Evaluation of the National Training Programme for Laparoscopic Colorectal Surgery of England (Lapco)

Transcription

1 Evaluation of the National Training Programme for Laparoscopic Colorectal Surgery of England (Lapco) Mr Hugh Mackenzie, Dr Melody Ni, Mr Danilo Miskovic, Mr Mark Coleman, Professor George Hanna

2 National Training Programme for Laparoscopic Colorectal Surgery Lapco Aims:» Disseminate LCS» Shorten the learning curve» Minimise patient morbidity and mortality Incorporates:» Expert supervised intraoperative training» Formative competency assessment monitoring of training progression» Summative competency assessment at end of training» Continuous clinical audit of patient outcomes

3 Competency Assessment Formative assessment of training progression 1 - Not performed, step had to be done by trainer 2 - Partly performed, step had to be partly done by trainer 3 - Performed, with substantial verbal support 4 - Performed with minor verbal support 5 - Competent performance, safe (without guidance) 6 - Proficient performance, couldn t be better

4 Competency Assessment Summative assessment sign-off Assessor 1 Trainer/ trainee agree to enter sign off process Trainee is invited to submit 2 videos of independently performed procedures Educational centre (Imperial College) Assessor 2 If positive result, recommend solo training, if negative, recommend further supervised training Aim: safe and solid technique for straight forward case (R/Hemi and L/Hemi)

5 Competency Assessment Summative assessment Competency Assessment Tool

6 Study Objectives Clinical Safety» Prospectively collected, clinical outcomes for the supervised NTP training Efficiency» Learning CUSUM curves, derived from a Global Assessment Score (GAS) Efficacy» Influence of training volume on CAT score» Impact of technical performance in sign-off on clinical outcomes» Analysis of clinical outcomes of cases performed independently within 12 months of sign-off

7 Clinical Safety Training clinical outcomes Clinical Outcome NTP Training Cases Number of cases 1560 Conversion 76 (4.9%) Complications Overall 217 (13.9%) Overall Surgical 190 (12.2%) Leak 34 (2.2%) Re-operation 61 (3.9%) Re-admission 47 (3.0%) Median Hospital Stay 5 (4-7) Mortality 8 (0.5%)

8 Clinical Safety Clinical Learning curves

9 CUSUM (Obs Exp) 10 Efficiency Competency Learning Curves Set up Exposure Vascular Pedicle Mobilisation of Colon Flexure Mesorectal Dissection Transection and Anastomosis Procedure Number Regime shift detection - competency (GAS score of 5) is reached: - theatre set-up case 6 - exposure case 11 - transection and anastomosis case 25 - mobilisation of colon case 30, - vascular pedicle case Flexure and mesorectal dissection do not reach a plateau.

10 Efficacy Sign-off outcomes 89 trainees have submitted videos for sign-off 63 have been signed off. Pass rate is 71%

11 Efficacy Sign-off outcomes

12 Efficacy Sign-off outcomes CAT score< 2.69 P-value CAT score P-value CAT score > 3.09 Number of Cases Complications 11 (25.0%) (12.9%) (3.5%) Surgical Complication 8 (18.2%) (10.0%) (1.8%) Lymph node count 13 (8 20) (11 22) (16 25) Distal Resection Margin (cm) 4.0 ( ) ( ) ( ) Number of NTP Cases 9 (2 13) (6 23) (13 28) Total Number of Laparoscopic Colorectal Cases 40 (27 60) (26 48) (27 54)

13 Efficacy Post-program clinical outcomes Clinical Outcome NTP Training Cases Post Sign-off Cases P-Value Number of cases Conversion 76 (4.9%) 72 (11.9%) <0.001 Complications Overall 217 (13.9%) 80 (13.3%) Overall Surgical 190 (12.2%) 72 (11.9%) Leak 34 (2.2%) 13 (2.2%) Re-operation 61 (3.9%) 32 (5.3%) Re-admission 47 (3.0%) 24 (4.0%) Mean Hospital Stay 5 (4-7) 5 (4-7) Mortality 8 (0.5%) 4 (0.7%) 0.673

14 Efficacy Case Complexity Demographic Category NTP Training Cases Post Sign-off Independent cases P-Value No. of Cases Lapco Risk Score No. of High Risk Cases 123 (8.3%) 71 (11.8%) Age Mean (S.D) 66.7 (13.8) 66.7 (13.0) Gender Male 833 (53.4%) 309 (51.2%) BMI Mean (S.D) 27.4 (5.0) 27.0 (3.4) Urgency Emergency 31 (2.0%) 17 (2.8%) (19.7%) 124 (24.4%) ASA grade (63.3%) 265 (52.2%) (16.7%) 114 (22.4%) < (0.3%) 5 (1.0%) Prior abdominal Surgery Yes 395 (25.3%) 97 (16.1%) <0.001 Right colectomy 589 (37.8%) 206 (34.2%) Resection Left Colectomy/ High AR/ Sigmoid Colectomy 675 (43.3%) 219 (36.3%) <0.001 Diagnosis Low AR /APER 165 (10.6%) 130 (21.6%) Other 131 (8.4%) 48 (8.0%) Cancer 1252 (80.3%) 480 (79.6%) Diverticular disease 82 (5.3%) 57 (9.5%) IBD 94 (6.0%) 26 (4.3%) Benign Polyp 117 (7.5%) 33 (5.5%) Other 0.002

15 Conclusions Structured supervised intraoperative training in laparoscopic colorectal surgery was safe for patients The learning curve is reduced Training improves technical performance and clinical outcomes in sign-off Clinical outcomes are maintained in independent practice