 0.2/209.86 ± 0.6 kcal mol-1 and 205.87 ± 0.2/196.36 ± 0.3 kcal mol-1 for the amino and carbonyl sites, respectively. The uncertainty of the determined values was approximated based on various sources including auxiliary corrections, basis-set effects, harmonic vibrational frequencies.

Benchmark Ab Initio Determination of the Conformers, Proton Affinities, and Gas-Phase Basicities of Cysteine.

A systematic conformational mapping combined with literature data leads to 85 stable neutral cysteine conformers. The implementation of the same mapping process for the protonated counterparts reveals 21 N-(amino-), 64 O-(carbonyl-), and 37 S-(thiol-)protonated cysteine conformers. Their relative energies and harmonic vibrational frequencies are given at the MP2/aug-cc-pVDZ level of theory. Further benchmark ab initio computations are performed for the 10 lowest-lying neutral and protonated amino acid conformers (for each type) such as CCSD(T)-F12a/cc-pVDZ-F12 geometry optimizations (and frequency computations for cysteine) as well as auxiliary correction computations of the basis set effects up to CCSD(T)-F12b/cc-pVQZ-F12, electron correlation effects up to CCSDT(Q), core correlation effects, second-order Douglass-Kroll relativistic effects, and zero-point energy contributions. Boltzmann-averaged 0 (298.15) K proton affinity and [298.15 K gas-phase basicity] values of cysteine are predicted to be 214.96 (216.39) [208.21], 201.83 (203.55) [194.16], and 193.31 (194.74) [186.40] kcal/mol for N-, O-, and S-protonation, respectively, also considering the previously described auxiliary corrections.

Educational interventions to improve ergonomics in gastrointestinal endoscopy: a systematic review.

Background and study aims Endoscopists are at high risk of musculoskeletal pain and injuries (MSPI). Recently, ergonomics has emerged as an area of interest to reduce and prevent the incidence of MSPI in endoscopy. The aim of this systematic review was to determine educational interventions using ergonomic strategies that target reduction of endoscopist MSPI from gastrointestinal endoscopy. Methods In December 2020, we conducted a systematic search in MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews for articles published from inception to December 16, 2020. Studies were included if they investigated educational interventions aimed at changing knowledge and/or behaviors related to ergonomics in gastrointestinal endoscopy. After screening and full-text review, we extracted data on study design, participants, type of training, and assessment of primary outcomes. We evaluated study quality with the Medical Education Research Study Quality Instrument (MERSQI). Results Of the initial 575 records identified in the search, five met inclusion criteria for qualitative synthesis. We found that most studies (n = 4/5, 80 %) were single-arm interventional studies that were conducted in simulated and/or clinical settings. The most common types of interventions were didactic sessions and/or videos (n = 4/5, 80%). Two (40 %) studies used both standardized assessment studies and formal statistical analyses. The mean MERSQI score was 9.7. Conclusions There is emerging literature demonstrating the effectiveness of interventions to improve ergonomics in gastrointestinal endoscopy.

Ceftolozane/tazobactam versus colistin in the treatment of ventilator-associated pneumonia due to extensively drug-resistant Pseudomonas aeruginosa.

Resistant strains of Pseudomonas aeruginosa are common pathogens in the intensive care unit (ICU), limiting available therapeutic options. We aimed to compare ceftolozane/tazobactam (C/T) with colistimethate sodium (CMS) in the treatment of ventilator-associated pneumonia (VAP) due to extensively drug-resistant (XDR) Pseudomonas aeruginosa. A retrospective, observational study was performed at a tertiary care ICU. Clinical and microbiological success rate, 28-day all-cause mortality, and adverse events were compared in patients who received C/T with those treated with systemic CMS. A total of 51 patients were included (18 in the C/T and 33 in the CMS group). Clinical success rates in the C/T and CMS groups were 13 (72.2%) and 10 (30.3%), respectively. On multivariate regression analysis, treatment with C/T was independently associated with clinical success (odds ratio 4.47, 95% CI 1.17-17.08). There was no difference in 28-day all-cause mortality (27.8% and 33.3% in the C/T and CMS group, p = 0.76). Acute kidney injury was more common in patients who received CMS (48.5% vs 11.1%, p = 0.01). In our study, ceftolozane/tazobactam was more efficacious in the treatment of XDR Pseudomonas aeruginosa VAP and showed a better safety profile compared to CMS.

Operative management of recalcitrant marginal ulcers following laparoscopic Roux-en-Y gastric bypass for morbid obesity: a systematic review.

