Accepted Manuscript Mastering minimally invasive esophagectomy requires a mentor; experience of a personal mentorship Miguel A. Cuesta, Nicole van der Wielen, Jennifer Straatman, Donald L. van der Peet PII:
S2049-0801(16)30289-8
DOI:
10.1016/j.amsu.2016.12.050
Reference:
AMSU 648
To appear in:
Annals of Medicine and Surgery
Received Date: 16 July 2016 Revised Date:
23 December 2016
Accepted Date: 24 December 2016
Please cite this article as: Cuesta MA, van der Wielen N, Straatman J, van der Peet DL, Mastering minimally invasive esophagectomy requires a mentor; experience of a personal mentorship, Annals of Medicine and Surgery (2017), doi: 10.1016/j.amsu.2016.12.050. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Mastering minimally invasive esophagectomy requires a mentor; experience of a personal mentorship.
Miguel A. Cuesta, MD, PhD1
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Nicole van der Wielen, MD1 Jennifer Straatman, MD1 Donald L. van der Peet, MD, PhD1
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1. Department of Surgery, VU medical center, Amsterdam, the Netherlands
Author correspondence:
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Prof. Dr. Miguel A. Cuesta
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Keywords: minimally invasive, esophagectomy, mentor
De Boelelaan 1117, ZH 7F020
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1018 HV Amsterdam The Netherlands
Tel: +31204444533
Fax: +31204444512
E-mail:
[email protected]
ACCEPTED MANUSCRIPT Abstract Since the first laparoscopic procedure, there has been an steady increase in advanced minimally invasive surgery. These procedures include oncological colorectal, hepatobiliary and upper gastrointestinal surgery. Implementation of these proce-
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dures requires different and new skills for the surgeons who wish to perform these procedures. To accomplish this surgical teaching program, a mentorship seems the
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most ideal method to teach the apprentice surgeon these specific skills.
At the VU medical center a teaching program for a minimally-invasive esophagecto-
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my for esophageal cancer started in 2009. At first it started in different centers in the Netherlands and later on we also started mentoring other institutes throughout Europe, Latin America and India.
In this article we describe our experience and the outcomes of this mentorship in
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advanced minimally invasive surgery.
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ACCEPTED MANUSCRIPT Introduction New teaching programs in Minimally Invasive Surgery (MIS) require mentoring and training (1). We see that, once a new MIS procedure has been validated, many surgical teams want to adopt the new procedure. The issue is how this is best learned,
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according to best standards of practice. Commonly, the teaching programs in MIS
may range from the institutionalized programs involved in the residency program to
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the quick one-or-two-day courses organized by surgical departments or companies
targeting (young) surgeons desirous but still unable to operate by the new MIS ap-
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proaches. While these opportunities offer interesting displays of new MIS, effective teaching programs in MIS developments are yet very variable and ad hoc. Because of years of experience in teaching MIS, we argue that learning new procedures could profit from proper assistance by an experienced team or particularly a
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mentor. Given our experience as a teaching mentor, we believe that MIS of technically demanding skills such as gastrectomy or esophagectomy is best mastered by the apprentice surgeons participating in the entire procedure. Thus involving the
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whole team, including anesthesiologists and operating room nurses, and thereby
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being assisted in carrying out procedures by the same mentor in one’s own hospital. Hence, in this paper a program of teaching Minimally Invasive Esophagectomy (MIE) by thoracoscopy and laparoscopy is evaluated, where mentoring has been practiced.
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ACCEPTED MANUSCRIPT Historical background At the VU medical center, we started the MIE program in 1998 by using the laparoscopic transhiatal approach for distal and gastro-esophageal junction cancers (GEJ) (2,3). Aiming for better radicality with an adequate lymphadenectomy, we started
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with the thoracoscopic approach in lateral position in 2006 (4). After a limited number of cases, and after watching the prone position approach live in a surgical con-
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gress, we switched to the right thoracoscopy in prone position. In 2007, we per-
formed the first intervention assisted by a thoracic surgeon who was already per-
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forming video assisted thoracic surgery for lung cancer.
