Preceptorship in robotic colorectal surgery: experience from the Australian private sector.

This article describes a post-fellowship preceptorship training program to train sub-specialty colorectal surgeons in gaining proficiency in robotic colorectal surgery using a dual-surgeon model in the Australian private sector. The Australian colorectal surgeon faces challenges in gaining robotic colorectal surgery proficiency with limited exposure and experience in the public setting where the majority of general and colorectal surgery training is currently conducted. This training model uses graded exposure with a range of simulation training, wet lab training, and clinical operative cases to progress through both competency and proficiency in robotic colorectal surgery which is mutually beneficial to surgeons and patients alike. Ongoing audit of practice has shown no adverse impacts.

Aorto-bronchial fistula masquerading as haematemesis: a rare late complication of thoracic aortic vascular grafts.

Aorto-bronchial fistula is an exceedingly rare pathology with high mortality. Late vascular graft infection may occur secondary to haematogenous seeding of bacteria from a distant source such as gastrointestinal infection. We present an unusual case of aorto-bronchial fistula masquerading as haematemesis in a patient with sigmoid diverticulitis, and review the pathophysiology, diagnosis, surgical and endovascular management of aorto-bronchial fistulas.

Colonic Perforation in Polyarteritis Nodosa With Concurrent Perforated Sigmoid Diverticulitis.

Polyarteritis nodosa (PAN) is a medium-sized vasculitis with neuropathy, cutaneous manifestation, and gastrointestinal tract symptoms. An acute surgical abdomen is a severe but rare development of gastrointestinal involvement of PAN, with large bowel involvement and subsequent perforation being sporadic. Here we present a rare case of PAN who had large bowel involvement with perforation due to newly diagnosed PAN, who also had concurrent and separately perforated sigmoid diverticulitis, confusing the clinical picture. High clinical suspicion and timely management are vital in diagnosing and managing patients with PAN and an acute surgical abdomen.

Survival and morbidity outcomes after pelvic exenteration for pelvic sarcoma: an institutional series.

BACKGROUND: To describe our institutional experience in the management of locally advanced primary, and recurrent pelvic sarcoma through pelvic exenteration (PE). METHODS: Patients undergoing PE for locally advanced primary or recurrent pelvic sarcoma between 2003 and 2017 were identified from a prospectively maintained database at a single quaternary referral hospital in Sydney, Australia were eligible for review. The primary outcomes measured were surgical resection margin and survival. Secondary outcome measures included 30-day morbidity, in hospital length of stay (LOS) and return to theatre. RESULTS: There were 29 patients who underwent PE for pelvic sarcoma during the study period, with 55% (n = 16) having advanced primary tumours and 45% (n = 13) having recurrent disease. The R0 resection rate was 52% (n = 15); and five-year-survival of 38% (n = 11). The R0 resection was noted to be higher in patients having primary advanced tumours (56%) compared to those with recurrent disease (46%), however this failed to reach statistical significance in this cohort. There was no recorded 30-day mortality. Grade 3 or higher Clavien-Dindo complications were uncommon (14%), but more likely in patients undergoing surgery for recurrent disease (75%). CONCLUSION: In our cohort of patients with locally advanced and recurrent disease, more than 50% achieved an R0 resection. Recurrent disease makes R0 resection more difficult and can lead to higher morbidity, need for 30-day re-intervention and longer in hospital LOS. PE surgery remains the only curative option for locally advanced, and recurrent sarcoma in the pelvis, and can be performed with acceptable survival and morbidity outcomes.

Proctorship in Minimally Invasive Colorectal Surgery.

Teaching an established surgeon in a novel technique by a colleague who has acquired a level of expertise is often referred to as "proctoring" or "precepting." Surgical preceptorships can be defined as supervised teaching programs, whereby individual or groups of surgeons (proctors) experienced in a certain technique support a colleague who wants to adopt this technique (sometimes referred to as "delegates" or "preceptees"). Preceptorship programs really focus on a specific technique, technology, or skill which is required to broaden, complement, or transform an established surgeon's practice. Within colorectal surgery, in the past 30 years, there is been an evolution of interventional options including open, laparoscopic, robotic, and endoscopic procedures. With each new emerging technology and technique, safe and effective uptake by established surgeons is best been attained by a period of proctorship by an experienced colleague. Formalizing this has been facilitated largely through industry support. There, however, remains a considerable chasm when it comes to standardization, quality control, and jurisprudence. This article aims to describe the requirements for a contemporary proctorship program, to examine instruments of quality control, and how to improve effectiveness.

