W. E. G. Thomas

Bio: W. E. G. Thomas is an academic researcher from Royal Hallamshire Hospital. The author has contributed to research in topics: Pancreatitis & Thrombophlebitis. The author has an hindex of 4, co-authored 7 publications receiving 206 citations.

Assessing the technical skills of surgical trainees.

Abstract: Background: The aims were to determine whether tests of technical skill on simple simulations can predict competence in the operating theatre and whether objective assessment in the operating theatre by direct observation and video recording is feasible and reliable. Methods: Thirty-three general surgical trainees undertook five simple skill simulations (knotting, skin incision and suturing, tissue dissection, vessel ligation and small bowel anastomosis). The operative competence of each trainee was then assessed during two or three saphenofemoral disconnections (SFDs) by a single surgeon. Video recordings of the operations were also assessed by two surgeons. Results: The inter-rater reliability between direct observation and blinded videotape assessment was high (α = 0·96 (95 per cent confidence interval 0·92 to 0·98)). Backward stepwise regression analysis revealed that the best predictors of operative competence were the number of SFDs performed previously plus the simulation scores for dissection and ligation, the key components of SFD (64 per cent of variance explained; P = 0·001). Conclusion: Deconstruction of operations into their component parts enables trainees to practise on simple simulations representing each component, and be assessed as competent, before undertaking the actual operation. Assessment of surgical competence by direct observation and video recording is feasible and reliable; such assessments could be used for both formative and summative assessment. Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Extracorporeal shockwave lithotripsy for common bile duct stones

Abstract: Background Successful extraction of common bile duct stones after endoscopic sphincterotomy may be achieved in 86–96 per cent of cases. However, some stones are too large to be removed in this manner. This study looks at the role of extracorporeal shock-wave lithotripsy to break up common bile duct stones as an adjunct to sphincterotomy in patients with stones greater than 10 mm in size. Methods Twenty-seven patients with large (10–35 mm) common bile duct stones were treated with piezoelectric generated extracorporeal shock-wave lithotripsy (ESWL) following failed stone extraction after endoscopic sphincterotomy (ES). The stones were visualized ultrasonographically and a piezolith 2300 Wolf lithotripter used to administer the shockwaves. Results Visualized stone fragmentation was reported in 20 of 48 sessions. Clearance of targeted stones was achieved in 18 of the 27 patients, but actual duct clearance was demonstrated in only 17 of the 27. There were few adverse effects and mortality was nil. Conclusion This study concludes that ESWL following failed ES is a useful additional treatment option for very large bile duct stones, but should only be used after surgical risk and past history of biliary disease have been carefully reviewed and found to contraindicate conventional surgical management. An algorithm of treatment options for common bile duct stones is presented.

Cholecystectomy: does subspecialization alter workload?

Abstract: Aims: Cholecystectomy is a common operation. This study reviewed the changes in workload and practice in a teaching hospital over a 4-year period, during which a hepatobiliary subspecialist unit was developed. Methods: Computerized demographic data, and details of operations and inpatient events were reviewed for all patients undergoing cholecystectomy in a single teaching hospital from 1993 to 1997. For statistical analysis the consultants were grouped into those with a hepatobiliary interest (n = 3) and those with other primary interests (n = 6); and the workload for the first 12 months of the study was compared with that of the last 12-month period. Results: Between April 1993 and April 1997, 1121 cholecystectomies were performed, of which 75 were excluded because they were performed with other simultaneous procedures. Of the remaining operations, 911 involved cholecystectomy alone (mean patient age 52·9 years), and 135 (12·9 per cent) comprised cholecystectomy with exploration of the common bile duct (ECBD) (mean age 60·1 years). Between the first and last years studied, the rate of ECBD rose significantly from 7·4 to 14·9 per cent (P < 0·01, χ2 test), and the proportion of ECBD procedures being performed by hepatobiliary specialists rose from 31·6 to 52·7 per cent, but this was not statistically significant (P = 0·13). However, for cholecystectomy in the same period the proportion performed by hepatobiliary surgeons rose from 40·4 to 58·5 per cent, representing a highly significant trend (P < 0·001). Following cholecystectomy alone there was a significantly shorter stay associated with patients treated by hepatobiliary surgeons (P = 0·002, F test), although the median postoperative hospital stay was 2 days for both groups of surgeons (interquartile range 1–3 days for hepatobiliary and 1–4 days for non-hepatobiliary surgeons). Conclusions: Although cholecystectomy is not viewed as a specialist procedure, the trend in this teaching hospital reveals a steady increase in the proportion of cholecystectomies being performed by teams with a biliary interest. The data indicate that this practice is associated with a shorter hospital stay. © 2000 British Journal of Surgery Society Ltd

A systematic review of the impact of volume of surgery and specialization on patient outcome

