Is Online Video-Based Education an Effective Method to Teach Basic Surgical Skills to Students and Surgical Trainees? A Systematic Review and Meta-analysis.

BACKGROUND: Online education has been increasingly utilized over the past decades. The COVID-19 pandemic accelerated the transition of conventional face-to-face curricula to online platforms, with limited evidence for its teaching efficacy. This systematic review aims to assess the effectiveness of online video-based education compared with standard conventional education in teaching basic surgical skills to surgical trainees and students undergoing medical training. METHODS: We performed a literature search in Embase, Medline, Cochrane CENTRAL and Scopus from inception until February 2022. Studies included were randomised controlled trials (RCTs) and observational studies. We included randomised controlled trials only for meta-analysis. The primary outcome was surgical skill proficiency. The secondary outcomes were participant perception, confidence and satisfaction. Two authors independently assessed the search results for eligibility, extracted the data and assessed the risk of bias using the Cochrane Risk of Bias tool 2. Where appropriate, we performed random effects meta-analyses of the pooled study data to calculate a standardized mean difference. RESULTS: A total of 11 studies met the inclusion criteria totaling 715 participants; 603 were included in qualitative analysis and 380 in meta-analysis. All included studies were assessed as having a low risk of bias. The majority of studies found no significant difference between conventional and video-based education in teaching basic surgical skills, three studies found video-based education was superior and one study found conventional education was superior. There was no statistically significant difference in skill proficiency between the two groups (standardized mean difference of -0.02 (95% CI: -0.34, 0.30); p=0.90). Video-based education results in an equivalent improvement in confidence and satisfaction rates. Additional benefits of video-based education include convenience, accessibility and efficiency. CONCLUSIONS: Basic surgical skills can be taught as effectively through online video-based education as conventional teaching methods. Online education should be utilized as an adjunct to medical curricula beyond the COVID-19 era.

Techniques to Ameliorate the Impact of Second Warm Ischemic Time on Kidney Transplantation Outcomes.

Anastomosing the renal artery and vein in transplant recipients without a cooling mechanism exposes the kidney to temperatures exceeding the metabolic threshold (15°C to 18°C), at which the protective effects of renal hypothermia are lost. This anastomotic time, or second warm ischemic time, can be deleterious to graft outcomes, especially if it is prolonged. Techniques to ameliorate organ warming prior to reperfusion have been designed, and range from simpler surface cooling techniques, to organ immersion in bags of ice slush, and the application of 'jackets' that incorporate their own internal cooling mechanism. The efficacy of these methods with respect to the minimization of kidney temperature prior to reperfusion and subsequent effects on graft outcomes are discussed using clinical and experimental data, in the setting of open, laparoscopic, and robotic kidney transplantation.

Liver and lung transplantation in cystic fibrosis: an adult cystic fibrosis centre's experience.

Liver disease develops in one-third of patients with cystic fibrosis (CF). It is rare for liver disease to have its onset after 20 years of age. Lung disease, however, is usually more severe in adulthood. A retrospective analysis was performed on nine patients. Three patients required lung transplantation approximately a decade after liver transplant, and another underwent combined liver and lung transplants. Four additional patients with liver transplants are awaiting assessment for lung transplants. One patient is awaiting combined liver and lung transplants. With increased survival in CF, several patients may require more than single organ transplantation.

A pre-operative clinical model to predict microvascular invasion and long-term outcome after resection of hepatocellular cancer: The Australian experience.

BACKGROUND: Hepatocellular cancer (HCC) is a leading cause of mortality worldwide. Liver resection or transplantation offer the best chance of long-term survival. The aim of this study was to perform a survival and prognostic factor analysis on patients who underwent resection of HCC at two major tertiary referral hospitals, and to investigate a pre-operative prediction model for microvascular invasion (MVI). METHODS: Clinico-pathological and survival data were collected from all patients who underwent liver resection for HCC at two tertiary referral centres (Royal North Shore/North Shore Private Hospitals and Westmead Hospital) from 1998 to 2012. An overall and disease-free survival analysis was performed and a predictive model for MVI identified. RESULTS: The total number of patients in this series was 125 and the 5-year overall and disease-free survival rates were 56% and 37%, respectively. MVI was the only factor to be independently associated with a poor prognosis on both overall and disease-free survival. Age ≥64 years, a serum alpha-fetoprotein (AFP) ≥400 ng/ml (×40 above normal) and tumor size ≥50 mm were independently associated with MVI. An MVI prediction model using these three pre-operative factors provides a good assessment of the risk of MVI. CONCLUSION: MVI in the resected specimen of patients with HCC is associated with a poor prognosis. A preoperative MVI prediction model offers a useful way to identify patients at risk of relapse. However, more precise predictive models using molecular and genetic variables are needed to improve selection of patients most suitable for radical surgical treatment.