Surgical Competencies Required in Newly Commencing Colorectal Surgeons: an Educational and Training Spectrum.

PURPOSE: Surgical training models have changed from master-apprentice to competency-based training. We aimed to determine the relative importance and peak periods of acquiring these competencies in newly commencing colorectal surgeons. METHODS: A mailed questionnaire to all current Colorectal Surgical Society of Australia and New Zealand (CSSANZ) members was conducted between October and December 2016 assessing the relative importance of each competency and the period or activity of learning or training contributing most to achieving that competency. RESULTS: The response rate was 43% (90/208) with 87% (n = 75) agreed or strongly agreed to the relevance and applicability of the nine RACS competencies. Competencies varied in perceived importance (strongly agreed: judgment-clinical decision-making (JU) 63%, collaboration/teamwork (CT) 53%, technical expertise (TE) 47%, communication (CO) 44%, medical expertise (ME) 34%, scholarship/teaching (ST) 33%, professionalism (PR) 33%/ethics (ET) 24%, health advocacy (HA) 18%, management (MX) 13%/leadership (LE) 17%), and the peak period for acquiring them (registrar: CO 39%, ST 30%; fellow: TE 62%, CT 44%, ME 40%, JU 38%; consultant: MX/LE 52%, HA 48%, PR/ET 33%). CONCLUSION: Surgical competencies for colorectal surgeons are accumulated and acquired at varying degrees and periods across a spectrum of continuing registrar, fellow, and consultant education and training. These findings serve as a baseline for further refinement of current and continuing educational and training programs.

Current practices and barriers to referral for cytoreductive surgery and HIPEC among colorectal surgeons: A binational survey.

INTRODUCTION: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has gained traction for the management of peritoneal metastases. The number of specialist units globally offering CRS/HIPEC is increasing. The aim of this survey was to assess current practices and barriers to referral for CRS/HIPEC among colorectal surgeons in Australia and New Zealand (ANZ). MATERIALS AND METHODS: An online questionnaire was emailed to members of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ). The survey contained 3 sections: namely; demographics, referral patterns and clinical scenarios. Questions on referral patterns included number of peritoneal metastases patients seen per year and referred to a CRS/HIPEC unit, awareness of such a unit and distance from principle place of practice. Different pathologies referred were also explored, as well as investigations performed. Barriers to referral were also surveyed. RESULTS: The response rate was 28% (83/296). Twenty-five percent received CRS training. Most surgeons (95%) were aware of a CRS/HIPEC unit and had referred to one previously. Thirty-nine percent would refer all patients. Provision of good service and/or relationship with CRS/HIPEC specialist were the main reasons for referring to the nearest unit, followed by accessibility. Major factors preventing referral included extent of peritoneal disease (48%), patient characteristics and comorbidities (44%) and lack of evidence (20%). The most common pathologies referred included colorectal and appendiceal peritoneal metastases and pseudomyxoma peritonei. CONCLUSION: Colorectal specialist awareness of CRS/HIPEC units and accessibility is high. Strategies to improve referring physician/surgeon knowledge on patient selection and indications for CRS/HIPEC should be investigated and instituted to ensure all appropriate patients are referred to specialist units for discussion of suitability.

Treatment of hemorrhoids: A survey of surgical practice in Australia and New Zealand.

