Operative experience in essential emergency general surgery procedures: is autonomy achievable during surgical training?

BACKGROUND: Readiness for practice is an ongoing concern in surgery. Surgeons who have completed general surgery training are expected to be proficient in performing common emergency procedures. The aim of this study was to assess the experience and autonomy of general surgery trainees in New Zealand in 10 emergency general surgery procedures, and identify factors associated with reaching primary operator (PO) thresholds. METHODS: Operative logbook data from all New Zealand general surgery trainees from 2013 to 2017 were analysed. Data for 10 emergency general surgery procedures were extracted to determine PO and autonomous PO (mentor not scrubbed) rates. A threshold of 70% for PO and APO rates was used to define two levels of proficiency. RESULTS: A total of 120 trainees performed 40 865 included procedures. Trainees met the PO threshold for all procedures by Surgical Education and Training (SET) 5. The APO threshold was met for three of 10 procedures (appendicectomy, drainage of perianal abscess and perforated peptic ulcer repair). Final APO rates for the other procedures ranged from 18% to 58%. On multivariate analysis, SET year and case volume were associated with increased odds of meeting the PO and APO thresholds. Female trainees were less likely to reach the PO and APO thresholds for three of 10 and four of 10 procedures, respectively. CONCLUSION: Trainees had increasing PO and autonomous PO rates over the course of their training. Graduating New Zealand general surgeons likely have sufficient operative experience in emergency general surgery procedures. However, rates of autonomy are lower, and further research is needed to determine whether this affects readiness for independent practice.

Computed Tomography Angiography in the Assessment of Great Saphenous Vein as Conduit for Infrainguinal Bypass Surgery.

INTRODUCTION: The great saphenous vein (GSV) is commonly used as a conduit during infrainguinal bypass (IIB) and is usually well seen on computed tomography angiography (CTA) which is frequently performed for preoperative planning. In this study, we asked whether CTA could replace ultrasonography (US) as the primary mode of conduit assessment, by comparing GSV measurements for patients who underwent both CTA and US vein mapping prior to IIB. METHODS: All IIB that were completed in the six-and-a-half-year period from January 1, 2012, to July 31, 2018, at the authors' institution were examined. Great saphenous vein measurements were analyzed for patients who had undergone both CTA and US vein mapping. Correlation between the measurements was calculated with the Pearson correlation coefficient. Data were then examined using Bland-Altman plots. Then categorical analysis was used to determine the adequacy of GSV for use as a bypass conduit. RESULTS: There were 302 patients who underwent IIB, with 73 legs, in 47 patients, examined with CTA and US. Computed tomography angiography and US measurements were moderately correlated (r = 0.531) across all measurement locations. Correlation progressively reduced distally (proximal thigh r = 0.534, midthigh r = 0.536, knee r = 0.35, midcalf r = 0.185, P = .074, ankle r = 0.078, P = .485). Bland-Altman plots of the pooled location data demonstrated no systematic bias. However, the upper and lower limits of agreement were wide, between -2.02 and +2.37 mm, demonstrating a lack of agreement between CTA and US. Analysis of each location revealed similar findings. A receiver operator characteristic curve was constructed based on a minimum US GSV diameter for adequate bypass conduit of 3 mm. The CTA value that maximized the Youden index was 3.8 mm. CONCLUSION: The level of error between CTA and US measurements, demonstrated by the large limits of agreement on Bland-Altman plots, would not be clinically acceptable. However, if a larger threshold is accepted, CTA has the potential to replace preoperative US vein mapping of GSV.

Pulseless Electrical Activity Arrest as the First Symptom of Testicular Cancer with Subsequent Phlegmasia Cerulea Dolens.

INTRODUCTION: Phlegmasia cerulea dolens (PCD) is a severe, rare complication of deep vein thrombosis, which is characterised by compartment syndrome, arterial compromise, venous gangrene, and shock. Prothrombotic states are the primary risk factor for PCD, which, in most cases, is associated with pulmonary embolism and carries a high mortality. CASE REPORT: A 46-year-old male presented following a pulseless electrical activity (PEA) arrest due to saddle pulmonary embolism (PE). He subsequently developed PCD and venous gangrene secondary to inferior vena cava obstruction, in the setting of a new diagnosis of testicular germ cell tumour. DISCUSSION: PEA arrest, as the initial presenting problem in malignancy, is rare. It is extreme for the first indication of cancer to be a PEA arrest from massive PE. While hypoxic brain injury from the cardiac arrest precluded intervention in this case, a surgical approach entailing en bloc resection of aortocaval metastasis, with subsequent IVC reconstruction, followed by lower limb venous thrombectomy would have been favoured as it was considered that an endovascular approach would not have been successful. CONCLUSION: A case of a patient with phlegmasia cerulea dolens secondary to testicular cancer, who presented following PEA arrest is described.

Application of Rasch analysis in health care is increasing and is applied for variable reasons in mobility instruments.

OBJECTIVE: To identify the frequency of Rasch analysis use in health instrument development or refinement and the characteristics of Rasch application in mobility scales. STUDY DESIGN AND SETTING: The entire databases of Medline, CINAHL, PEDro, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were searched until January 2009. Articles that reported the development or refinement of health instruments using Rasch analysis were included. Of the 234 articles that met inclusion, 10 were categorized as "mobility" instruments. Data were extracted relating to each instrument and the use of Rasch analysis in the development or refinement of the instruments. RESULTS: The number of articles reporting the use of Rasch analysis of health instruments is increasing, from 1 article in 1987 to 48 articles in 2007. Of the 10 mobility instruments examined, the primary reason Rasch was used varied. Reasons included assessing instrument unidimensionality, differential item functioning, rating categories, item hierarchy, and redundant items. CONCLUSION: The application of Rasch analysis in health instrument development has markedly increased in recent years. However, few mobility instruments have been developed or refined using Rasch analysis. The reasons that the Rasch model was used varied across mobility instruments.