Chairmen, Ladies and Gentlemen. Thank you for the opportunity to present our data at this meeting. I am going to talk about educational and clinical outcomes of the National Training programme in Laparoscopic Colorectal Surgery.
This was the rationale for the setup of the an educational programme funded by the Department of health. The Programme has a very pragmatic approach as shown on this diagram. Colorectal consultants who successfully applied for the programme and completed a course in LCS will be allocated to one of the 11 training centres across the country. They will perform laparoscopic colorectal resections under the supervision of an expert laparoscopic surgeon until they reach competence, before they embark on solo training in their own hospitals. >> This should ideally reflect their increasing levels of proficiency and can last up to two years. >> At each step of training a structured assessment and audit process is performed guided by Imperial College. In this presentation I would like to concentrate on the outcomes during this phase of supervised training.
Since the publication of the amended NICE guidelines the benefits of LCS for short term outcomes got official character.
Nevertheless, considering that the introduction of LCS took place in the early nineties it is striking that the uptake of LCS in this country was very poor. For the period of 2007 only 10% of all colorectal procedures have been performed laparoscopically. There are several reasons for this slow uptake.
At the same time a meta-analysis, that will be published in the December issue of the Ann Surg, shows that clinical outcomes are not at risk as long surgeons are adequatly supervised during their training period.
Plotting the overall scores on as CUSUM proficiency gain curves show that on average roughly 25 supervised cases are required before the trainees are recommended for sign off and independent training. It also shows us that different parts of the procedure are learnt at different speeds. >> More importantly, the tool allows us to differentiate between learning curves of different trainees in order to define the time it takes them individually to reach the plateau.
. Update on Lapco Mark G Coleman, Derriford Hospital, PlymouthDirector, Lapco National Training Programme for Laparoscopic Colorectal Surgery Advisor, LOREC National Training Programme for Low Rectal CancerLOREC Low Rectal Cancer National Development Programme
Lapco Training Centres (11) The National Training Programme (NTP) Competence – safe performance of an operation to required standard within a reasonable time BEGINNER ADVANCED COMPETENT PROFICIENT APPLICATION COURSE SUPERVISED TRAINING SOLO TRAINING 1-2 YEARS Clinical, CAT Sign off: GAS form + clinical CAT, HRA video assessment GAS formSelection criteria 60 experts (>100 cases) Inreach Outreach 20-25 cases in 6 months
Uptake of laparoscopic colorectal surgery in England30%25%20%15%10%5%0% 2004/2005 2005/2006 2006/2007 2007/2008 Source: Hospital Episode Statistic (HES)
Fear of long learning curve is justified - Big data base: n (patients)=4907, n (surgeons)=27 - Appropriate statistical methods (RA-CUSUM) CONVERSION COMPLICATION 10 CUSUM (obs-exp)CUSUM (obs-exp) 5 152 143 0 0 100 200 300 400 500 600 0 100 200 300 400 500 600 CASE NUMBER CASE NUMBER 200 2000 OP TIME LN HARVEST CUSUM (obs-exp) CUSUM (obs-exp) 100 1000 139 0 88 0 -100 -500 0 100 200 300 400 500 600 0 100 200 300 400 500 600 CASE NUMBER CASE NUMBER Miskovic et al. 2011
The impact of the presence of a trainer on clinical outcomes in laparoscopic colorectal surgeryMeta-analysis of 6’064 patients by surgeons with and without supervised training Conversion rates p=0.2835 p=0.0002 p=0.0332 Miskovic and Wyles, Ann Surg 2010 (in press)
The impact of the presence of a trainer on clinical outcomes in laparoscopic colorectal surgeryMeta-analysis of 6’064 patients by surgeons with and without supervised training Miskovic and Wyles, Ann Surg 2010
Rationale for National Training Programme (NTP)• Evidence of benefits of LCS• Slow uptake in the UK• Long learning curve for self-taught surgeons• Better outcomes for supervised surgeons• Shortening of proficiency gain curve with active training?
