Flat Learning Curve Research Articles

Influence of specialization on primary success and complication rate in ERCP. Proposal to improve the quality of ERCP

Endoscopic retrograde cholangiopancreatography [ERCP] is a complex procedure with a flat learning curve. It is associated with the risk of serious complications such as pancreatitis, bleeding, cholangitis and perforation. Endosonography should therefore also be offered for the precise indication of the higher-risk ERCP. Numerous factors influence the success of ERCP. In addition to structured training for the initial acquisition of skills and a minimum number of ERCPs of varying degrees of difficulty, maintaining a good quality of ERCP also requires a regular minimum number of examinations performed per year. There is extensive evidence that shows a significant correlation between ERCP volumes and primary success rates, lower lengths of hospital stay, fewer unwanted readmissions and fewer complications. The cut-offs for differentiating between high-volume and low-volume centers were chosen inconsistently in the studies, with the highest evidence for a cut-off value of 200 ERCPs/year. The question of specialization in ERCP has been given a relevance by the current developments in german hospital reform. Here, a minimum number of ERCPs should be defined for groups of different specialization. However, a minimum number alone will not be able to achieve good treatment quality. In terms of high-quality patient care, it is necessary to offer ERCPs in specialized gastroenterology center, which, in addition to a sufficient number of ERCPs for training and to maintain competence, offer an on-call service and complementary procedures such as EUS and which are embedded in appropriately accessible clinics that have the necessary resources for complication management.

Outcomes of V-Y Quadricepsplasty for the Management of Genu Recurvatum Deformity in Congenital Dislocation Knee

Abstract Background: Congenital dislocation knee (CDK) is a rare congenital anomaly clinically presented with genu recurvatum deformity. In early reported cases, conservative management with manipulation and serial casting once a week for up to 4 weeks can be successful. Surgical methods of deformity correction include percutaneous quadriceps recession, Z-plasty, V-Y quadricepsplasty (VYQ), and Achilles tendon reconstruction for the reconstruction of the quadriceps tendon. Very few studies are reported in Indian literature describing the outcomes of surgical intervention in such an uncommon congenital deformity. The purpose of this study is to evaluate the outcomes of VYQ in CDK. Materials and Methods: Ten children with CDK with a mean age of 44.4 months, who met the inclusion criteria, were included in the study. All the children had undergone VYQ as described by Curtis and Fisher and subsequently modified by Tercier and Shah. Outcome measures such as active and passive knee range of motion, quadriceps power, and modified knee functional scoring system were assessed at the final follow-up. Results: Most of the children in the current study achieved knee flexion of >90° with an average flexion of 90.5° + 21.73 (standard deviation), and 50% of them achieved quadriceps power Grade 4 or more (median 3.5). Modified knee function score was good in 60% of cases, fair in 20%, and excellent function in 10% of cases. Conclusion: Adequate knee flexion without quadriceps weakness and good knee function can be achieved by VYQ in CDK. This is a simple surgical procedure that can be easily learned with a flat learning curve.

Construction and remote demonstration of an inexpensive but efficient experimental setup for studying self-inductance and mutual-inductance between two coils

Measurement of self-inductance and mutual-inductance has been demonstrated as a laboratory experiment with great simplicity. The novelty of this demonstration lies in its straightforward circuitry and methodology, enabling the experiment accessible to students with minimal prerequisite knowledge. A coil-pair setup was constructed using discarded common household articles, costing very low but provides high quality throughput in teaching-learning experience. The demonstration can be easily conducted online using a laptop without the need of extra power supply. The experiment suits for high school and pre-university students, as evident by twenty first-semester undergraduate physics and electronics students who found it both satisfying and enjoyable with a relatively flat learning curve.

Learning curves of robotic extended totally extraperitoneal (eTEP) hernia repair among two surgeons at a high-volume community hospital: a cumulative sum analysis.

