RESUMO
BACKGROUND: The Covid-19 pandemic had a profound impact on surgical training. In this longitudinal cohort study, we quantify the effects of the pandemic on United Kingdom (UK) surgeons in higher specialty training by analyzing the Annual Review of Competency Progression (ARCP) Outcomes issued to them prior to, and during, the pandemic. METHODS: Anonymized records were provided from the UK training management system- the Intercollegiate Surgical Curriculum Programme (ISCP)- on the ARCP Outcomes of higher specialty trainees in General Surgery over the period between January 2017 and December 2022. Demographic data including sex and age group on starting higher specialty training were considered, as were working pattern, phase of training during the height of the pandemic (2020 and 2021), and training region. The proportion of nonstandard outcomes, and the use of specific Covid-19 outcomes, were analyzed to assess the impact of these variables on ARCP outcome using univariate and multivariate logistic regression. Prepandemic outcomes in 2017 were used as a comparator. RESULTS: A total of 7414 ARCP outcomes issued to 1874 General Surgery higher speciality trainees were analysed. The Adjusted Odds Ratio (AOR) for receiving a nonstandard outcome in 2020 (compared to 2017) was 3.07 (95% CI: 2.47-3.81, p < 0.001) not recovering to prepandemic levels by the end of 2022 (AOR 2.11 (95% CI: 1.69-2.64, p < 0.001)). Female sex (AOR 1.27 (95% CI: 1.13-1.43, p < 0.001) and being older on starting higher surgical training (AORâ¯=â¯1.51 (95% CI: 1.34-1.70, p < 0.001) were both significantly associated with a higher chance of nonstandard outcome. Working pattern was linked to ARCP outcome on univariate analysis, but this relationship disappeared once corrected for other demographic factors (1.05, 95% CI: 0.88-1.24, pâ¯=â¯0.582). Being at a later stage of training during the pandemic was not linked to an increase in AOR of receiving a nonstandard outcome (1.09, 95% CI: 0.97-1.22, pâ¯=â¯0.134), but trainees receiving a nonstandard outcome in this group were more likely to have extra training time advised (15.49%, vs 4.27% in 2021). The highest AOR of receiving a Covid-19 outcome was in the Wessex Deanery at 2.85 (95% CI: 1.83-4.46, p < 0.001), whilst the lowest AOR were seen in Yorkshire and the Humber (0.32, 95% CI: 0.17-0.62, p < 0.001). Removing Covid-19 specific outcomes from the analysis shows a continued rise in the use of nonstandard outcomes in all years except 2020. CONCLUSIONS: The Covid-19 Pandemic had a significant impact on the trajectory of training in General Surgery in the UK. Training extensions were more likely to be recommended later in training. There was considerable variation in the use of Covid-19 ARCP outcomes across the UK. There is ongoing evidence of differential attainment at ARCP in General Surgery, with female trainees and older graduates having greater chances of nonstandard outcomes. The underlying reasons for these associations need to be explored. Efforts to urgently address deficits in training post Covid-19 with an awareness of the intersectional nature of differential attainment are needed.
RESUMO
BACKGROUND/AIM: Circumferential resection margin involvement is an independent prognostic factor in patients with adenocarcinoma of the distal esophagus and esophago-gastric junction. However, there is currently no consensus on the extent and the technique of hiatal dissection. We describe a minimally invasive technique of circumferential hiatal dissection for adenocarcinoma of the distal esophagus and esophago-gastric junction with its related histopathological results. PATIENTS AND METHODS: A prospective study of 40 consecutive patients undergoing hybrid (laparoscopic/thoracotomic) or totally minimally invasive Ivor-Lewis esophagogastrectomy over a period of 21 months was conducted. Dissection of the hiatus included peri-esophageal surrounding tissues in a cylindrical fashion maximizing the distance from the oesophageal wall. Crural muscle fibers and pleura bilaterally, pericardial fat anteriorly and pre-aortic tissue posteriorly were excised en bloc. Histopathological results particularly focused on involvement of the circumferential resection margin. Neoadjuvant chemotherapy was given to 24 (60%) patients. RESULTS: Complete histological clearance (R0) was achieved in 92.5% (n=37) according to the criteria of the College of American Pathologists and in 87.5% (n=35) according to those of the Royal College of Pathologists. In pT3 tumors (n=22), the circumferential resection margin was negative in 20 patients (91%) according to the College of American Pathologists, and in 17 (77%) according to the Royal College of Pathologists. CONCLUSION: Adoption of this safe and reproducible technique might reduce the incidence of circumferential resection margin involvement and improve pathological outcomes. In addition, there may be positive implications for training and quality control.
