Coaching to enhance qualified surgeons' non-technical skills: a systematic review.

INTRODUCTION: The lack of an effective continuing professional development programme for qualified surgeons, specifically one that enhances non-technical skills (NTS), is an issue receiving increased attention. Peer-based coaching, used in multiple professions, is a proposed method to deliver this. The aim of this study was to undertake a systematic review of the literature to summarize the quantity and quality of studies involving surgical coaching of NTS in qualified surgeons. METHODS: A systematic search of the literature was performed through MEDLINE, EMBASE, Cochrane Collaboration and PsychINFO. Studies were selected based on predefined inclusion and exclusion criteria. Data for the included studies was independently extracted by two reviewers and the quality of the studies evaluated using the Medical Education and Research Study Quality Instrument (MERSQI). RESULTS: Some 4319 articles were screened from which 19 met the inclusion criteria. Ten studies involved coaching of individual surgeons and nine looked at group coaching of surgeons as part of a team. Group coaching studies used non-surgeons as coaches, included objective assessment of NTS, and were of a higher quality (average MERSQI 13.58). Individual coaching studies focused on learner perception, used experienced surgeons as coaches and were of a lower quality (average MERSQI 11.58). Individual coaching did not show an objective improvement in NTS for qualified surgeons in any study. CONCLUSION: Surgical coaching of qualified surgeons' NTS in a group setting was found to be effective. Coaching of individual surgeons revealed an overall positive learner perception but did not show an objective improvement in NTS for qualified surgeons.

Systematic review of congenital and acquired portal-systemic shunts in otherwise normal livers.

BACKGROUND: Portal-systemic shunts (PSSs) are rarely seen in healthy individuals or patients with non-cirrhotic liver disease. They may play an important role in hepatic metabolism as well as in the spread of gastrointestinal metastatic tumours to specific organs. Small spontaneous PSSs may be more common than generally thought. However, epidemiological data are scarce and inconclusive. This systematic review examined the prevalence of reported PSSs and the associated detection methods. METHODS: Literature up to 2011 was reviewed for adult patients with proven congenital or acquired PSSs. Only PSSs in normal livers were analysed for the methods of diagnosis. Eligible studies were identified by searching relevant databases, including PubMed, Embase, MEDLINE and the Cochrane Library. The selection of eligible articles was carried out using predefined inclusion criteria (adult, non-surgical PSS) and a set of search terms that were established before the articles were identified. RESULTS: Eighty studies were included describing 112 patients with congenital or acquired PSSs. The majority were diagnosed incidentally using Doppler ultrasound imaging and CT. CONCLUSION: Congenital and acquired PSSs are rare. They are usually clinically asymptomatic and discovered incidentally by radiological techniques. They may be clinically relevant owing to drug, tumour cell, metabolic and pathogen shunting.

Isolated non-hepatic metastasis from upper gastrointestinal adenocarcinoma: A case for surgical resection.

INTRODUCTION: Upper Gastrointestinal Tract (UGIT) malignancy is an increasing problem in western society and its prognosis is generally poor. The prognosis dims even further with the presence of loco regional recurrences or distant metastasis. This article looks at the feasibility and potential benefit from resection of non-hepatic, non-nodal metastases and recurrences. PRESENTATION OF CASE: Case 1. A 72-year-old male who underwent total gastrectomy for a gastric adenocarcinoma presented with a splenic mass 40 months later and underwent a splenectomy. He is disease free at 30 months post-metastectomy. Case 2. A 54-year-old male with oesophagogastric junctional adenocarcinoma, underwent an Ivor-Lewis oesophagectomy. He developed a distal pancreatic mass at 24 months follow-up and underwent distal pancreatectomy and splenectomy. He is disease free at 12 months post-metastectomy. Case 3. A 75-year-old male underwent subtotal gastrectomy for lesser curvature adenocarcinoma. At 42 months follow-up, he developed solitary abdominal wall recurrence. This was locally resected with clear margins. After 12 months, he developed another full thickness abdominal wall recurrence with involvement of the hepatic flexure. Enbloc resection including right hemicolectomy was performed and he is disease free at 3 months. DISCUSSION: There is very scarce literature on resection of non-hepatic, non-nodal recurrences/distant metastasis in oesophagogastric cancers. Based on these cases, a surgical resection in selected cases may provide prolonged survival with good quality of life. CONCLUSION: Resection for isolated recurrences and metachronous metastasis from UGIT cancers may be worthwhile, especially if patients have minimal co-morbidities.

Pancreaticoduodenectomy: outcomes in a low-volume, specialised Hepato Pancreato Biliary unit.

BACKGROUND: This study was designed to evaluate the outcomes of pancreaticoduodenectomy (PD) at a low-volume specialised Hepato Pancreato Biliary (HPB) unit. Volume outcome analyses show significantly better results for patients undergoing PD at high-volume centres (Begg et al. JAMA 280:1747-1751, 1998; Finlayson et al. Arch Surg 138:721-725, 2003; Birkmeyer et al. N Engl J Med 346:1128-1137, 2002; Gouma et al. Ann Surg 232:786-795, 2000). Centralisation of PD seems to be the logical conclusion to be drawn from these results. In countries like Australia with a small and widely dispersed population, centralisation may not be always feasible. Alternative strategy would be to have similar systems in place to those in high-volume centres to achieve similar results at low-volume centres. Many Australian tertiary care centres perform low to medium volumes of PD (Chen et al. HPB 12:101-108, 2010; Kwok et al. ANZ J Surg 80:605-608, 2010; Barnett and Collier ANZ J Surg 76:563-568, 2006; Samra et al. Hepatobiliary Pancreat Dis Int 10:415-421, 2011). Most of these have a specialised HPB unit, accredited by the Australia and New Zealand Hepatic pancreatic and biliary association (ANZHPBA), as training units for post fellowship training in HPB surgery. It is imperative to perform outcome-based analyses in these units to ensure safety and high quality of care. METHODS: Retrospective analysis of database for periampullary carcinoma (1998 till date) was performed in an ANZHPBA accredited HPB unit based at a tertiary care teaching hospital in South Australia. Because age older than 74 years is shown to be a predictive marker of increased morbidity and mortality after a PD, we analysed the outcomes in this subset of patients separately. RESULTS: Fifty-three patients underwent PD in 14 years. Overall mortality was 3.8 %. The last in hospital mortality was in 1999. The morbidity rates and the oncologic outcomes were similar to those in high-volume units. CONCLUSIONS: PD can be safely performed in a low-volume specialised unit at centres where the amenities and processes at high-volume centres can be replicated.

Technical note: facilitating laparoscopic liver biopsy by the use of a single-handed disposable core biopsy needle.

Despite the use of advanced radiological investigations, some liver lesions cannot be definitely diagnosed without a biopsy and histological examination. Laparoscopic Tru-Cut biopsy of the liver lesion is the preferred approach to achieve a good sample for histology. The mechanism of a Tru-Cut biopsy needle needs the use of both hands to load and fire the needle. This restricts the ability of the surgeon to direct the needle into the lesion utilising the laparoscopic ultrasound probe. We report a technique of laparoscopic liver biopsy using a disposable core biopsy instrument (BARD (R) disposable core biopsy needle) that can be used single-handedly. The needle can be positioned with laparoscopic graspers in order to reach posterior and superior lesions. This technique can easily be used in conjunction with laparoscopic ultrasound.