Atallah Sam B, DuBose Arielle C, Burke John P, Nassif George, deBeche-Adams Teresa, Frering Taylor, Albert Matthew R, Monson John R T
Center for Colon and Rectal Surgery, Florida Hospital, Orlando, Florida.
Dis Colon Rectum. 2017 Oct;60(10):1023-1031. doi: 10.1097/DCR.0000000000000823.
Transanal total mesorectal excision is a new approach to curative-intent rectal cancer surgery. Training and surgeon experience with this approach has not been assessed previously in America.
The purpose of this study was to characterize a structured training program and to determine the experience of delegate surgeons.
Data were assimilated from an anonymous, online survey delivered to attendees on course completion. Data on surgeon performance during hands-on cadaveric dissection were collected prospectively.
This study was conducted at a single tertiary colorectal surgery referral center, and cadaveric hands-on training was conducted at a specialized surgeon education center.
The main outcome measurement was the use of the course and surgeon experience posttraining.
During a 12-month period, eight 2-day transanal total mesorectal excision courses were conducted. Eighty-one colorectal surgeons successfully completed the course. During cadaveric dissection, 71% achieved a complete (Quirke 3) specimen; 26% were near complete (Quirke 2), and 3% were incomplete (Quirke 1). A total of 9.1% demonstrated dissection in the incorrect plane, whereas 4.5% created major injury to the rectum or surrounding structures, excluding the prostate. Thirty eight (46.9%) of 81 surgeon delegates responded to an online survey. Of survey respondents, 94.6% believed training should be required before performing transanal total mesorectal excision. Posttraining, 94.3% of surgeon delegates planned to use transanal total mesorectal excision for distal-third rectal cancers, 74.3% for middle-third cancers, and 8.6% for proximal-third cancers. The most significant complication reported was urethral injury; 5 were reported by the subset of survey respondents who had performed this operation postcourse.
The study was limited by inherent reporting bias, including observer and recall biases.
Although this structured training program for transanal total mesorectal excision was found to be useful by the majority of respondents, the risk of iatrogenic injury after training remains high, suggesting that this training pedagogy alone is insufficient. See Video Abstract at http://links.lww.com/DCR/A335.
经肛门全直肠系膜切除术是一种治疗直肠癌的新手术方法。此前美国尚未对这种手术方法的培训及外科医生的经验进行评估。
本研究旨在描述一个结构化培训项目的特点，并确定参加培训的外科医生的经验。
数据来自课程结束时发给学员的匿名在线调查问卷。前瞻性收集了外科医生在尸体解剖操作过程中的表现数据。
本研究在一家三级结直肠外科转诊中心进行，尸体解剖实践培训在一个专业外科医生教育中心开展。
主要观察指标是课程的使用情况及培训后外科医生的经验。
在12个月期间，共举办了8期为期2天的经肛门全直肠系膜切除术课程。81名结直肠外科医生成功完成了该课程。在尸体解剖过程中，71%的人获得了完整（Quirke 3级）标本；26%接近完整（Quirke 2级），3%不完整（Quirke 1级）。共有9.1%的人在错误层面进行解剖，而4.5%的人对直肠或周围结构（不包括前列腺）造成了严重损伤。81名参加培训的外科医生中有38名（46.9%）回复了在线调查问卷。在回复问卷的人中，94.6%的人认为在进行经肛门全直肠系膜切除术之前应进行培训。培训后，94.3%的参加培训的外科医生计划将经肛门全直肠系膜切除术用于治疗直肠下段癌，74.3%用于治疗直肠中段癌，8.6%用于治疗直肠上段癌。报告的最严重并发症是尿道损伤；在课程结束后进行过该手术的回复问卷的人群中，有5人报告了这一情况。
本研究受到固有报告偏倚（包括观察者偏倚和回忆偏倚）的限制。
尽管大多数受访者认为这个经肛门全直肠系膜切除术结构化培训项目有用，但培训后医源性损伤风险仍然很高，这表明仅靠这种培训方法是不够的。见视频摘要：http://links.lww.com/DCR/A335 。