Prolonged Ischemic Time, Delayed Graft Function, and Graft and Patient Outcomes in Live Donor Kidney Transplant Recipients.

The association between prolonged cold ischemic time (CIT) and graft and patient outcomes in live donor kidney transplant recipients remains unclear. The aims of this study were to examine the association of CIT with delayed graft function and graft loss in live donor kidney transplant recipients and those who participated in the Australian Paired Kidney Exchange program using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry. Of 3717 live donor transplant recipients between 1997 and 2012 who were followed for a median of 6.6 years (25 977 person-years), 224 (25%) experienced CIT >4-8 h. Donor age was an effect modifier between CIT and graft outcomes. In recipients who received kidneys from older donors aged >50 years, every hour of increase in CIT was associated with adjusted odds of 1.28 (95% confidence interval [CI] 1.07-1.53, p = 0.007) for delayed graft function, whereas CIT >4-8 h was associated with adjusted hazards of 1.93 (95% CI 1.21-3.09, p = 0.006) and 1.91 (95% CI 1.05-3.49, p = 0.035) for overall and death-censored graft loss, respectively, compared with CIT of 1-2 h. Attempts to reduce CIT in live donor kidney transplants involving older donor kidneys may lead to improvement of graft outcomes.

Increasing liver transplantation waiting list mortality: a report from the Australian National Liver Transplantation Unit, Sydney.

BACKGROUND: We aimed to describe the demand for liver transplantation (LTx) and patient outcomes on the waiting list at the Australian National Liver Transplantation Unit, Sydney over the last 20 years. METHODS: We performed a retrospective analysis with the data divided into three eras: 1985-1993, 1994-2000 and 2001-2008. RESULTS: The number of patients accepted for LTx increased from 320 to 372 and 548 (P < 0.001) with the number of LTx being performed increasing from 262 to 312 and 452 respectively (P < 0.001). The median adult recipient age increased from 45 to 48 and 52 years (P < 0.001) while it decreased in children from 4 to 2 and 1 years respectively (P = 0.001). In parallel, the deceased donor offers decreased from 1003 to 720 and 717 (P < 0.001). Methods to improve access to donor livers have been used with the use of split livers, extended criteria and non-heart beating donors, resulting in increased acceptance of deceased donor offers by 65% and 115% in the second and third eras when compared with the first era (P < 0.001). However, the adult median waiting time has increased from 23 to 41 and 120 days respectively (P < 0.001). This was associated with increased adult mortality on the waiting list from 23 to 40 and 122 respectively (P < 0.001). CONCLUSIONS: Despite the increasing proportion of donor offers being used, the waiting list mortality is increasing. A solution to this problem is an increase in organ donation to keep pace with the escalating demand for LTx.

Kidney damage during organ retrieval: data from UK National Transplant Database. Kidney Advisory Group.

BACKGROUND: Kidney damage at organ retrieval is believed to be an increasing problem that is under reported. We aimed to identify the true rate of such damage and assess the effects on transplant survival. METHODS: Data from the UK National Transplant Database were analysed on all cadaveric kidneys donated over a 5-year period in the UK. Records indicated whether kidneys had been retrieved by a liver or renal surgical team and whether damage was noted at the time of retrieval or at the transplant procedure. Multivariate Cox's regression models were fitted to 1-year and 3-year transplant-survival data in those kidneys that were transplanted between 1992 and 1994. FINDINGS: Of 9014 kidneys retrieved, 96 could not be transplanted because of damage sustained at retrieval. Damage was reported in 1726 (19%) kidneys although by both donor and recipient centres in only 270 (3%). 1070 (62%) of the damaged organs were from donors aged 40 years or older. Reported kidney damage was more likely for retrievals of kidney only by a renal team (503 [26%]) than for multiorgan retrieval (454 [21%]), the proportion was lower when a liver team retrieved both liver and kidneys (415 [17%]). 794 (14%) kidneys retrieved and retained locally were reported as damaged, compared with 932 (29%) kidneys which had been exported. Donors' age had a significant effect on both 1-year and 3-year transplant survival (p<0.01 for both) but kidney damage did not (1 year p=0.40; 3 year p=0.81). INTERPRETATION: Despite the high rate of damage to kidneys at retrieval, most of the organs can be transplanted with no adverse effect on transplant survival. Kidney damage is least likely to occur with kidneys from young donors, and when liver teams or centres undertaking more than 50 retrievals per year do the retrieval.