After five three-stage MIE in prone position, without any conversion and only one postoperative respiratory infection, we felt that we could properly perform MIE through this approach. Consequentially, we continued operating all patients through
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this approach, with the exception of patients included in the CROSS trial (neoadjuvant chemoradiotherapy plus surgery versus surgery alone for esophageal or junctional cancer) (5). The department’s participation in the CROSS trial meant that all
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patients in this trial were approached by an open procedure. By 2009 we had oper-
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ated 80 patients and considered ourselves experienced enough with this approach to engage evaluation . Our search for evidence led to a randomized controlled trial, the TIME trial, where we compared the total open procedure by thoracotomy and laparotomy with the total MIE by right thoracoscopy and laparoscopy after neoadjuvant chemo radiotherapy according to the CROSS scheme (6). Since 2009 we insti-
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ACCEPTED MANUSCRIPT tuted the teaching program of MIE, at first doing so in the Netherlands and later elsewhere.
Material and methods
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Since 2009, we have taught the MIE approach in our own department, to 4 young
fellows, and in 20 centers located in Europe, Latin America and India. In our hospital
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surgeons and fellows could participate in the teaching program, no residents were included in the program. The fellow was always under supervision of another sur-
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geon. In the other participating hospitals only surgeons could participate. From the beginning our teaching strategy differentiated between teaching situations; namely a) centers already using MIE and harboring initial experience, and b) centers with no experience in MIE but having enough volume of patients.
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Using this approach, we served centers in the Netherlands (9), Sweden (1), Spain (5), Brazil (1), Switzerland (1), Greece (1) and India (2). Of these, 12 centers had no previous MIE experience. The other eight centers already had some experience with
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the MIE, but wanted to gain competences in the prone thoracoscopy or aimed, by
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means of proctoring and a master class, to gain the required proficiencies. Criteria for teaching at a center involved is having a sufficient volume of patients with esophageal cancer, at least 20 cases per year, and having at least two surgeons who were dedicated, totally or partially, to upper gastrointestinal surgery (upper GI). We also adapted the teaching policy to ask the whole team of the centers with no previous experience to visit our center in Amsterdam for watching at least two
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ACCEPTED MANUSCRIPT whole procedures performed at the operating room. A whole team would include two surgeons, an anesthesiologist involved with the procedure and one or two scrub nurses. After some weeks, the mentor assisted the surgeons to be proctored in a variable number of procedures where the initial intention was doing five. In our hos-
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pital, half of the surgeries were used for the teaching program.
Regarding the centers with some experience with MIE, a visit was arranged to oper-
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ate together with the corresponding team, and involving one or more procedures as a master class training.
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Our protocol included that each to-be-treated patient was discussed beforehand and accepted as a good candidate for the operation. In the beginning stage I and II patients with esophageal cancer were chosen, later on no selection was made after proper response to neoadjuvant therapy. All patients had given informed consent;
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the mentor had been introduced to(the patient or the apprentice surgeon?) and had spoken with them before the operation. Moreover, insurance items were arranged properly.
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With regards to complications, postoperative complications were recorded at the
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participating hospital. Peroperative complications included bleeding, trancheobronchial lesion or lesion of the tumor. Postoperative complications included chyle leak, anastomotic leak and recurrent nerve palsy. Daily contact with the surgeons was maintained during the treatment of the patient.
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ACCEPTED MANUSCRIPT Reimbursement for the mentor was usually arranged for travel, hotel if necessary, and payment for each operation, in some cases through the intervention of a commercial company. Moreover, other items such as the way to do the cervical anastomosis, the use of a
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fast track program after MIE, and the treatment of major postoperative complications were broadly discussed.
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Considering the prominent role of mentoring in our teaching strategy, we are interested in knowing whether the proctored centers had continued with the MIE pro-
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grams and what significance the mentoring had for the acquisition of requisite skills.