BACKGROUND: Hemorrhoidal disease is the most common anorectal disorder. Hemorrhoids can be classified as external or internal, according to their relation to the dentate line. External hemorrhoids originate below the dentate line and are managed conservatively unless the patient cannot keep the perianal region clean, or they cause significant discomfort. Internal hemorrhoids originate above the dentate line and can be managed according to the graded degree of prolapse, as described by Goligher. Generally, low-grade internal hemorrhoids are effectively treated conservatively, by non-operative measures, while high-grade internal hemorrhoids warrant procedural intervention. AIM: To determine the application of clinical practice guidelines for the current management of hemorrhoids and colorectal surgeon consensus in Australia and New Zealand. METHODS: An online survey was distributed to 206 colorectal surgeons in Australia and New Zealand using 17 guideline-based hypothetical clinical scenarios. RESULTS: There were 82 respondents (40%) to 17 guideline-based scenarios. Nine (53%) reached consensus, of which only 1 (6%) disagreed with the guidelines. This was based on low quality evidence for the management of acutely thrombosed external hemorrhoids. There were 8 scenarios which showed community equipoise (47%) and they were equally divided for agreeing or disagreeing with the guidelines. These topics were based on low and moderate levels of evidence. They included the initial management of grade I internal hemorrhoids, grade III internal hemorrhoids when initial management had failed and the patient had recognised risks factors for septic complications; and finally, the decision-making when considering patient preferences, including a prompt return to work, or minimal post-operative pain. CONCLUSION: Although there are areas of consensus in the management of hemorrhoids, there are many areas of community equipoise which would benefit from further research.

Congenital peritoneal encapsulation: A review and novel classification system.

Congenital peritoneal encapsulation (CPE) is a very rare, congenital condition characterised by the presence of an accessory peritoneal membrane which encases a variable extent of the small bowel. It is unclear how CPE develops, however it is currently understood to be a result of an aberrant adhesion in the peritoneal lining of the physiological hernia in foetal mid-gut development. The condition was first described in 1868, and subsequently there have been only 45 case reports of the phenomenon. No formal, systematised review of CPE has yet been performed, meaning the condition remains poorly understood, underdiagnosed and mismanaged. Diagnosis of CPE remains clinical with important adjuncts provided by imaging and diagnostic laparoscopy. Two thirds of patients present with abdominal pain, likely secondary to sub-acute bowel obstruction. A fixed, asymmetrical distension of the abdomen and differential consistency on abdominal palpation are more specific clinical features present in approximately 10% of cases. CPE is virtually undetectable on plain imaging, and is only detected on 40% of patients with computed tomography scan. Most patients will undergo diagnostic laparotomy to confirm the diagnosis. Management of CPE includes both medical management of the critically-unstable patient and surgical laparotomy, partial peritonectomy and adhesiolysis. Prognosis following prompt surgical treatment is excellent, with a majority of patients being symptom free at follow up. This review summarises the current literature on the aetiology, diagnosis and treatment of this rare disease. We also introduce a novel classification system for encapsulating bowel diseases, which may distinguish CPE from the commoner, more morbid conditions of abdominal cocoon and encapsulating peritoneal sclerosis.

Karydakis procedure can be effectively performed in the lateral position.

BACKGROUND: Karydakis published a large pilonidal series in 1992, reporting a recurrence rate of less than 1% and complication rate of 8.5%. The aim of this study was to compare the outcomes of Karydakis procedure (KP) performed in the lateral versus the prone position in a consecutive series. METHODS: Ninety-seven consecutive patients undergoing a KP between March 2000 and February 2018 were retrospectively assessed. Patients with disease sinuses or fistulas extending from the midline to either left or right sides only were considered for KP in the contralateral side position. RESULTS: Surgery was carried out for primary pilonidal disease in 71 patients (73%) and for recurrent disease in 26 patients (27%). The majority (62%) of pilonidal tracts veered off from the midline to either the left or right side only. Wound complications, mostly minor skin separation, occurred in 37 patients (38%). Disease recurrence occurred in eight patients (8%). There was no difference between patients who had KP in a lateral position compared with those operated in a prone position regarding wound complications (41% versus 35%, P = 0.675), disease recurrence (9% versus 7%, P = 1.000), mean operating time (64.6 min versus 66.6 min, P = 0.259) and mean length of hospital stay (1 day for both groups). CONCLUSIONS: Pilonidal surgery in the lateral position has potential benefits for patient safety, patient comfort and theatre efficiency. The clinical results of this series show that the KP can be performed safely and effectively with the patient in the lateral position for most cases of pilonidal disease.

Peritoneal encapsulation as a cause of chronic recurrent abdominal pain in a young male.

This case report describes an otherwise well 20-year-old male who presented to hospital with vague, long-standing abdominal symptoms and was found to have peritoneal encapsulation.

Coaching Experts: Applications to Surgeons and Continuing Professional Development.