Early diagnosis of hepatocellular carcinoma in haemochromatosis influences surgical management.

Using case note review, a retrospective analysis was carried out of all patients referred with haemochromatosis and suspected hepatocellular carcinoma between 1988 and 1997 to define the mode of presentation, management and outcome of such patients. All 12 patients were male with a mean age of 67 years. Four patients presented whilst asymptomatic by alpha-fetoprotein screening. Mean time interval between diagnosis of haemochromatosis and hepatocellular carcinoma was 6.7 years. One patient underwent right hepatectomy, seven patients were treated by chemoembolisation and the remaining four patients were treated symptomatically. The median survival of the chemoembolised patients was 13 months. Of those patients treated symptomatically, the median survival was four months. Screening for hepatocellular carcinoma is often not undertaken in patients with haemochromatosis. Survival prospects are poor in patients whose tumour presents symptomatically.

Aortoiliac aneurysm with arteriocaval fistula treated by a bifurcated endovascular stent-graft.

A 71-year-old patient with high-output cardiac failure was found to have an aneurysmal distal aorta with evidence of an arteriocaval fistula on ultrasound scanning. CT demonstrated an aneurysm of the distal aorta and right common iliac artery and an intraarterial digital subtraction angiogram confirmed an arteriocaval fistula. In view of the patient's cardiac failure and general condition an endovascular stent was considered. The right internal iliac artery was occluded with Tungsten coils prior to the insertion of a bifurcated stent-graft. This resulted in total occlusion of the aneurysm and obliteration of the arteriocaval fistula. To our knowledge such a case has not been previously reported.

Audit of introduction of hand-held Doppler and duplex ultrasound in the management of varicose veins.

Hand-held Doppler (HHD) examination and duplex ultrasound scanning of patients with varicose veins are more accurate than clinical assessment alone. To assess how the introduction of HHD and the availability of duplex ultrasound scanning affects patient management, a retrospective review was carried out comparing the year before the introduction with the subsequent 2 years. Information was extracted from a computer database containing details of all new venous outpatients, their initial management and investigations and subsequent operations. HHD and duplex ultrasound resulted in a marked increase in secondary investigations (16% versus 41%) and fewer patients being listed directly for surgery (47% versus 29%). Operations on the long saphenous vein decreased from 84% to 76% whereas short saphenous surgery increased from 6% to 21% during this time.

Developing the ideal immunosuppressive protocol by internal audit.

To identify the best immunosuppressive protocol in a centre where five different regimens are employed, 227 consecutive renal recipients who were transplanted over a 2.5-year period were studied. The five different regimens employed were cyclosporin monotherapy, dual therapy (cyclosporin and prednisolone), triple therapy (cyclosporin, azathioprine, prednisolone), antithymocyte globulin (ATG) followed by dual therapy and ATG followed by triple therapy. Recipients were chosen for the different regimens according to HLA mismatch, positive donor crossmatch due to IgM, regraft and delayed graft function. The group with the lowest risk, cyclosporin monotherapy, had the highest acute rejection rate, with only 13% free of acute rejection (in comparison to triple immunosuppression, P = 0.024, chi-square test). The overall infection rate and graft success rate were similar between the different groups.

Xenotransplantation: an examination of the adhesive interactions between human lymphocytes and porcine renal epithelial cells.

Specific adhesion molecules stabilize the binding between lymphocytes and antigen bearing cells; this intercellular adhesion is vital to both the affector and effector phases of an immune response. It is not known whether adhesion molecules and their counter-receptors can form the cross-species interactions that will facilitate human T cell recognition of xenogeneic porcine target cells. In this report it is demonstrated that a higher proportion of mitogen-activated than of resting human lymphocytes adhere to cultured porcine renal epithelial cells. Furthermore, antibody blocking experiments demonstrated that at least part of this cell-cell binding is stabilized by the human adhesion molecules LFA-1 (lymphocyte function-associated antigen-1) and the alpha 4-containing integrins. It is possible that this capacity for cross-species adhesion will play a role during the cell-mediated rejection of clinical porcine xenografts.