Results
The results are depicted in Table 1. There were eight centers with previous experi-
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ence and 12, with no experience. In participating all centers at least 2 surgeons, mostly with partial dedication to Upper GI, were involved in the training. Of those eight centers harboring previous experience in MIE, three applied thoraco-
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scopy in lateral position, four used the prone position and one implemented the hy-
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brid procedure, involving thoracoscopy in prone and laparotomy. Out of 12 centers with no MIE experience, ten whole teams visited our center before the mentoring was applied in their own center; of these, an average of two interventions have been watched. The number of interventions performed under the guidance of the mentor was 3.7 (average 1 to 6) with different complications recorded. The complications that occurred were two perioperative bleedings (being solved
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ACCEPTED MANUSCRIPT during the thoracoscopy), five respiratory infections and four anastomotic leakages, also one patient deceased due to partial necrosis of the gastric conduit. All the centers with previous experience continued with the mentoring program, leading to switching the technique to thoracoscopy in prone position. Of the 12 cen-
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ters with no experience only three terminated the mentoring program; one of them temporarily. Reason for termination in one center was the non-participation of one
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of the surgeons in the program, in another center this was due to a decision to continue with the open approach and in the last case because the group had decided to
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stop with the Upper GI program. Moreover, in six centers the taught MIE interventions not only involved the 3-stage procedure but also the 2-stage Ivor Lewis by thoracoscopy in prone position. Interesting is that five surgeons of the proctored cen-
Discussion
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ters subsequently started mentoring other centers.
Surgical residents and young surgeons are the principle targets for learning advanced
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MIS such as colorectal surgery. It is obvious that the majority of surgical residents
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with institutional programs will learn this approach during their residency period or during a fellowship period. However there are still surgeons to be taught various newly developed MIS procedures, mostly by quick courses or by mentoring programs (7-11). For other minimally invasive interventions, such as gastric and esophageal resections for cancer, there are no regular programs involving the teaching opportunities with guidance of dedicated mentors. It is obvious that MIE taught to fel-
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ACCEPTED MANUSCRIPT lows in an experienced hospital will be the favorable choice, however this is not always available (12). Apart from the fellowships institutional programs, there are other didactic courses including hands-on cadaver courses, live surgery courses, and two-day courses organized by surgical academic departments, frequently in coopera-
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tion with the industry, where the attendees will be limited in numbers. Moreover,
according to the Society of American Gastrointestinal and Endoscopic Surgeons re-
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port of 2014, the continuing education committee found that two of the most de-
sired topics were the introduction of new procedures into clinical practice and the
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management of complications (13). Moreover, other educational modalities introduce the education and control at a distance for minimally invasive procedures. We believe that telementoring may also be used for MIE. However, in the initial phase and for the first contact a visit to the teaching center will remain an essential part of
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the process. After some procedures in the proctored hospital, telementoring may be further considered. (14)
As explained in this article above, the mentoring programs in laparoscopic colorectal
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surgery had not only gained optimal results, but also acknowledged that a good
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mentor pupil relationship serves as the most optimal manner to learning this complicated approach (12,15). Our experience in implementing a mentorship since 2009 confirms the excellence of this approach. The specific problems in our approach for MIE concern foremost the following: 1) the requisite features of the centers involved, 2) the characteristics of the mentors engaged in proctoring, 3) the volume of surgeries that the teams complete, 4) the number of surgeons involved, and 5) de-
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ACCEPTED MANUSCRIPT termining which procedure to start with. This type of program can be used for other major procedures such as laparoscopic liver surgery, pancreatic surgery, gastric surgery and even robot assisted operations. Concerns include the financial aspects of this program and the insurances for the
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mentors. Costs have to be paid by the participating centers or by involved compa-
nies. Although, companies involved in those education programs cannot be involved
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in the choice of instruments and equipment.
