Hospital and departmental level strategies for managing the impact of adverse events on surgeons.

Adverse events have a profound impact on surgeons. This impact extends to physical and mental health, psychological wellbeing, and professional performance. Surgeons are ill prepared for these consequences of adverse events and are under-supported when they inevitably occur. Here we review the data on how adverse events affect surgeons. We explore the efforts made to date to both prepare surgeons before and support them after such events and we make recommendations regarding how this should and could be done better.

The current and possible future role of 3D modelling within oesophagogastric surgery: a scoping review.

BACKGROUND: 3D reconstruction technology could revolutionise medicine. Within surgery, 3D reconstruction has a growing role in operative planning and procedures, surgical education and training as well as patient engagement. Whilst virtual and 3D printed models are already used in many surgical specialities, oesophagogastric surgery has been slow in their adoption. Therefore, the authors undertook a scoping review to clarify the current and future roles of 3D modelling in oesophagogastric surgery, highlighting gaps in the literature and implications for future research. METHODS: A scoping review protocol was developed using a comprehensive search strategy based on internationally accepted guidelines and tailored for key databases (MEDLINE, Embase, Elsevier Scopus and ISI Web of Science). This is available through the Open Science Framework (osf.io/ta789) and was published in a peer-reviewed journal. Included studies underwent screening and full text review before inclusion. A thematic analysis was performed using pre-determined overarching themes: (i) surgical training and education, (ii) patient education and engagement, and (iii) operative planning and surgical practice. Where applicable, subthemes were generated. RESULTS: A total of 56 papers were included. Most research was low-grade with 88% (n = 49) of publications at or below level III evidence. No randomised control trials or systematic reviews were found. Most literature (86%, n = 48) explored 3D reconstruction within operative planning. These were divided into subthemes of pre-operative (77%, n = 43) and intra-operative guidance (9%, n = 5). Few papers reported on surgical training and education (14%, n = 8), and were evenly subcategorised into virtual reality simulation (7%, n = 4) and anatomical teaching (7%, n = 4). No studies utilising 3D modelling for patient engagement and education were found. CONCLUSION: The use of 3D reconstruction is in its infancy in oesophagogastric surgery. The quality of evidence is low and key themes, such as patient engagement and education, remain unexplored. Without high quality research evaluating the application and benefits of 3D modelling, oesophagogastric surgery may be left behind.

Current and possible future role of 3D modelling within oesophagogastric surgery: a scoping review protocol.

INTRODUCTION: Three-dimensional (3D) reconstruction describes the generation of either virtual or physically printed anatomically accurate 3D models from two-dimensional medical images. Their implementation has revolutionised medical practice. Within surgery, key applications include growing roles in operative planning and procedures, surgical education and training, as well as patient engagement and education. In comparison to other surgical specialties, oesophagogastric surgery has been slow in their adoption of this technology. Herein the authors outline a scoping review protocol that aims to analyse the current role of 3D modelling in oesophagogastric surgery and highlight any unexplored avenues for future research. METHODS AND ANALYSIS: The protocol was generated using internationally accepted methodological frameworks. A succinct primary question was devised, and a comprehensive search strategy was developed for key databases (MEDLINE, Embase, Elsevier Scopus and ISI Web of Science). These were searched from their inception to 1 June 2020. Reference lists will be reviewed by hand and grey literature identified using OpenGrey and Grey Literature Report. The protocol was registered to the Open Science Framework (osf.io/ta789).Two independent reviewers will screen titles, abstracts and perform full-text reviews for study selection. There will be no methodological quality assessment to ensure a full thematic analysis is possible. A data charting tool will be created by the investigatory team. Results will be analysed to generate descriptive numerical tabular results and a thematic analysis will be performed. ETHICS AND DISSEMINATION: Ethical approval was not required for the collection and analysis of the published data. The scoping review report will be disseminated through a peer-reviewed publication and international conferences. REGISTRATION DETAILS: The scoping review protocol has been registered on the Open Science Framework (https://osf.io/ta789).

Langer's arch: A rare but important consideration for axillary surgery with implications for training.

Langer's arch (LA), although rare, is an important anatomical anomaly in the axilla that may be encountered during axillary lymph node dissection (ALND). Failure to recognize this anomaly may cause disorientation during ALND, resulting in inadequate clearance, with implications for local disease recurrence and inaccurate staging. Here, we present a case that highlights the confusion LA can cause even in experienced surgeons. With indications for ALND decreasing, resulting in lower operative numbers, surgeons are less likely to be exposed to this structure during their training. Improving knowledge and understanding of LA is important to ensure breast surgeons' preparedness for axillary surgery.