Robotic extended totally extraperitoneal hernia (eTEP) repair is a novel technique for minimally invasive ventral hernia repair with retromuscular placement of mesh. This study aimed to evaluate the learning curve for robotic eTEP hernia repair using risk-adjusted cumulative sum (RA-CUSUM) analysis for two general surgeons-one with dedicated fellowship training in robotic eTEP technique (surgeon 2) and another without robotic eTEP-specific training (surgeon 1). We conducted a retrospective analysis of 98 patients undergoing robotic eTEP hernia repair from July 2020 to February 2022 for two surgeons. RA-CUSUM method was applied to the overall operative time (OT) in minutes, adjusting for transversus abdominis release (TAR). Figures 3 (surgeon 1) and 4 (surgeon 2) illustrate the three phases in the RA-CUSUM graphs of OT. For surgeon 1, the cases for each phase were determined: phase 1 (1 to 12), phase 2 (13 to 24), and phase 3 (25 to 51). For surgeon 2, the three phases were similarly determined as 1 to 8, 9 to 32, and 33 to 47, respectively. A significant (p = 0.017) difference existed for the OTs between phases 1 (262 ± 69) and 3 (192 ± 63.0) for surgeon 1. OT compared to the risk-adjusted value stabilized after case 12 and decreased after case 24 for surgeon 1; it began to decrease after case 8 for surgeon 2. The initial learning curve for surgeon 1 reached its plateau after 12 cases, shorter than comparable studies. This was likely due to the surgeon's intentional focus on learning this technique through courses, proctoring, and active mentorship. The flat learning curve seen in surgeon 2's series illustrates the value of experience gained during fellowship training. Our data support that, given the right resources and support, a short learning curve for eTEP is attainable for community surgeons without prior training in the technique.

Attendance System Using Face Detection and Face Recognition in Python Programming Language

The programming language Python is gaining popularity. It has a fairly flat learning curve and is a free, high-level language. It features a large selection of free libraries. The first topic covered in this study is computer vision libraries. The capabilities of the existing libraries for face detection and identification are next examined. The algorithm utilised in the libraries is provided a basic description. An example of the generated image is given for each significant stage. Even though the study only includes two sample photographs, the technique was tested on a large number of images. The investigation proved that Python is the go-to programme for tasks requiring face recognition and detection.

Accuracy of dynamic implant navigation surgery performed by a novice operator.

The main objective was to evaluate the accuracy of dynamic navigation-guided surgery (DNGS) for implant positioning performed by a novice operator. The secondary objectives were to analyze the operator's learning curve and identify possible complications deriving from the technique. Twenty-five implants were placed in eight partially edentulous human heads. Preoperative CBCT scans were imported to planning software to determine the implant positions. Implants were placed using a dynamic navigation system. Postoperative CBCTs were superimposed onto the implant planning images. Discrepancies between the virtually planned implant positions and the postoperative positions were evaluated by measuring horizontal platform deviation, apex deviation, apicocoronal (vertical) deviation, and angular deviation. Mean platform, apex, vertical, and angle deviations were 1.55 ± 0.81 mm, 2.45 ± 0.84 mm, 1.59 ± 0.70 mm, and 5.56 ± 4.03 degrees, respectively. No significant differences were found between the maxilla and mandible or between anterior and posterior sites. A flat learning curve was observed, with the exception of the implant platform, where a tendency toward improvement in accuracy was observed between the 8th and the 17th implant placed. No complications were reported. Based on the results of a study performed by a novice operator on a cadaveric model, DNGS allows accurate implant placement within a 2-mm safety margin in terms of implant platform and vertical positions, and a 3-mm margin in apical vicinities. The technique requires practice to learn the required eye-hand coordination. (Int J Comput Dent 2022;25(4):377-0; doi: 10.3290/j.ijcd.b2588207).

An Energy-aware Ad-hoc Routing Strategy for Queriable Wireless Sensor Networks

The data volume handled by wireless sensor networks (WSN) is ever growing due to increasing node counts and node complexity – be it in traditional WSN applications or for Car2X or Internet-of-Things. Queriable WSN are a concept to handle the large data volumes in such networks by abstracting the network as a virtual database table to which users can pose queries. This declarative approach enables networks which can flexibly adapt to changing application requirements. In addition they possess a flat learning curve since users do not need to have a high technological understanding of the sensor node firmware. Upon executing a query it is first propagated through the network and once it has reached the desired nodes, results are collected and send back through the query-posing node (usually the sink). The routing which is used for the data aggregation step plays a major role in the energy efficiency in networks with increasing node and sensor value counts as represented by Car2X networks for instance. In this paper, an ad-hoc routing strategy for queriable WSN is proposed which is both energy-aware and application-specific. It will be shown that this routing can contribute greatly towards decreasing the energy consumption needed for data aggregation and thus helps increasing the network’s lifespan.

