Peer Coaching as a Form of Performance Improvement: What Surgeons Really Think.

OBJECTIVE: Coaching has been proposed as a potential form of continuing professional development (CPD) for surgeons. Our study aimed to elicit qualified surgeons' perceptions of peer coaching as a form of CPD and to determine the effect of demographic factors on surgeons' views. METHODS: A cross-sectional paper survey was conducted across 2 South Australian metropolitan hospitals from November 2018 to January 2019. This comprised 5 demographic questions and 6 Likert items eliciting views on peer-based coaching and was distributed at departmental unit meetings to surgical consultants and fellows. Participation was voluntary and a definition of "peer-based coaching" was provided. RESULTS: Hundred and eighteen surgeons of a possible 125 (94.4% response rate) from 8 surgical specialties completed the survey with 45.4% (n = 54) having received coaching since obtaining their fellowship. The majority of participants (72.9%, n = 86) reported consultant surgeons would benefit from peer coaching and that one-on-one coaching in an individual setting would be a useful CPD activity (73.7%, n = 87). Just over half the participants (53.4%, n = 63) felt that coaching by a nonsurgeon such as a psychologist would benefit their nonoperative skills. Many participants (61.8%, n = 73) felt more inclined to participate if CPD points were awarded. Despite the support in favor of coaching, a significant percentage of participants (45.8%, n = 54) wanted further evidence of its efficacy. CONCLUSIONS: There is support amongst surgeons for peer coaching and its inclusion as a form of CPD, however, many require more evidence of its benefits, thus highlighting the need for ongoing research studies, consultation and pilot coaching programs.

Impact of Ageing on Hepatic Malignancy Resection: Is Age Really a Risk Factor for Mortality?

BACKGROUND: With an ageing population, it is paramount for surgeons to comprehend the implications of age on surgical outcomes. This study aims to identify the effects of age on perioperative outcomes post-hepatectomy. METHODS: Between 2001 and 2017, 357 hepatectomies were performed in our centre for malignancy. Data recorded include demographic, histopathology and perioperative outcomes. Patients were divided into three age groups (Group 1 < 65 years, Group 2 65-74 years, Group 3 ≥ 75 years). RESULTS: With increasing age, there was a trend towards patient having: ASA ≥ 3 (from 32.1% to 60.9%, p < 0.0001), clear margins (from 80.4% to 88.3%, p = 0.2256), days of hospitalisation (from 9.5 ± 6.9 to 12 ± 8.0, p = 0.0003), days of ICU admission (from 2.3 ± 2.8 to 2.8 ± 12.9, p = 0.0790) and morbidity (from 39% to 58.5%, p = 0.0073). Cardiovascular complications and postoperative delirium increase with age. There was no significant difference in mortality across the three groups. Univariate and bivariate binary logistic regressions found no association between mortality and age. When adjusted for age, 30- and 90-day mortality was significantly associated with Clavien-Dindo ≥ 3, length of hospital and cardiac complications. Additionally, 90-day mortality was significantly associated with ASA score ≥3, mass of liver resected, length of ICU stay and hepatobiliary, pulmonary and genitourinary complications. CONCLUSION: Increased age is associated with increased post-hepatectomy complications, prolonged hospital stay and ICU admission. However, age itself is not a contraindication for hepatectomy and is not associated with increased mortality. Good histopathology outcomes and low mortality rates are achievable with careful patient selection and appropriate perioperative management.

Progress towards near-zero 90-day mortality: 388 consecutive hepatectomies over a 16-year period.