The Accuracy of Noninvasive Peripheral Pulse Oximetry After Palliative Cardiac Surgery in Patients With Cyanotic Congenital Heart Disease.

BACKGROUND: Children with cyanotic congenital heart disease (CCHD) live with oxyhemoglobin saturations that are typically expressed as percentages in the range of 70s and 80s. Peripheral pulse oximetry (measurement of SpO2) performs poorly in this range and yet is widely used to inform clinical decisions in these patients. The reference standard is co-oximetry of arterial samples (SaO2). METHODS: In this study, 515 paired measurements of SpO2 and SaO2 were taken from 19 children who had undergone palliative cardiac surgery. RESULTS: SpO2 (Masimo SET LNCS Neo pulse oximeter) overestimated oxyhemoglobin saturation in 82% of measurements (mean 4.6% ± 6.6%). There was a strong negative correlation between mean bias and SaO2 ( r = -.96, P = .002, 95% confidence interval: -0.99 to -0.68). CONCLUSION: The results raise a concern that critical hypoxemia may go undetected and untreated if pulse oximetry is relied upon as the primary means of assessing oxyhemoglobin saturation in children with CCHD. Strong preference must be given to co-oximetry of arterial samples.

Accuracy of the Masimo SET® LNCS neo peripheral pulse oximeter in cyanotic congenital heart disease.

UNLABELLED: Introduction Non-invasive peripheral pulse oximeters are routinely used to measure oxyhaemoglobin saturation (SpO2) in cyanotic congenital heart disease. These probes are calibrated in healthy adult volunteers between arterial saturations of ~75 and 100%, using the gold standard of co-oximetry on arterial blood samples. There are little data to attest their accuracy in cyanotic congenital heart disease. Aims We aimed to assess the accuracy of a commonly used probe in children with cyanotic congenital heart disease. METHODS: Children with cyanotic congenital heart disease admitted to the Paediatric Intensive Care Unit with an arterial line in situ were included to our study. Prospective simultaneous recordings of SpO2, measured by the Masimo SET® LNCS Neo peripheral probe, and co-oximeter saturations (SaO2) measured by arterial blood gas analysis were recorded. RESULTS: A total of 527 paired measurements of SpO2 and SaO2 (using an ABL800 FLEX analyser) in 25 children were obtained. The mean bias of the pulse oximeter for all SaO2 readings was +4.7±13.8%. The wide standard deviation indicates poor precision. This mean bias increased to +7.0±13.7% at SaO2 recordings <75%. The accuracy root mean square of the recordings was 3.30% across all saturation levels, and this increased to 4.98% at SaO2 <75%. CONCLUSIONS: The performance of the Masimo SET® LNCS Neo pulse oximeter is poor when arterial oxyhaemoglobin saturations are below 75%. It tends to overestimate saturations in children with cyanotic congenital heart disease. This may have serious implications for clinical decisions.

Gas induction for pyloromyotomy.

BACKGROUND: Infants with pyloric stenosis are considered to be at high risk of aspiration on induction of anesthesia. Traditionally, texts have recommended classic rapid sequence induction (RSI) or awake intubation (AI). AI has generally fallen out of favor, while the components of RSI have become increasingly controversial. Infants are at high risk of hypoxemia if ventilation is not maintained while waiting for neuromuscular blockade to establish. The efficacy of cricoid pressure (CP) to prevent aspiration has not been proven. It can impair visualization of the glottis and make intubation difficult. It is debatable whether any RSI technique is needed for pyloromyotomy. A recent review of 235 infants reported no aspiration events. These children were anesthetized with a variety of techniques, including RSI, gas induction, and AI. In our institution, we teach a gaseous induction. The nasogastric tube is used to empty the stomach and anesthesia is induced with sevoflurane. A nondepolarizing muscle relaxant is administered and ventilation maintained until neuromuscular blockade is established and intubating conditions are optimal. We report our experience of this technique. METHOD: A retrospective medical notes review of all patients undergoing pyloromyotomy between 2005 and 2012. RESULTS: There were 269 patients (84.4% male, mean weight 3.74 kg ± 0.74). Two hundred and fifty-two (93.7%) received gas inductions and 17 (6.3%) intravenous (IV) inductions. Two children received an RSI. No patient-specific factors were identified to explain operator choice in those receiving IV inductions. There were no recorded aspiration events. CONCLUSION: Gas induction can be considered for children undergoing pyloromyotomy.