The percutaneous learning curve of 3rd generation minimally-invasive Chevron and Akin osteotomy (MICA)

BackgroundMinimally-invasive Chevron and Akin osteotomy (MICA) represents the third-generation percutaneous hallux valgus surgery which is characterized by an extra-articular osteotomy, stable internal fixation and a high potential for correction. Compared to other percutaneous techniques of the foot, MICA is generally regarded as an advanced and demanding surgical procedure with a flat learning curve. The aim of this study is to analyze a single-surgeons experience with his first 50 consecutive MICA procedures. MethodsBetween May 2018 and February 2021, 50 consecutive MICA procedures performed by the author with the "K-wires-First technique" were prospectively analyzed focusing on surgery duration, number of fluoroscopies, correction results and surgery-associated complications. A modification of the original MICA technique as described by its inaugurators Redfern and Vernois allows the use of a standard-sized C-arm and aims to reduce revison rates and conversion to open surgery by placing the guidewires prior to performing the osteotomy. ResultsThe average surgery time for all MICA procedures was 46.8 min (SD 12.1, range 31–90 min). The average amount of fluoro shots required to perform MICA was n = 126.6 (SD 40.8, range 65–231). Comparing the preoperative and 6-week postoperative radiographs, the IMA decreased after MICA by a mean of 10.8° from 16.2° to 5.4° and the HVA by a mean of 22.1° from 30.6° to 8.5°. One case required intraoperative conversion to open hallux correction. There were 4 feet in three patients with secondary screw removal of the Chevron fixation due to prominent proximal screw tips. ConclusionsAlthough the learning curve of 3rd generation MICA is flat and requires specific training and intensive practice, the rate of complications is not elevated compared to other percutaneous hallux valgus techniques. Strict adherence to the principles of 3rd generation MICA with stable fixation and meticulous intraoperative control of each surgical step helps to reduce surgery-associated complications. The learning curve showed a continous improvement in regard to surgery time and use of fluoroscopy. After 40 procedures, the surgery time consistently dropped under 45 min and required less than 100 fluoro-shots. The modified surgical technique may help reduce Chevron screw mal-positioning when using large C-arm fluoroscopy for this procedure.

The pelvitrainer for training in laparoscopic surgery – A prospective, multicenter, interdisciplinary study: Experimental research

BackgroundMinimally invasive surgical procedures have a flat learning curve, especially in the initial period of a surgeon's training. Pelvitrainers enable the prospective surgeon to drill the surgical technique, including camera navigation, instrument manipulation, and the individual steps of the operation, on a model rather than a patient. Integrating the pelvitrainer into standardized surgical training programs is challenging, but would be essential to achieve optimum effects of long duration in surgical education. Material and methodsThe pelvitrainer Realsimulator 2.0 (Endodevelop) was evaluated in 16 standardized training courses (at three training centers) of the German Working Group for Gynecological Endoscopy (AGE e.V.) from 2017 to 2020, The training concept was implemented and evaluated in a prospective, multicenter, interdisciplinary, multinational setting. ResultsOne hundred and eighty of 206 physicians (response rate 87.4%) completed the multi-stage training concept successfully. A significant (p < 0.001) objective improvement (positive learning curve) was observed for all exercises on the pelvitrainer. The trainer's subjective evaluation revealed positive ratings for design (median 82%, IQR 71–91%), camera navigation (87%, IQR 76–95%), and instrument manipulation (median 87%, IQR 77–94%). A follow-up survey performed six months after the course confirmed its sustainable and high benefits in clinical routine (median 82%, IQR 70–97%). ConclusionThe present investigation proved the high educational value of pelvitrainers, which can be enhanced by using a structured training concept. The benefit of training courses for health care justifies their incorporation into a standardized training curriculum. The completion of such training courses should be regarded as a prerequisite for a doctor to qualify as an independent surgeon.

Mini-Implants in Dentistry - A Review.

Mini-implants were introduced as an alternative to standard implants for use in narrow alveolar ridges due to their smaller length and size. They are also used to provide anchorage in orthodontic treatments. Mini-implants offer simplified treatment procedures with a flat learning curve, low cost, and a possible flapless surgical procedure that can decrease post-surgical morbidity. Before being implemented into clinical practice, they were subjected to in vivo testing using animal models as is with all implant research. The biomechanical properties of mini-implants have earned them a high rate of acceptance in treatment among patients. In this review, we focus on mini-implants, extrapolation from mini-implant testing on animal models, and their latest use in dentistry.

