Characteristics of laparoscopic and open hernia repair simulation models: a systematic review.

PURPOSE: Barriers to education in open and laparoscopic hernia repair technique include a steep learning curve and reduced theatre time for junior surgical trainees. This is particularly evident during the current COVID-19 pandemic. Simulation models may provide further opportunities for training in hernia repair outside of the traditional surgical apprenticeship model. METHODS: A systematic review was carried out following PRISMA guidelines to identify and evaluate simulation models in hernia repair. Of the 866 records screened, 27 were included in the analysis. These were assessed for face, content and construct validity, as well as their attempt to measure educational impact. RESULTS: Simulation models were identified comprising of animal tissues, synthetic materials and virtual reality (VR) technology. Models were designed for instruction in repair of inguinal, umbilical, incisional and diaphragmatic hernias. Twenty-one laparoscopic hernia repair models were described. Many models demonstrated validity across several domains, and three showed transferability of skills from simulation to the operating room. Of the six open hernia repair simulation models, none were found to have demonstrated an educational impact in addition to assessing validity. CONCLUSION: Few models individually were able to demonstrate validity and educational impact. Several novel assessment tools have been developed for assessment of progress when performing simulated and real laparoscopic inguinal hernia repair. More study is required, particularly for open hernia repair, including randomized controlled trials with large sample sizes to assess the transferability of skills.

A systematic review of low-cost simulators in ENT surgery.

BACKGROUND: Simulation training has become a key part of the surgical curriculum over recent years. Current trainees face significantly reduced operating time as a result of the coronavirus disease 2019 pandemic, alongside increased costs to surgical training, thus creating a need for low-cost simulation models. METHODS: A systematic review of the literature was performed using multiple databases. Each model included was assessed for the ease and expense of its construction, as well as its validity and educational value. RESULTS: A total of 18 low-cost simulation models were identified, relating to otology, head and neck surgery, laryngeal surgery, rhinology, and tonsil surgery. In only four of these models (22.2 per cent) was an attempt made to demonstrate the educational impact of the model. Validation was rarely formally assessed. CONCLUSION: More efforts are required to standardise validation methods and demonstrate the educational value of the available low-cost simulation models in otorhinolaryngology.

Hypofractionated Radiotherapy in Oesophageal Cancer for Patients Unfit for Systemic Therapy: A Retrospective Single-Centre Analysis.

AIMS: Chemoradiotherapy (CRT) is established as a superior treatment option to definitive radiotherapy in the non-surgical management of oesophageal cancer. For patients precluded from CRT through choice or comorbidity there is little evidence to guide delivery of single-modality radiotherapy. In this study we outline outcomes for patients unfit for CRT who received a hypofractionated radiotherapy (HRT) regimen. MATERIALS AND METHODS: A retrospective UK single-centre analysis of 61 consecutive patients with lower- or middle-third adenocarcinoma (OAC; 61%) or squamous cell carcinoma of the oesophagus managed using HRT with radical intent between April 2009 and 2014. Treatment consisted of 50 Gy in 16 fractions (n = 49, 80.3%) or 50-52.5 Gy in 20 fractions (n = 12, 19.7%). Outcomes were referenced against a contemporaneous comparator cohort of 80 (54% OAC) consecutive patients managed with conventionally fractionated CRT within the same centre. RESULTS: Three-year and median overall survival were, respectively, 56.9% and 29 months with HRT compared with 55.5% and 26 months for CRT; adjusted hazard ratio 0.79 (95% confidence interval 0.48-1.28). Grade 3 and 4 toxicity rates were low at 16.4% (n = 10) for those receiving HRT and 40.2% (n = 32) for the CRT group. In patients with OAC, CRT delivered superior overall survival (hazard ratio 0.46; 95% confidence interval 0.25-0.85) and progression-free survival (hazard ratio 0.45; 95% confidence interval 0.23-0.88) when compared with HRT. CONCLUSIONS: The HRT regimen described here was safe and tolerable in patients unable to receive CRT, and delivered promising survival outcomes. The use of HRT for the treatment of oesophageal cancer, both alone and as a sequential or concurrent treatment with chemotherapy, requires further study. New precision radiotherapy technologies may provide additional scope for improving outcomes in oesophageal cancer using HRT-based approaches and should be evaluated.

Tuberculosis skin testing, anergy and protein malnutrition in Peru.

SETTING: Malnutrition and intestinal parasites cause immunosuppression. This may cause false-negative tuberculin skin tests (TST) and failure to identify tuberculosis (TB) infection. OBJECTIVE: To assess factors associated with TST positivity and anergy in disadvantaged communities in Peru. DESIGN: A study of 212 randomly selected adults: 102 in a rural Amazonian village and 110 shanty town residents in urban Lima. RESULTS: Respectively 52% and 53% of urban and rural jungle populations were TST-positive. Using simultaneous tetanus and candida skin tests, 99% had at least one positive skin test. Generalised anergy was therefore rare, despite frequent intestinal parasitic infection, including 34% helminth infection prevalence in the jungle. TST positivity was associated with age (P = 0.001), known TB contact (P = 0.02) and poor household ventilation (P = 0.007). TST positivity was not significantly associated with crowding, reported past TB, single/multiple BCG vaccination, income, intestinal parasites, dietary factors, body mass index or body fat. Individuals with lower anthropometric body protein, as measured by corrected arm muscle area, were less likely to be TST-positive (P = 0.02), implying that protein malnutrition caused tuberculin-specific anergy. CONCLUSION: These results identify the importance of household ventilation for community TB transmission and add to the evidence that protein malnutrition suppresses TB immunity, causing false-negative TST results.