Surgery is a science and an art, which is mastered through years of training and refined by the accumulation of individual experience and preference. Continuing professional development (CPD) is a concept that emphasizes a self-directed approach to education. Coaching is a process that leads to increased utilization of a person's current skills and resources without counselling or advising. Coaching in surgery could be used to facilitate and optimize feedback and reflection, thus enhancing performance and outcomes through elite performance of an operative procedure. Therefore, it can be applied under the umbrella of CPD. Ultimately also emphasizing that better quality surgery is not necessarily purely based on technical outcomes, it is a combination of both technical and nontechnical practice. Coaching of surgeons is a conceptually formidable tool in the successful implementation of effective CPD programs. CPD currently provides an opportunity for surgeons to gain access to constantly evolving medical knowledge and technique; however, there is no accountability to its understanding or implementation. Coaches have the potential to provide confidential appraisal and feedback in a constructive approach with the aim to eliminate any barriers to the transfer of technique and knowledge.

Colorectal surgeon consensus with diverticulitis clinical practice guidelines.

AIM: To determine the application of clinical practice guidelines for the current management of diverticulitis and colorectal surgeon specialist consensus in Australia and New Zealand. METHODS: A survey was distributed to 205 colorectal surgeons in Australia and New Zealand, using 22 hypothetical clinical scenarios. RESULTS: The response rate was 102 (50%). For 19 guideline-based scenarios, only 11 (58%) reached consensus (defined as > 70% majority opinion) and agreed with guidelines; while 3 (16%) reached consensus and did not agree with guidelines. The remaining 5 (26%) scenarios showed community equipoise (defined as less than/equal to 70% majority opinion). These included diagnostic imaging where CT scan was contraindicated, management options in the failure of conservative therapy for complicated diverticulitis, surgical management of Hinchey grade 3, proximal extent of resection in sigmoid diverticulitis and use of oral mechanical bowel preparation and antibiotics for an elective colectomy. The consensus areas not agreeing with guidelines were management of simple diverticulitis, management following the failure of conservative therapy in uncomplicated diverticulitis and follow-up after an episode of complicated diverticulitis. Fifty-percent of rural/regional based surgeons would perform an urgent sigmoid colectomy in failed conservative therapy of diverticulitis compared to only 8% of surgeons city-based (Fisher's exact test P = 0.016). In right-sided complicated diverticulitis, a greater number of those in practice for more than ten years would perform an ileocecal resection and ileocolic anastomosis (79% vs 41%, P < 0.0001). CONCLUSION: While there are areas of consensus in diverticulitis management, there are areas of community equipoise for future research, potentially in the form of RCTs.

Incidental detection of colorectal lesions by FDG PET/CT scans in melanoma patients.

BACKGROUND: Increased use of PET/CT scans in oncology patients has raised detection of Colorectal incidentalomas (CIs). The frequency and diagnostic outcomes of identifying these lesions in melanoma patients have not previously been studied. This studies primary objective was to determine the prevalence of CIs found on PET/CT scans in melanoma patients. The secondary objectives were to correlate the PET/CT findings with the pathology found at colonoscopy, and identify which patients were referred for colonoscopy. METHODS: A retrospective analysis of patients identified from the prospectively collected research database of Melanoma Institute Australia. 2509 patients with melanoma underwent PET/CT scans between 2001 and 2013. The prevalence of CIs, the correlation of lesions, and the survival of patients who underwent colonoscopy versus patients who did not were analyzed. RESULTS: The prevalence of CIs in melanoma patients who had PET/CT scans was 3.2%. Forty-five of the 81 (56%) patients with CIs underwent colonoscopy. Of these, premalignant or malignant disease was found in 58%. Patients with previous metastatic melanoma were significantly less likely to be referred for colonoscopy. Patients undergoing colonoscopy had significantly better survival, as did those without previous distant metastases before the CIs were found, and those without any metastases at the time the CIs were found. These factors were not significant on multivariate analysis. CONCLUSION: The prevalence of incidental colorectal lesions identified on PET/CT scans in melanoma patients was found to be equivalent to that in the general cancer population. Patients undergoing colonoscopy had better survival than those who did not.

Hypothesized summative anal physiology score correlates but poorly predicts incontinence severity.