Nevertheless, it is clear that the teaching program involving the type of mentoring
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we provided, does assure a more than sufficient introduction of new procedures with good results in patient outcomes (16) Questions that must still be addressed are which organization or surgical society will appoint centers for implementation of the program and how qualified mentors can be selected. Given our positive experi-
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ence, we argue that our teaching model involving mentoring should also be applied for teaching gastric cancer by laparoscopy and robot assisted programs.
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Recommendations
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MIE is best taught to those surgical departments who have certain properties. To start with, there must be enough volume of esophageal cancer patients. Moreover, the willingness to master MIE must include the conviction that its advantages are evidence-based. The departments must have at least two dedicated surgeons in Upper GI surgery, comprising experience with MIS. Furthermore, the whole team must be supportive, thus the entire surgical department and the hospital’s board
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ACCEPTED MANUSCRIPT need to approve the collaboration. Finally, the MIE program should be taught by an
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experienced mentor.
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ACCEPTED MANUSCRIPT Conflict of interest statement. All authors declare no conflict of interest. This research did not receive any specific grant from funding agencies in the public,
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commercial, or not-for-profit sectors.
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ACCEPTED MANUSCRIPT References 1. Nickel F, Hendrie JD, Kowalewski Kf, Bruckner T, GArrow CR, Mantel M, Kenngott HG, Romero P, Fischer L, Müller-Stich BP. Sequential learning of psychomotor and visuospatial skills for laparoscopic suturing and knot tying-a
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randomized controlled trial “The Shoebox Study” DRKS00008668.
2. Scheepers JJG, Mulder CJJ, van der Peet DL, Meijer S, Cuesta MA. Minimally
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invasive esophageal resection for distal esophageal cancer. A review of literature. Scand J Gastroenterol; Suppl 2006;123-134
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3. Scheepers JJG, Veenhof AAFA, van der Peet DL et al. Laparoscopic transhiatal resection for malignancies of the distal esophagus: outcome of the first 50 resected patients. Surgery 2008;143:278-285.
4. Scheepers JJG, van der Peet DL, Veenhof AAFA, Cuesta MA. Thoracoscopic re-
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section for esophageal cancer. A review of literature. J Min Access Surg 2007;5:149-160
5. van Hagen P, Hulshof MC, van Lanschot JJ et al. Preoperative Chemoradio-
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therapy for Esophageal or Junctional Cancer. N Eng J Med 2012;366:2074-84
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6. Biere SSAY, van Berge Henegouwen MI, Maas KW et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet 2012;379:1887-92.
7. Fleshman J, Marcello P, Stamos MJ, Wexner SD. Focus group on Laparoscopic Colectomy Education as endorsed by the American Society of Colon and Rec-
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ACCEPTED MANUSCRIPT tal surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic surgeons (SAGES). Dis Colon Rectum 2006;49:945-949. 8. Verheijen PM, vd Ven AW, Davids PH, Clark DA, Pronk A. Teaching colorectal surgery in the laparoscopic era. Is it safe ? J Surg Educ 2010;67:217-221
training. Surg Endosc 2013;27:3548-54.
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9. Fowler DL, Hogle NJ. The fellowship council: a decade of impact on surgical
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10. Palter VN, Grantcharov TP. Development and validation of a comprehensive
curriculum to teach an advanced Minimally invasive procedure: a randomized
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controlled trial. Ann Surg 2012;256:25-32
11. Bosker R, Groen H, Hoff C, Totte E, Ploeg R, Pierie JP. Effect of proctoring on implementation and results of elective laparoscopic colon surgery. Int J Colorectal Surg, 2011;26:941-7.
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12. Rossidis G, Kissane N, Hochwald SN, Zingarelli W, Sarosi G, Ben-David K. Overcoming challenges in implementing a Minimally invasive esophagectomy program at a Veterans Administration medical center. Am J Surg
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2011;202:395-9.
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13. McLemore EC, Paige JT, Bergman S, Hori Y, Schwartz E, Farrel TM. Ongoing evolution of practice gaps in GI and endoscopic surgery: 2014 report from the SAGES continuing education committee. Surg Endosc 2015;29:3017-29.