One of the short- and long-term complications following Roux-en-Y gastric bypass (RYGB) for morbid obesity is the development of marginal ulcers (MUs). Although chronic and recalcitrant/recurrent marginal ulcers (rMUs) are common, there is no consensus on their optimal management. The objective of this study was to perform a systematic review of the elective operative management of rMUs. A systematic search of the literature was conducted. Relevant databases were searched up to May 16, 2020. Articles were included if they met the following inclusion criteria: (1) bariatric patients were included as the study population, (2) laparoscopic RYGB was performed as the index operation, (3) study patients developed rMUs, and (4) MUs required elective operative (surgical, endoscopic) interventions. Quality of articles was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The search identified 3470 citations; of these, 16 observational studies were included. Elective management of rMUs consisted of endoscopic (oversewing ± stents) and surgical interventions (gastrojejunostomy revision, vagotomy, conversion to sleeve gastrectomy, subtotal/total gastrectomy, reversal to normal anatomy). Quality of the studies as assessed by the GRADE system was low to very low. Recalcitrant/recurrent MUs are challenging complications both for bariatric patients and for their treating surgeons. There are no established algorithms for the management of rMUs, and the currently available evidence in the literature is limited both in quantity and in quality. Future multicentre, multisurgeon, randomized, controlled trials are needed to address this issue.

The Effect of Tissue Adhesive on Surgical Site Infection Following Elective Bariatric Surgery: a Retrospective Cohort Study.

PURPOSE: The reported incidence of surgical site infection (SSI) following bariatric surgery ranges from 1.4 to 30%. The use of skin staples and tissue adhesive was shown to be superior to sutures in reducing SSI in a variety of surgical disciplines; however, this area is under-investigated in elective bariatric surgery. The aim of this study was to examine the effect of tissue adhesive for skin closure on SSI in patients undergoing bariatric surgery. METHODS: A retrospective analysis was performed to determine the incidence of SSI in patients who underwent elective laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Tissue adhesive was selectively used for skin closure during the study period. Patient characteristics, operative data, and 30-day postoperative outcomes were collected from patient charts and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. RESULTS: A total of 1,579 patients were included in the study. Tissue adhesive was used in 31.2% of all operations (n = 494). The rate of incisional SSI in our study was 2.2% (n = 35). The use of tissue adhesive was more common in patients who developed incisional SSI compared with those without incisional SSI (54.3 vs. 30.8%, p = 0.003). On multivariate analysis, the use of tissue adhesive remained an independent predictor for the development of incisional SSI (OR 2.77, p = 0.007). CONCLUSION: The use of tissue adhesive was an independent predictor for incisional SSI following elective bariatric surgery. This is the first study to report the effects of tissue adhesive in this patient population.

Benchmark ab initio proton affinity of glycine.

A systematic conformational search reveals three N- (amino) and eight O- (carbonyl) protonated glycine conformers with benchmark equilibrium(adiabatic) relative energies in the 0.00-7.51(0.00-7.37) and 25.91-31.61(24.45-30.28) kcal mol-1 ranges, respectively. Benchmark ab initio structures of the glycine conformers and its protonated species are obtained at the CCSD(T)-F12b/aug-cc-pVTZ level of theory and the relative energy computations consider basis-set effects up to aug-cc-pVQZ with CCSD(T)-F12b, electron correlation up to CCSDT(Q), core correlation corrections, scalar relativistic effects, and zero-point energy contributions. The best predictions for Boltzmann-averaged 0(298.15) K proton affinities and [298.15 K gas-phase basicities] of glycine are 211.00(212.43)[204.75] and 186.38(187.64)[180.21] kcal mol-1 for N- and O-protonation, respectively, in excellent agreement with experiments.

Conformers of dehydrogenated glycine isomers.

We report a comprehensive ab initio investigation of the conformers of dehydrogenated glycine radicals using the STO-3G, 3-21G, and aug-cc-pVDZ (aVDZ) basis sets and the UHF and UMP2 (H2 N-CH-COOH and HN-CH2 -COOH) as well as MCSCF and MRCI (H2 N-CH2 -COO) methods via two different conformational search strategies generating initial structures for optimizations by (a) removing H atoms from glycine conformers and (b) scanning torsional angles describing internal rotation along the CC, CN, and CO (except for H2 N-CH2 -COO) bonds of the radicals. We find four H2 N-CH-COOH {InCH , IInCH , IIInCH , IVnCH } and seven HN-CH2 -COOH {IpNH , IIpNH , IIInNH , IVpNH VnNH , VIpNH , VIIpNH } conformers with classical(adiabatic) relative energies of {0.00(0.00), 1.57(1.55), 5.25(5.03), 9.85(9.72)} and {0.00(0.00), 0.78(1.06), 1.93(2.08), 3.34(3.16), 3.39(3.29), 5.00(4.86), 9.27(8.87)} kcal/mol, respectively, obtained with UCCSD(T)-F12b/aug-cc-pVTZ(+UCCSD(T)-F12b/aVDZ ZPE correction) and four H2 N-CH2 -COO {IpCOO , IInCOO , IIIpCOO , IVnCOO } conformers with MRCI-F12+Q/aVDZ(+MRCI/aVDZ ZPE correction) energies of {0.00(0.00), 1.65(1.64), 1.78(1.75), 2.21(2.21)} kcal/mol, where n and p denote C1 and Cs symmetry. The MRCI-F12+Q[UCCSD(T)-F12b] InCH → IpNH and InCH → IpCOO classical(adiabatic) isomerization energies are 18.51(17.32)[21.20(20.01)] and 31.88(31.66) kcal/mol, respectively.

