Effects of intraoperative pyloric stretch procedure on outcomes after esophagectomy.

Various methods have been described to aid pyloric drainage in patients undergoing esophagectomy with gastric reconstruction. These techniques are intended to prevent delayed gastric empting following esophagectomy that can be associated with early morbidity and long-term functional complaints. The current study aims to review the safety and efficacy of a pyloric stretch procedure performed at the time of esophagectomy. To achieve this, a retrospective review of 100 consecutive patients undergoing esophagectomy during the period 2011-2016 was performed. Until May 2013, no patients received intraoperative pyloric intervention. After May 2013, all patients (N = 50) underwent intraoperative pyloric stretch procedure that involved bidirectional mechanical dilatation of the pylorus. Postoperative outcomes including result of routine oral contrast swallow and early morbidity were evaluated. Intraoperative pyloric stretching was performed safely and without local complications in all patients. Delayed gastric emptying was observed significantly less frequently in patients who received intraoperative pyloric stretching (48% vs. 22%, P = 0.006). No significant differences were observed in postoperative outcomes. When considering all patients as a single cohort, the presence of delayed gastric emptying was associated with significantly higher rates of postoperative pneumonia (71% vs. 45%, P = 0.010), cardiac complications (57% vs. 25%, P = 0.001) as well as longer hospital say (12 vs. 15 days, P < 0.001) and delay to free oral fluid intake (7 vs. 9 days, < 0.001). Binary logistic regression identified age and postoperative delayed gastric emptying as independent risk factors for postoperative pneumonia. In conclusion, this study has demonstrated the safety and efficacy an intraoperative pyloric stretch procedure for the prevention of delayed gastric emptying following esophagectomy.

Utilisation, Reliability and Validity of Clinical Evaluation Exercise in Otolaryngology Training.

OBJECTIVES: To investigate the utilisation, reliability and validity of clinical evaluation exercise (CEX) in otolaryngology training. DESIGN: Retrospective database analysis. SETTING: Online assessment database. PARTICIPANTS: We analysed all CEXs submitted by north London core (CT) and speciality trainees (ST) in otolaryngology from 2010 to 2013. MAIN OUTCOME MEASURES: Internal consistency of the 7 CEX items rated as either O: outstanding, S: satisfactory or D: development required. Overall performance rating (pS) of 1-4 assessed against completion of training level. Receiver operating characteristic was used to describe CEX sensitivity and specificity. Overall score (cS), pS and the number of 'D'-rated items were used to investigate construct validity. RESULTS: One thousand one hundred and sixty CEXs from 45 trainees were included. CEX showed good internal consistency (Cronbach's alpha= 0.85). CEX was highly sensitive (99%), yet not specific (6%). cS and pS for ST was higher than CT (99.1% ± 0.4 versus 96.6% ± 0.8 and 3.06 ± 0.05 versus 1.92 ± 0.04, respectively P < 0.001). pS showed a significant stepwise increase from CT1 to ST6 (P < 0.001). In contrast, cS only showed improvement up to ST4 (P = 0.025). The most frequently utilised item 'management and follow-up planning' was found to be the best predictor of cS and pS (rs  = +0.69 and +0.21, respectively). CONCLUSION: CEX is reliable in assessing early years otolaryngology trainees in clinical examination, but not at higher level. It has the potential to be used in a summative capacity in selecting trainees for ST positions. This would also encourage trainees to master all domains of otolaryngology clinical examination by end of CT.

Utilisation and outcomes of case-based discussion in otolaryngology training.

OBJECTIVES: To assess the reliability, validity and outcomes of Case-based Discussion (CBD) in otolaryngology training. DESIGN: Retrospective database analysis. SETTING: National electronic database. PARTICIPANTS: North London otolaryngology trainees. MAIN OUTCOME MEASURES: We tested the tool's reliability along with its capacity to denote trainee progress. A score was calculated (cS) and compared across core (CT) and specialty trainees (ST) at all levels. The number of items rated as "development required" (D) was also examined. RESULTS: One thousand four hundred and fifty-six CBDs were submitted by 46 trainees from 2007 to 2013, averaging 13.6 per trainee per year. Items relating to knowledge, management and judgement were more popular (98% usage), and better predictors of cS compared to other parameters (rs: +0.74, +0.70 and +0.72, respectively). CBD was found to be reliable (Cronbach's α = 0.848) and highly sensitive (99%), yet not specific. cS was significantly higher in ST than CT (95.3% ± 0.6 versus 88.7% ± 1.3). pS showed a similar pattern (3.15 ± 0.4 versus 2.0 ± 0.05) (P < 0.001). cS and pS increased from CT1 to ST8 (rs: +0.60 and +0.34, respectively). The number of D-rated items decreased with increasing year of training. CONCLUSION: Case-based discussion is a reliable and valid tool in otolaryngology training. It is highly sensitive but not specific. Trainees should be encouraged to use it at all levels.

Does direct observation of procedural skills reflect trainee's progress in otolaryngology?

BACKGROUND: UK surgical trainees are required to undertake work-based assessments each year in order to progress in their training. Direct Observation of Procedural Skills (DOPS) is one of these assessments. We aim to investigate the validity of DOPS in assessing otolaryngology trainees at all levels. METHODS: A retrospective search of the portfolios of all otolaryngology trainees in North Thames was carried out to identify otolaryngology-specific DOPS. A score (Cs) was calculated for each DOPS based on the percentage of satisfactorily-rated items. The overall performance rating (Ps) was analysed as a separate variable and compared with Cs. The Ps and Cs results were then compared across trainee grades and levels within each grade: Core trainees (CT1-CT2) and specialty trainees (ST3-ST8). RESULTS: Seven hundred and sixty-seven otolaryngology DOPS were completed between August 2008 and September 2013. The tool was found to be reliable and internally consistent. Trainees in ST grade had higher Cs and Ps scores than CT grade (P < 0.001). Pairwise comparison showed that both Cs and Ps increased from CT1 to ST3 (P = 0.005) but not from ST4 onwards (P = 0.198). CONCLUSIONS: Otolaryngology DOPS is a useful tool in assessing otolaryngology trainees especially from CT1-ST3 level. DOPS can also differentiate between junior and senior trainees. However, it was not able to demonstrate progress at levels above ST3, most likely due to the simplicity of the procedures which trainees tend to master in the first few years of training.