Abstract: Background and methods: Volume of surgery and specialization may affect patient outcome. Articles examining the effects of one or more of three variables (hospital volume of surgery, surgeon volume and specialization) on outcome (measured by length of hospital stay, mortality and complication rate) were analysed. Reviews, opinion articles and observational studies were excluded. The methodological quality of each study was assessed, a correlation between the variables analysed and the outcome accepted if it was significant. Results: The search identified 55 391 articles published between 1957 and 2002; 1075 were relevant to the study, of which 163 (9 904 850 patients) fulfilled the entry criteria. These 163 examined 42 different surgical procedures, spanning 13 surgical specialities. None were randomized and 40 investigated more than one variable. Hospital volume was reported in 127 studies; high-volume hospitals had significantly better outcomes in 74·2 per cent of studies, but this effect was limited in prospective studies (40 per cent). Surgeon volume was reported in 58 studies; high-volume surgeons had significantly better outcomes in 74 per cent of studies. Specialization was reported in 22 studies; specialist surgeons had significantly better outcomes than general surgeons in 91 per cent of studies. The benefit of high surgeon volume and specialization varied in magnitude between specialities. Conclusion: High surgeon volume and specialization are associated with improved patient outcome, while high hospital volume is of limited benefit. Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Guidelines on the management of common bile duct stones (CBDS).

Abstract: The last 30 years have seen major developments in the management of gallstone-related disease, which in the United States alone costs over 6 billion dollars per annum to treat. Endoscopic retrograde cholangiopancreatography (ERCP) has become a widely available and routine procedure, whilst open cholecystectomy has largely been replaced by a laparoscopic approach, which may or may not include laparoscopic exploration of the common bile duct (LCBDE). In addition, new imaging techniques such as magnetic resonance cholangiography (MR) and endoscopic ultrasound (EUS) offer the opportunity to accurately visualise the biliary system without instrumentation of the ducts. As a consequence clinicians are now faced with a number of potentially valid options for managing patients with suspected CBDS. It is with this in mind that the following guidelines have been written.

Objective assessment of technical surgical skills

Abstract: BACKGROUND: Surgeons are increasingly being scrutinized for their performance and there is growing interest in objective assessment of technical skills. The purpose of this study was to review all evidence for these methods, in order to provide a guideline for use in clinical practice. METHODS: A systematic search was performed using PubMed and Web of Science for studies addressing the validity and reliability of methods for objective skills assessment within surgery and gynaecology only. The studies were assessed according to the Oxford Centre for Evidence-based Medicine levels of evidence. RESULTS: In total 104 studies were included, of which 20 (19.2 per cent) had a level of evidence 1b or 2b. In 28 studies (26.9 per cent), the assessment method was used in the operating room. Virtual reality simulators and Objective Structured Assessment of Technical Skills (OSATS) have been studied most. Although OSATS is seen as the standard for skills assessment, only seven studies, with a low level of evidence, addressed its use in the operating room. CONCLUSION: Based on currently available evidence, most methods of skills assessment are valid for feedback or measuring progress of training, but few can be used for examination or credentialing. The purpose of the assessment determines the choice of method.

Postgame Analysis: Using Video-Based Coaching for Continuous Professional Development

Abstract: Background The surgical learning curve persists for years after training, yet existing continuing medical education activities targeting this are limited. We describe a pilot study of a scalable video-based intervention, providing individualized feedback on intraoperative performance. Study Design Four complex operations performed by surgeons of varying experience—a chief resident accompanied by the operating senior surgeon, a surgeon with less than 10 years in practice, another with 20 to 30 years in practice, and a surgeon with more than 30 years of experience—were video recorded. Video playback formed the basis of 1-hour coaching sessions with a peer-judged surgical expert. These sessions were audio recorded, transcribed, and thematically coded. Results The sessions focused on operative technique—both technical aspects and decision-making. With increasing seniority, more discussion was devoted to the optimization of teaching and facilitation of the resident's technical performance. Coaching sessions with senior surgeons were peer-to-peer interactions, with each discussing his preferred approach. The coach alternated between directing the session (asking probing questions) and responding to specific questions brought by the surgeons, depending on learning style. At all experience levels, video review proved valuable in identifying episodes of failure to progress and troubleshooting alternative approaches. All agreed this tool is a powerful one. Inclusion of trainees seems most appropriate when coaching senior surgeons; it may restrict the dialogue of more junior attendings. Conclusions Video-based coaching is an educational modality that targets intraoperative judgment, technique, and teaching. Surgeons of all levels found it highly instructive. This may provide a practical, much needed approach for continuous professional development.

Linking simulation-based educational assessments and patient-related outcomes: a systematic review and meta-analysis.

Abstract: PurposeTo examine the evidence supporting the use of simulation-based assessments as surrogates for patient-related outcomes assessed in the workplace.MethodThe authors systematically searched MEDLINE, EMBASE, Scopus, and key journals through February 26, 2013. They included original studies that as