Box- or Virtual-Reality Trainer: Which Tool Results in Better Transfer of Laparoscopic Basic Skills?-A Prospective Randomized Trial.

OBJECTIVE: Simulation training improves laparoscopic performance. Laparoscopic basic skills can be learned in simulators as box- or virtual-reality (VR) trainers. However, there is no clear recommendation for either box or VR trainers as the most appropriate tool for the transfer of acquired laparoscopic basic skills into a surgical procedure. DESIGN: Both training tools were compared, using validated and well-established curricula in the acquirement of basic skills, in a prospective randomized trial in a 5-day structured laparoscopic training course. Participants completed either a box- or VR-trainer curriculum and then applied the learned skills performing an ex situ laparoscopic cholecystectomy on a pig liver. The performance was recorded on video and evaluated offline by 4 blinded observers using the Global Operative Assessment of Laparoscopic Skills (GOALS) score. Learning curves of the various exercises included in the training course were compared and the improvement in each exercise was analyzed. SETTING: Surgical Skills Lab of the Department of General and Visceral Surgery, University Hospital Muenster. PARTICIPANTS: Surgical novices without prior surgical experience (medical students, n = 36). RESULTS: Posttraining evaluation showed significant improvement compared with baseline in both groups, indicating acquisition of laparoscopic basic skills. Learning curves showed almost the same progression with no significant differences. In simulated laparoscopic cholecystectomy, total GOALS score was significantly higher for the box-trained group than the VR-trained group (box: 15.31 ± 3.61 vs. VR: 12.92 ± 3.06; p = 0.039; Hedge׳s g* = 0.699), indicating higher technical skill levels. CONCLUSIONS: Despite both systems having advantages and disadvantages, they can both be used for simulation training for laparoscopic skills. In the setting with 2 structured, validated and almost identical curricula, the box-trained group appears to be superior in the better transfer of basic skills into an experimental but structured surgical procedure.

Postoperative complications do not affect long-term outcome in esophageal cancer patients.

BACKGROUND: As esophagectomy is associated with a considerable complication rate, the aim of this study was to assess the impact of postoperative complications and neoadjuvant treatment on long-term outcome of adenocarcinoma (EAC) and squamous cell carcinoma (SCC) patients. METHODS: Altogether, 134 patients undergoing transthoracic esophagectomy between 2005 and 2010 with intrathoracic stapler anastomosis were included in the study. Postoperative complications were allocated into three main categories: overall complications, acute anastomotic insufficiency, and pulmonary complications. Data were collected prospectively and reviewed retrospectively for the purpose of this study. RESULTS: SCC patients suffered significantly more often from overall and pulmonary complications (SCC vs. EAC: overall complications 67 vs. 45 %, p = 0.044; pulmonary complications 56 vs. 34 %, p = 0.049). The anastomotic insufficiency rates did not differ significantly (SCC 11%, EAC 15%, p = 0.69). Long-term survival of EAC and SCC patients was not affected by perioperative (overall/pulmonary) complications or by the occurrence of anastomotic insufficiency. Also, neoadjuvant treatment did not influence the incidence of complications or long-term survival. CONCLUSIONS: This is the first time the patient population of a center experienced with esophageal cancer surgery was assessed for the occurrence of general and esophageal cancer surgery-specific perioperative complications. Our results indicated that these complications did not affect long-term survival of EAC and SCC patients. Our data support the hypothesis that neoadjuvant treatment might not affect the incidence of perioperative complications or long-term survival after treatment of these tumor subtypes.

Laparoscopic simulation training: does timing impact the quality of skills acquisition?