AIM: To explore the relationship between such a construct and an existing continence score. METHODS: A retrospective study of incontinent patients who underwent anal physiology (AP) was performed. AP results and Cleveland Clinic Continence Scores (CCCS) were extracted. An anal physiology score (APS) was developed using maximum resting pressures (MRP), anal canal length (ACL), internal and external sphincter defects and pudendal terminal motor latency. Univariate associations between each variable, APS and CCCS were assessed. Multiple regression analyses were performed. RESULTS: Of 508 (419 women) patients, 311 had both APS and CCCS measured. Average MRP was 51 mmHg (SD 23.2 mmHg) for men and 39 mmHg (19.2 mmHg) for women. Functional ACL was 1.7 cm for men and 0.7 cm for women. Univariate analyses demonstrated significant associations between CCCS and MRP (P = 0.0002), ACL (P = 0.0006) and pudendal neuropathy (P < 0.0001). The association between APS and CCCS was significant (P < 0.0001) but accounted for only 9.2% of the variability in CCCS. Multiple regression showed that the variables most useful in predicting CCCS were external sphincter defect, pudendal neuropathy and previous pelvic surgery, but only improving the scores predictive ability to 12.5%. CONCLUSION: This study shows that the ability of AP tests to predict continence scores improves when considered collectively, but that a constructed summation model before and after multiple regression is poor at predicting the variability in continence scores.

Surgical Supervisor Feedback Affects Performance: A Blinded Randomized Study.

While performing a simple task of following: a suture while closing a surgical wound in a simulated environment, we hypothesized that negative reinforcement results in increased procedural errors, longer operating time and poorer trainee satisfaction. We aimed to measure the effect on participant performance and the perception of the instructor, following positive or negative supervisor feedback during the task. A blinded randomized study was conducted assessing positive and negative supervisor feedback styles on participant performance in a simulated operation room. Students performed the task twice, with a reflection in between the repeated task. We found that the change in procedure time between the two tasks was adversely affected by feedback style. Participants receiving negative feedback sought cues to improve. From this study, it was found that negative supervisor feedback has the potential to adversely affect elements of performance. Despite this, participants receiving negative feedback express a willingness to improve their performance by seeking cues from the supervisor.

Making decisions using radiology in lower GI hemorrhage.

Acute lower gastrointestinal bleeding (LGIB) is a common diagnosis in current practice that may warrant hospitalization and invasive management. There is a shift in the paradigm in the management of this condition away from traditional extensive operative intervention to minimally invasive radiological techniques. These newer modalities offer an opportunity to provide more accurate information on location of bleeding and subsequent management. The increased ease of access to interventional radiology units in major teaching hospitals represents an opportunity to adopt its use in the management of gastrointestinal bleeding. Further, with technological improvements, it is becoming an increasingly favoured option. Traditional endoscopic techniques have been fraught with poor vision in the acute setting, requiring the colon to be purged to aide in better visualization. The use of these newer technologies have been the subject of many reviews which highlight their efficacy in providing a road map to the bleeding site and eventual intervention. We aim to review the literature regarding the use of radiology in the management of LGIB, to provide surgeons with a discourse with regards to the approach in synthesizing the data and applying it when deciding its use.

How to decide on stent insertion or surgery in colorectal obstruction?

Colorectal cancer is one of the most common cancers in western society and malignant obstruction of the colon accounts for 8%-29% of all large bowel obstructions. Conventional treatment of these patients with malignant obstruction requiring urgent surgery is associated with a greater physiological insult on already nutritionally replete patients. Of late the utility of colonic stents has offered an option in the management of these patients in both the palliative and bridge to surgery setting. This has been the subject of many reviews which highlight its efficacy, particulary in reducing ostomy rates, allowing quicker return to oral diet, minimising extended post-operative recovery as well as some quality of life benefits. The uncertainity in managing patients with malignant colonic obstructions has lead to a more cautious use of stenting technology as community equipoise exists. Decision making analysis has demonstrated that surgeons' favored the use of stents in the palliative setting preferentially when compared to the curative setting where surgery was preferred. We aim to review the literature regarding the use of stent or surgery in colorectal obstruction, and then provide a discourse with regards to the approach in synthesising the data and applying it when deciding the appropriate application of stent or surgery in colorectal obstruction.