Online live learning curve 0•Online resource for all CUSUM (obs-exp) -1 Trainee 1 -2 Trainee 2•Track trainees -3 -4 Trainee 3 -5•Task-specific learning curves -6 Trainee 4 1 5 9 13 17 21 25 Procedure number•Underperformers and “highflyers” canbe identified•Identification of point when ready forsign off (flat curve)
THE NATIONAL TRAINING PROGRAMME Clinical outcomes ofSIGN OFF PROCEDURE the NTP Parameter X2 Experts* NTP Assessor 1 Trainee is invited Trainer/ trainee agree to enter sign Conversionsvideos to submit 2 of independently 10% 7% Educational centre (Imperial College) performed off process procedures Assessor 2 Complications 25% 15% 3% LCAT x4: If positive result, recommend solo Anastomotic leak training, if negative, recommend further 3% supervised training Mortality 2% 2%Aim: safe and solid technique for straight forward case (R/Hemi and L/Hemi) *Miskovic and Wyles, Ann Surg 2010 (in press)
Lapco TT Clinical outcomes of the NTP Parameter Experts* NTP Conversions 10% 7%•Train theTrainer course Complications 25% 15%•2 Day Course Anastomotic leak•4 Faculty, 6-8 delegates 3% 3% Mortality 2% 2% *Miskovic and Wyles, Ann Surg 2010 (in press)
Clinical outcomes ofTHE NATIONAL TRAINING PROGRAMME the NTP Parameter Experts* NTP Conversions 10% 7% 25% Complications 1 - DRY SKILLS DAY 15% Lapco TT Anastomotic leak 3% 3% Mortality 2% 2% *Miskovic and Wyles, Ann Surg 2010 (in press)
Clinical outcomes ofTHE NATIONAL TRAINING PROGRAMME the NTP Parameter Experts* NTP Conversions 10% 7% DAY 2 – IN THEATRE Complications Lapco TT 25% 15% Anastomotic leak 3% 3% Mortality 2% 2% *Miskovic and Wyles, Ann Surg 2010 (in press)
Lapco TT Clinical outcomes of the NTPTrain theTrainer course•2 Day Course Parameter Experts* NTP•4 Faculty Conversions 10% 7%•6 delegates Complications 25% 15%•41/60 trainersparticipated by Anastomotic leak 3% 3%Jan 2012 Mortality 2% 2% *Miskovic and Wyles, Ann Surg 2010 (in press)
Clinical outcomes ofHow do I get trained ? the NTP 1.Plan Parameter Experts* NTP 2.Talk Conversions 10% 7% 3.Be there! Complications 25% 15% Anastomotic leak 3% 3% Mortality 2% 2% *Miskovic and Wyles, Ann Surg 2010 (in press)
Clinical outcomes of the NTP acknowledgmentsTraining centres :Basingstoke/Frimley: Mr Tom Cecil, Mr Mark Gudgeon Parameter Experts*Bradford: Mr John Griffith, Mr Matt Clarke & Mr Richard Slater NTPHull: Mr James Gunn, John Hartley Conversions 10%King’s/St Thomas: Mr Savvas Papagrigoriadis, Mr Vivek DattaNewcastle/Gateshead: Mr Alan Horgan, Mr Hugh Gallagher, Mr Mark Kratory 7%North West: Mr Selva Sekar, Mr David Watson, Complications 25%Nottingham: Mr Charles Maxwell-Armstrong, Mr Austin Acheson, Mr Andy Miller 15%Oxford: Mr Chris Cunningham, Mr Ian Lindsey, Mr Mike StellakisPortsmouth: Mr Amjad Parvaiz, Mr Jim Khan Anastomotic leak 3% 3%South West: Mr Nader Francis, Mr Rob Longman, Mr Tony Dixon, Mr Steve Mansfield, Mr Nick Kenefick, MrAdam WiddisonSt Marks/Colchester/Guildford: Mr Robin Kennedy, Mr Iain Jenkins, Prof Roger Motson, Mr Tan Mortality 2%Arulampalam, Prof Tim Rockall, Mr Ralph Austin, Mr Zulfiqar Khan 2%Programme Manager Laura Langsford Administrator Tania Dorey NCAT Lead Andrew McMeekingNational Director of Cancer Services Professor Sir Michael Richards *Miskovic and Wyles, Ann Surg 2010 (in press)