BACKGROUND: Current surgical training involves integration of educational interventions together with service requirements during regular working hours. Studies have shown that voluntary training has a low acceptance among surgical trainees and obligatory simulation training during the regular working week leads to better skill acquisition and retention. We examined the difference in training effectiveness depending on the time of day. METHODS: Surgical novices underwent a curriculum consisting of nine basic laparoscopic tasks. The subjects were permitted to choose a training session between during regular working hours (8:00-16:00) or after hours (16:00-20:00). Each subject underwent baseline and post-training evaluation after completion of two 4-h sessions. Task completion was measured in time (s), with penalties for inaccurate performance. Statistical analysis included matched-pairs analysis (sex, age, and previous operative experience) with χ(2) und Mann-Whitney U test for between groups and Wilcoxon signed-rank test for testing within one group. RESULTS: There were no differences in demographic characteristics between the groups. Comparison of the individual baseline and post-training performance scores showed a significant (P < 0.05) improvement for all subjects in all exercises. No significant differences between groups were observed. CONCLUSION: All subjects improved in skill significantly throughout the week regardless of the timing of the training intervention. Simulation training can be offered outside of regular working hours with acceptable effectiveness.

Laparoscopic simulation training: Testing for skill acquisition and retention.

BACKGROUND: Simulation in laparoscopy leads to skill acquisition. Although many curricula for simulation training have been described, the nature of skill deterioration remains unclear. We evaluated skill acquisition and retention after laparoscopic simulation training. METHODS: Thirty-six novices in surgery (medical students) underwent a 5-day curriculum consisting of 9 skills of increasing complexity. Each subject underwent baseline and post-training evaluation after completion of the course. Skill retention testing was measured after 6 weeks (group 1; n = 18) and after 11 weeks (group 2; n = 18). Neither group had access to a training facility during this interval. Task completion was measured in time (s) with penalties for inaccurate performance. RESULTS: Comparison of the baseline and post-training values revealed a significant learning outcome for all exercises in both groups (P < .001). In group 1, skill retention testing found no significant decrease in skill level when compared to post-training values in all but 1 task (extracorporeal knot tying; P = .007). In group 2, differences between skill retention and post-training evaluation were observed for 5 of the 9 tasks (transfer task, positioning, loop tie, extracorporeal knot, and intracorporeal knot; P ≤ .05 for each). CONCLUSION: Basic laparoscopic skills can be learned successfully by novices in surgery using a compact curriculum. These skills are retained for at least 6 weeks. Eleven weeks after initial training, skill deterioration is likely, and therefore an opportunity for practice and repetition is desirable.

Angiotensin II impairs endothelial progenitor cell number and function in vitro and in vivo: implications for vascular regeneration.

Endothelial progenitor cells (EPCs) contribute to endothelial regeneration. Angiotensin II (Ang II) through Ang II type 1 receptor (AT(1)-R) activation plays an important role in vascular damage. The effect of Ang II on EPCs and the involved molecular mechanisms are incompletely understood. Stimulation with Ang II decreased the number of cultured human early outgrowth EPCs, which express both AT(1)-R and Ang II type 2 receptor, mediated through AT(1)-R activation and induction of oxidative stress. Ang II redox-dependently induced EPC apoptosis through increased apoptosis signal-regulating kinase 1, c-Jun N-terminal kinase, and p38 mitogen-activated protein kinase phosphorylation; decreased Bcl-2 and increased Bax expression; and activation of caspase 3 but had no effect on the low cell proliferation. In addition, Ang II impaired colony-forming and migratory capacities of early outgrowth EPCs. Ang II infusion diminished numbers and functional capacities of EPCs in wild-type (WT) but not AT(1)a-R knockout mice (AT(1)a(-/-)). Reendothelialization after focal carotid endothelial injury was decreased during Ang II infusion. Salvage of reendothelialization by intravenous application of spleen-derived progenitor cells into Ang II-treated WT mice was pronounced with AT(1)a(-/-) cells compared with WT cells, and transfusion of Ang II-pretreated WT cells into WT mice without Ang II infusion was associated with less reendothelialization. Transplantation of AT(1)a(-/-) bone marrow reduced atherosclerosis development in cholesterol-fed apolipoprotein E-deficient mice compared with transplantation of apolipoprotein E-deficient or WT bone marrow. Randomized treatment of patients with stable coronary artery disease with the AT(1)-R blocker telmisartan significantly increased the number of circulating CD34/KDR-positive EPCs. Ang II through AT(1)-R activation, oxidative stress, and redox-sensitive apoptosis signal-regulating kinase 1-dependent proapoptotic pathways impairs EPCs in vitro and in vivo, resulting in diminished vascular regeneration.