14. Bogen EM, Angestad KM, Patel HR, Lindsetmo RO. Telementoring in education of laparoscopic surgeons. An emerging technology. World J Gastrointest Endosc. 2014;16:148-55
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ACCEPTED MANUSCRIPT 15. Dominguez EP, Barrat C, Shaffer L, Gruner R, Whisler D, Taylor P. Minimally invasive surgery adoption into an established surgical practice: impact of a fellowship-trained collega. Surg Endosc 2013;27:1267-72 16. Birch DW, Asiri AH, de Gara CJ. The impact of a formal program for Minimally
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invasive surgery on surgeon practice and patient outcomes. Am J Surg
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2007;193:589-91
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Table 1. Results participating centers
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Dedicated team
Experience with MIE
Visit to our center
MIE in the proctored center
Complications
Continuation with the program
Proctored center start mentoring other centers
Financial arrangement for mentor
Step to other technique
1
2(p)
Yes
Lateral
No
5
Yes
No
Yes (company)
No
2
2(p)
Yes
Prone
No
>5
Yes
No
Yes (hotel)
Yes + Ivor Lewis
3
2(p)
Yes
Hybrid 2
No
1
Leakage (1) Unresectable (1) Postoperative bleeding (1) No
Yes
No
Yes (hotel)
No
4 5 6
2(p) 2(p) 2(p)
No No Yes
Prone Lateral Lateral
No No No
2 4 2
Yes Yes Yes
No Yes Yes
Yes trip + hotel Yes trip + hotel No
Yes + Ivor Lewis Yes + robot No
3(p)
Yes
No
Yes (2)
5
2(p) 2(t)
Yes Yes
No No
Yes (2) Yes (3)
5 5
10
2(p)
Yes
No
No
5
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4(p)
Yes
No
Yes (2)
6
12
2(t)
Yes
No
Yes (2)
13 14
2(p) 2(p)
No Yes
No No
No Yes (2)
15 16
2(p) 3(p)
Yes Yes
No No
Yes (2) No
17
2(p)
Yes
No
18
2(p)
Yes
No
19 20
2(p) 2(p)
Yes Yes
No Lateral
Table 1. Results participating centers.
5
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5 2 3 1
Yes (1)
4
No
2
No Yes (1)
2 2
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Yes
Yes (hotel)
Yes + Ivor Lewis
No Leakage (1)
Yes Yes
No Yes
Yes (hotel) No
Yes + Ivor Lewis Yes + Ivor Lewis
Respiratory infection (1) No
Stopped
No
Yes (company)
No
Yes
No
Yes (hotel)
No
Perioperative bleeding (1) No Leakage (1)
Stopped momentarily Yes Yes
No
No
No
Yes No
Yes (hotel) Yes trip + hotel
No Yes + Ivor Lewis
No Respiratory infection (1) ARDS (1)
Yes Stopped
No No
Yes (company) Yes trip + hotel
No No
Yes
No
Yes trip + hotel
No
Respiratory infection (1) No No
Yes
No
Yes trip + hotel
No
Yes Yes
No No
Yes trip + hotel Yes trip + hotel
No No
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7 8 9
No No Respiratory infection (1) Leakage (1)
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Surgeon
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Not all residency programs include a teaching program with the guidance of dedicated mentors. Teaching minimally invasive surgery requires a mentor. A dedicated team should be set up for learning new minimally invasive techniques.
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This article was based on mentoring other surgeons, therefore ethical approval was not indicated.
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Author contribution
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This article was based on mentoring other surgeons, therefore ethical approval was not indicated.
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Please specify the contribution of each author to the paper, eg study concept or design, data collection, data analysis or interpretation, writing the paper, others, who have contributed in othe ways should be listed as contributors. MA Cuesta: study concept and design, data collection, data analysis, writing N van der Wielen: data collection, data analysis, writing J Straatman: data collection, data analysis, writing DL van der Peet: study concept and design, data collection, data analysis, writing
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This is not applicable
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The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish
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