Technical Performance as a Predictor of Clinical Outcomes in Laparoscopic Gastric Cancer Surgery.

OBJECTIVE: The purpose of this study was to evaluate the relationship between technical performance and patient outcomes in laparoscopic gastric cancer surgery. BACKGROUND: Laparoscopic gastrectomy for cancer is an advanced procedure with high rate of postoperative morbidity and mortality. Many variables including patient, disease, and perioperative management factors have been shown to impact postoperative outcomes; however, the role of surgical performance is insufficiently investigated. METHODS: A retrospective review was performed for all patients who had undergone laparoscopic gastrectomy for cancer at 3 teaching institutions between 2009 and 2015. Patients with available, unedited video-recording of their procedure were included in the study. Video files were rated for technical performance, using Objective Structured Assessments of Technical Skills (OSATS) and Generic Error Rating Tool instruments. The main outcome variable was major short-term complications. The effect of technical performance on patient outcomes was assessed using logistic regression analysis with backward selection strategy. RESULTS: Sixty-one patients with available video recordings were included in the study. The overall complication rate was 29.5%. The mean Charlson comorbidity index, type of procedure, and the global OSATS score were included in the final predictive model. Lower performance score (OSATS ≤29) remained an independent predictor for major short-term outcomes (odds ratio 6.49), while adjusting for comorbidities and type of procedure. CONCLUSIONS: Intraoperative technical performance predicts major short-term outcomes in laparoscopic gastrectomy for cancer. Ongoing assessment and enhancement of surgical skills using modern, evidence-based strategies might improve short-term patient outcomes. Future work should focus on developing and studying the effectiveness of such interventions in laparoscopic gastric cancer surgery.

Clinical Indicators of Postoperative Bleeding in Bariatric Surgery.

The purpose of this study was to evaluate the relationship between patient, clinical and laboratory characteristics, and bleeding after bariatric surgery. A retrospective chart review was performed for all patients, who underwent a laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy at our institution between March 2012 and May 2014. In total, 788 patients were included in this study. Seventeen patients had postoperative bleeding. The demographics, comorbidities, and preoperative medications were similar between the groups. Mean postoperative hemoglobin in the bleeding group was significantly lower (94 vs. 126; P<0.001) with a larger decrease from the baseline value (-43 vs. -12; P<0.001). The mean heart rate (91 vs. 81; P<0.001) and its increase from baseline (12 vs. -0.01; P<0.001) were significantly different in the bleeding patients. Postoperative hemoglobin and heart rate were associated with bleeding but not systolic blood pressure or patient characteristics. Further research is needed to develop a robust predictive model.

Practice does not always make perfect: need for selection curricula in modern surgical training.

BACKGROUND: It is hypothesized that not all surgical trainees are able to reach technical competence despite ongoing practice. The objectives of the study were to assess a trainees' ability to reach technical competence by assessing learning patterns of the acquisition of surgical skills. Furthermore, it aims to determine whether individuals' learning patterns were consistent across a range of open and laparoscopic tasks of variable difficulty. METHODS: Sixty-five preclinical medical students participated in a training curriculum with standardized feedback over forty repetitions of the following laparoscopic and open technical tasks: peg transfer (PT), circle cutting (CC), intracorporeal knot tie (IKT), one-handed tie, and simulated laparotomy closure. Data mining techniques were used to analyze the prospectively collected data and stratify the students into four learning clusters. Performance was compared between groups, and learning curve characteristics unique to trainees who have difficulty reaching technical competence were quantified. RESULTS: Top performers (22-35%) and high performers (32-42%) reached proficiency in all tasks. Moderate performers (25-37%) reached proficiency for all open tasks but not all laparoscopic tasks. Low performers (8-15%) failed to reach proficiency in four of five tasks including all laparoscopic tasks (PT 7.8%; CC 9.4%; IKT 15.6%). Participants in lower performance clusters demonstrated sustained performance disadvantage across tasks, with widely variable learning curves and no evidence of progression towards a plateau phase. CONCLUSIONS: Most students reached proficiency across a range of surgical tasks, but low-performing trainees failed to reach competence in laparoscopic tasks. With increasing use of laparoscopy in surgical practice, screening potential candidates to identify the lowest performers may be beneficial.