BACKGROUND: Hepatectomy has been the gold standard procedure for curative treatment of benign and malignant hepatobiliary lesions for over a century. The aim of this study is to report on the 16-year experience of a single institution. METHODS: All patients admitted to The Queen Elizabeth Hospital, South Australia, for a hepatectomy between 2001 and 2016 were included in this audit. Data regarding demographics, tumour type and operative outcomes were prospectively collected. To identify trends, patients were divided into four periods, each spanning 4 years (Period 1 = 2001-2004, Period 2 = 2005-2008, Period 3 = 2009-2012 and Period 4 = 2012-2016). RESULTS: Between 2001 and 2016, 388 consecutive patients (230 men; 158 women; mean age ± SD = 63.7 ± 13.0 years) underwent hepatectomy. From Periods 2 to 4, complex cases increased from 14.4% to 18.9%, and there was an increase in mean duration of operation time from 187.0 ± 60.6 to 217.3 ± 78.7 min. Length of hospitalization decreased from Periods 1 to 4 (12.2 ± 9.2 to 8.1 ± 5.6 days). Intraoperative and 90-day mortalities were 0.5% and 2.3%, respectively. Length of stay, morbidity and 90-day mortality were significantly affected by mass of resection. CONCLUSION: Hepatectomy can be safely performed in a specialized Western centre with low mortality. Advances in health care have facilitated in shorter duration of hospitalization despite more frequent complex resections, operating on older patients and patients with worse American Society of Anesthesiologists scores, without increasing rates of mortality.

Surveillance colonoscopies frequently booked earlier than the National Health and Medical Research Council guidelines: findings of a single centre audit.

BACKGROUND: To assess the adherence rate of surveillance colonoscopy booking intervals to recommended National Health and Medical Research Council guidelines at The Queen Elizabeth Hospital, Adelaide, Australia. METHODS: Patients on The Queen Elizabeth Hospital colorectal unit surveillance colonoscopy waiting list were included in this audit. Patient demographics, colonoscopy findings, follow-up plans and pathology results were analysed. Patients were categorized as normal/non-neoplastic finding, low-risk adenomas, high-risk adenomas, personal history of colorectal cancer (CRC) and family history of CRC. Booked colonoscopy within 2 months of guideline recommended interval was considered correct. RESULTS: A total of 467 patients were included (59.1% male; mean age 60 years). Two hundred and fifty-one (53.7%) patients had an incorrect surveillance colonoscopy booking. Twenty-seven patients with a normal/non-neoplastic previous colonoscopy not requiring surveillance colonoscopy were incorrectly booked for a colonoscopy. For the 222 patients booked incorrectly and requiring surveillance colonoscopy, 88.7% were early and 11.3% were late. The proportions of incorrect bookings were highest in the low-risk finding (66.1%) and history of CRC (67.6%) groups. For the 186 patients requiring a 3-year surveillance interval, 38.7% were booked incorrectly. For the 197 patients requiring a 5-year surveillance interval, 63.5% were booked incorrectly, of which 99.2% were early. More 5-year surveillance interval patients were booked at 3 years (n = 79), than at the correct interval of 5 years (n = 72). CONCLUSION: Adherence to the National Health and Medical Research Council guidelines for surveillance colonoscopy is poor. The majority of deviations represent early follow-up, which is most common among patients with low-risk findings or history of CRC. There is a tendency towards 3-year surveillance among low-risk patients.

The safety and effectiveness of liver resection for breast cancer liver metastases: A systematic review.

Breast cancer liver metastases have traditionally been considered incurable and any treatment given therefore palliative. Liver resections for breast cancer metastases are being performed, despite there being no robust evidence for which patients benefit. This review aims to determine the safety and effectiveness of liver resection for breast cancer metastases. A systematic literature review was performed and resulted in 33 papers being assembled for analysis. All papers were case series and data extracted was heterogeneous so a meta-analysis was not possible. Safety outcomes were mortality and morbidity (in hospital and 30-day). Effectiveness outcomes were local recurrence, re-hepatectomy, survival (months), 1-, 2-, 3-, 5- year overall survival rate (%), disease free survival (months) and 1-, 2-, 3-, 5- year disease free survival rate (%). Overall median figures were calculated using unweighted median data given in each paper. Results demonstrated that mortality was low across all studies with a median of 0% and a maximum of 5.9%. The median morbidity rate was 15%. Overall survival was a median of 35.1 months and a median 1-, 2-, 3- and 5-year survival of 84.55%, 71.4%, 52.85% and 33% respectively. Median disease free survival was 21.5 months with a 3- and 5-year median disease free survival of 36% and 18%. Whilst the results demonstrate seemingly satisfactory levels of overall survival and disease free survival, the data are of poor quality with multiple confounding variables and small study populations. Recommendations are for extensive pilot and feasibility work with the ultimate aim of conducting a large pragmatic randomised control trial to accurately determine which patients benefit from liver resection for breast cancer liver metastases.