A new model of inexpensive portable homemade PERC Mentor (IPHOM) and its validation

BackgroundPercutaneous nephrolithotomy (PCNL) is a complex surgery and has a flat learning curve. Due to this and the ethical issues, trainees do not get enough hands on exposure. Virtual simulator is very expensive and bulky. Animal model requires legal clearance. This inexpensive portable homemade PERC Mentor (IPHOM) teaches all the major aspects of PCNL surgery. This article has shown the way to make this model and its validation study.MethodsIPHOM can be made at home with carton box, ball bearings, LED torch and some hospital wastes. After a short demonstration of IPHOM, 14 residents and 4 urologists were given 8 tasks to perform on it followed by 15-min supervised practice exercise on day 0 and day 1. Their performance was reassessed on day 2 and 3. Response to 17 feedback points was recorded on a seven-point Likert scale.ResultsThere was significant difference between the performance of expert and novice on day 0. Expert completed all the tasks in less time and no. of attempts. The time for tract dilatation and duration of radiation exposure were significantly less in the expert group. The performance of both expert and novice improved on day 2 and 3, but the improvement was significantly more in novice. Response to the feedback points showed no difference between expert and novice (p > .05).ConclusionsWe have found that training on IPHOM has improved the concept and skills of PCNL in residents. The simplicity and low cost of the model make it constructible at home.

PD58-09 SURGICAL EXPERIENCE AND ONCOLOGIC QUALITY IN ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY: ARE THEY ALWAYS LINKED?

You have accessJournal of UrologySurgical Technology & Simulation: Training & Skills Assessment (PD58)1 Sep 2021PD58-09 SURGICAL EXPERIENCE AND ONCOLOGIC QUALITY IN ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY: ARE THEY ALWAYS LINKED? Turki Altaylouni, Pimrapat Gebert, Sefer Elezkurtaj, Florian Rossner, Bernhard Ralla, Jonas Busch, Thorsten Schlomm, and Bertrand Guillonneau Turki AltaylouniTurki Altaylouni More articles by this author , Pimrapat GebertPimrapat Gebert More articles by this author , Sefer ElezkurtajSefer Elezkurtaj More articles by this author , Florian RossnerFlorian Rossner More articles by this author , Bernhard RallaBernhard Ralla More articles by this author , Jonas BuschJonas Busch More articles by this author , Thorsten SchlommThorsten Schlomm More articles by this author , and Bertrand GuillonneauBertrand Guillonneau More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002092.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Previous studies reported that surgical outcomes improve with surgeons’ experience and surgeons’ generation. We assessed this statement in our tertiary university care center regarding pathologic outcomes after Robot-Assisted Laparoscopic Prostatectomy (RALP). METHODS: The study cohort included 1348 prostate cancer patients treated with RALP between February, 2010 and April, 2020. The 1st and 2nd surgeons’ generation of Surgeons included 3 surgeons each and have operated on 662 and 676 patients respectively. The two groups of patients were comparable regarding prostate specific antigen (PSA) and clinical stage by using Mann-Whitney U test and Chi-square test, respectively. We created learning curves for positive surgical margin (PSM) rate, pelvic lymph node dissection (PLND) probability and number of LN removed after adjusting for pre-operative PSA, pTNM stage, Gleason grade and the use of intra-operative frozen section (Neurosafe strategy). We also compared results between the 1st and 2nd generation of surgeons in regression models. RESULTS: Regarding PSM rate, learning curves after adjustment were flat at around 20% and didn’t show any improvement with experience. The comparison between, learning curves for PSM demonstrated no differences between the 2 generations of surgeons’ generation (p=0.794). Regarding PLND indications, a statistical significant improvement of PLND performed was found according to the surgeon’s experience for the 1rst generation. The 2nd generation had a learning curve that remained flat with experience at a high level (92.3%) and overall significant better than the first generation (p<0.001). Identically, numbers of LN removed showed a significant increase with experience in both generations but the overall the 1rst generation only while the second generation had a flat learning curve with a mean median number of LN removed significantly higher in the 2nd generation compared to the 1st generation (12 versus 10 for the 1rst generation, p<0.001) . CONCLUSIONS: In our study about experience of surgeons with robot-assisted radical prostatectomy, surgeons demonstrated improvement with experience regarding the indication for PLND and the number of nodes removed. Regarding PSM, surgeons demonstrated no improvement over time and through generation. Experience alone is not an intrinsic quality factor. Other factors might play a role for oncological improvement aside from experience only. Improvement in quality insurance concept should be implemented as a possible factor. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1020-e1020 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Turki Altaylouni More articles by this author Pimrapat Gebert More articles by this author Sefer Elezkurtaj More articles by this author Florian Rossner More articles by this author Bernhard Ralla More articles by this author Jonas Busch More articles by this author Thorsten Schlomm More articles by this author Bertrand Guillonneau More articles by this author Expand All Advertisement Loading ...