The Effect of Technical Performance on Patient Outcomes in Surgery: A Systematic Review.

OBJECTIVE: Systematic review of the effect of intraoperative technical performance on patient outcomes. BACKGROUND: The operating room is a high-stakes, high-risk environment. As a result, the quality of surgical interventions affecting patient outcomes has been the subject of discussion and research for years. METHODS: MEDLINE, EMBASE, PsycINFO, and Cochrane databases were searched. All surgical specialties were eligible for inclusion. Data were reviewed in regards to the methods by which technical performance was measured, what patient outcomes were assessed, and how intraoperative technical performance affected patient outcomes. Quality of evidence was assessed using the Medical Education Research Study Quality Instrument (MERSQI). RESULTS: Of the 12,758 studies initially identified, 24 articles (7775 total participants) were ultimately included in this review. Seventeen studies assessed the performance of the faculty alone, 2 assessed both the faculty and trainees, 1 assessed trainees alone, and in 4 studies, the level of the operating surgeon was not specified. In 18 studies, a performance assessment tool was used. Patient outcomes were evaluated using intraoperative complications, short-term morbidity, long-term morbidity, short-term mortality, and long-term mortality. The average MERSQI score was 11.67 (range 9.5-14.5). Twenty-one studies demonstrated that superior technical performance was related to improved patient outcomes. CONCLUSIONS: The results of this systematic review demonstrated that superior technical performance positively affects patient outcomes. Despite this initial evidence, more robust research is needed to directly assess intraoperative technical performance and its effect on postoperative patient outcomes using meaningful assessment instruments and reliable processes.

Setting Performance Standards for Technical and Nontechnical Competence in General Surgery.

OBJECTIVES: The objectives of this study were to (1) create a technical and nontechnical performance standard for the laparoscopic cholecystectomy, (2) assess the classification accuracy and (3) credibility of these standards, (4) determine a trainees' ability to meet both standards concurrently, and (5) delineate factors that predict standard acquisition. BACKGROUND: Scores on performance assessments are difficult to interpret in the absence of established standards. METHODS: Trained raters observed General Surgery residents performing laparoscopic cholecystectomies using the Objective Structured Assessment of Technical Skill (OSATS) and the Objective Structured Assessment of Non-Technical Skills (OSANTS) instruments, while as also providing a global competent/noncompetent decision for each performance. The global decision was used to divide the trainees into 2 contrasting groups and the OSATS or OSANTS scores were graphed per group to determine the performance standard. Parametric statistics were used to determine classification accuracy and concurrent standard acquisition, receiver operator characteristic (ROC) curves were used to delineate predictive factors. RESULTS: Thirty-six trainees were observed 101 times. The technical standard was an OSATS of 21.04/35.00 and the nontechnical standard an OSANTS of 22.49/35.00. Applying these standards, competent/noncompetent trainees could be discriminated in 94% of technical and 95% of nontechnical performances (P < 0.001). A 21% discordance between technically and nontechnically competent trainees was identified (P < 0.001). ROC analysis demonstrated case experience and trainee level were both able to predict achieving the standards with an area under the curve (AUC) between 0.83 and 0.96 (P < 0.001). CONCLUSIONS: The present study presents defensible standards for technical and nontechnical performance. Such standards are imperative to implementing summative assessments into surgical training.

Training in Laparoscopic Gastric Cancer Surgery in the Western World: Current Educational Practices, Challenges, and Potential Opportunities at a Large University Centre.

OBJECTIVE: The purpose of this study was to explore and understand how surgeons distribute tasks during a laparoscopic gastrectomy for gastric cancer in an academic teaching environment. DESIGN: An anonymous, cross-sectional, census survey was used to poll trainees' and staff members' opinions pertaining to laparoscopic gastrectomy. SETTING: Academic and community tertiary teaching hospitals, affiliated with the University of Toronto. PARTICIPANTS: All surgeons, within the Department of General Surgery at the University of Toronto, who practice laparoscopic gastrectomy for gastric cancer, were invited to participate. All general surgery residents, postgraduate year 1-5, minimally invasive surgery and surgical oncology fellows at the University of Toronto were invited to participate. Overall response rate was 74.35% (n = 87/117). RESULTS: The results suggested that trainees do not routinely perform the major operative steps. Trainees agreed with faculty in this regard; however, there was a statistically significant difference in opinions, related to the degree of the perceived active operating of the trainees. There was also a difference in opinion, between trainees and faculty, regarding the common reasons for takeover. CONCLUSIONS: The present survey highlights that current level of active exposure of surgical trainees to laparoscopic gastric surgery might be insufficient. A lack of role clarity may further hinder an optimal educational experience during these cases. Adopting a stepwise approach, with task deconstruction, could optimize training. Additional training modalities may be required to ensure technical proficiency is acquired before independent practice.