Treatment of unresectable hepatocellular carcinoma with radiolabelled lipiodol.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the most common solid organ tumours, with approximately 500,000 new cases being reported each year. It has a very high prevalence in Asia, and almost two-thirds of all cases occur in this region. The incidence of this tumour in Australia has nearly doubled in the past decade. Surgical resection is the mainstay of treatment, but only 10-30% of HCC are amenable to surgical resection at the time of diagnosis. The prognosis for patients with unresectable HCC remains dismal. Internal radiotherapy with radiolabelled lipiodol has been used with some success in treatment of HCC. Several studies have validated its usefulness in an adjuvant setting, but it also appears to have a role in treating unresectable tumours. METHODS: Twenty-two patients with proven HCC, not amenable to or having failed surgical treatment, were evaluated for radiolabelled lipiodol treatment. Of these, 10 patients were excluded after initial evaluation and 12 patients underwent treatment. Patients were followed up every 3 months with physical examination, computed tomography scan and alpha-fetoprotein levels. Overall survival, change in tumour size and alpha-fetoprotein levels were used to evaluate the efficacy of treatment. RESULTS: The median overall survival in patients undergoing lipiodol therapy was 15 months. Tumour size was stabilized in most patients and very few side-effects of the treatment were observed. CONCLUSION: This study has shown that radiolabelled lipiodol is an effective method for the treatment of unresectable locally advanced HCC.

Pablo Luis Mirizzi: the man behind the syndrome.

Pablo Luis Mirizzi (1893-1964), who was born and died in the city of Cordoba in Argentina, dedicated his life to the service of surgery and the teaching of his students. Although known for the introduction of the intraoperative cholangiogram and for describing the Mirizzi syndrome - a partial obstruction of the common hepatic duct secondary to an impacted gallstone in the cystic duct, very little else is known about this man behind the brilliant surgical pioneer of the twentieth century. This biography looks beyond his important contributions to medicine, to the many facets of the man himself.

The clinical risk score: emerging as a reliable preoperative prognostic index in hepatectomy for colorectal metastases.

HYPOTHESIS: The purpose of this study was to examine the validity of the clinical risk score (CRS), a prognostic tool developed by Fong et al, when translated to another center. DESIGN: This study assesses 5 independent preoperative prognostic criteria, nodal status of the primary lesion, disease-free interval, number of hepatic metastases, size of the largest metastasis, and preoperative carcinoembryonic antigen level, to determine a preoperative CRS for each patient included in the study. SETTING: The hepatobiliary unit of The Queen Elizabeth Hospital, Adelaide, South Australia. PATIENTS: Medical records of patients admitted to The Queen Elizabeth Hospital undergoing potentially curative hepatic resection for colorectal metastases during the period of July 1993 to April 2003 were included in the study. Main Outcome Measure The primary outcome measure of the study was survival. The calculated CRS was analyzed with respect to patient postoperative survival. RESULTS: During the 10-year period, 77 patients underwent hepatic resection. Overall survival rates for 1, 3, and 5 years were found to be 80.9%, 57.5%, and 42.3%, respectively. One- and 5-year survival rates for CRSs of 0 and 1 were found to be 93.8% and 72.5%, respectively; for scores of 2 and 3, 76.6% and 31.2%, respectively;and for scores of 4 and 5, 75% and 0%, respectively. No patient with a CRS greater than 3 survived more than 2 years. CONCLUSION: This study validates the CRS, finding it to be highly predictive of patient outcome and survival.

Ite Boerema--surgeon and engineer with a double-Dutch legacy to medical technology.

Ite Boerema, 1902-1978: a Dutchman with a brilliant academic surgical career, and war hero, decorated for resistance to the Germans in World War II. As a man who regarded surgery as "engineering in medicine," we still feel his legacy in medical technology today, specifically with regard to his work on esophageal anastomoses and hyperbaric oxygen therapy. This biography places his major contributions to medicine in context of the man himself and of contemporary medicine.