Linguistic and neurocognitive correlates of probabilistic classification learning in schizophrenia

Individuals with schizophrenia demonstrate impaired implicit learning on cognitively complex tasks and preserved implicit motor learning. However, little is known about how implicit learning may be related to other linguistic and cognitive variables, including development of complex language including comprehension and syntax. This study explored the relationship between probabilistic classification learning, a type of implicit learning style, and linguistic and cognitive skills in schizophrenia. This was done by examining how schizophrenia patients perform on the Weather Prediction Task (WPT) relative to controls, particularly during a dual-task interference condition that assesses task automaticity. Individuals with schizophrenia (N = 34) demonstrated depressed cognitive functioning relative to the controls (N = 18) across nearly all cognitive functions. On the Weather Prediction Task, the schizophrenia group performed less accurately than the control group in later blocks and had a relatively flat learning curve. A significant Group X Block effect when controlling for age and sex suggested differential learning throughout the task. A subgroup of patients did not develop automaticity during the repeated blocks of trials. For those patients who did not develop automaticity over the course of the WPT, linguistic and cognitive skills were strongly correlated with their Block 1 performance. For patients who developed automaticity, overall neurocognitive ability was correlated with their ultimate level of performance on the WPT but not with their Block 1 performance. That language was related to differential learning emphasizes the role of explicit, verbal processes on making initial rapid improvement on the WPT.

Microscopic extra-laminar sequestrectomy (MELS) for the treatment of hidden zone lumbar disc herniation: report of the surgical technique, patient selection, and clinical outcomes

BackgroundThe area which located at the medial pedicle, posterior vertebral body and ventral hemilamina is defined as the hidden zone. Surgical management of hidden zone lumbar disc herniation (HZLDH) is technically challenging due to its difficult surgical exposure. The conventional interlaminar approach harbors the potential risk of post-surgical instability, while other approaches consist of complicated procedures with a steep learning curve and prolonged operation time.ObjectiveTo introduce microscopic extra-laminar sequestrectomy (MELS) technique for treatment of hidden zone lumbar disc herniation and present clinical outcomes.MethodsBetween Jan 2016 to Jan 2018, twenty one patients (13 males) with HZLDH were enrolled in this study. All patients underwent MELS (19 patients underwent sequestrectomy only, 2 patients underwent an additional inferior discectomy). The nerve root and fragment were visually exposed using MELS. The operation duration, blood loss, intra- and postoperative complications, and recurrences were recorded. The Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and the modified MacNab criteria were used to evaluate clinical outcomes. Postoperative stability was evaluated both radiologically and clinically.ResultsThe mean follow-up period was 20.95 ± 2.09 (18–24) months. The mean operation time was 32.43 ± 7.19 min and the mean blood loss was 25.52 ± 5.37 ml. All patients showed complete neurological symptom relief after surgery. The VAS and ODI score were significantly improved at the final follow-up compared to those before operation (7.88 ± 0.70 vs 0.10 ± 0.30, 59.24 ± 10.83 vs 11.29 ± 3.59, respectively, p < 0.05). Seventeen patients (81%) obtained an “excellent” outcome and the remaining four (19%) patients obtained a “good” outcome based the MacNab criteria. One patient suffered reherniation at the same level one year after the initial surgery and underwent a transforaminal endoscopic discectomy. No major complications and postoperative instability were observed.ConclusionsOur observation suggest that MELS is safe and effective in the management of HZLDH. Due to its relative simplicity, it comprises a flat surgical learning curve and shorter operation duration, and overall results in reduced disturbance to lumbar stability.

Simplified biplanar (0-90°) fluoroscopic puncture technique for percutaneous nephrolithotomy: the learning curve.

To evaluate the learning curve of the simplified fluoroscopic biplanar (0-90º) puncture technique for percutaneous nephrolithotomy. We prospectively evaluated patients with renal stones treated with percutaneous nephrolithotomy by a single institution's fellows employing the simplified bi-planar (0-90º) fluoroscopic puncture technique for renal access. The learning curve was assessed with the fluoroscopic screening time and the percutaneous renal puncture time. Data obtained were compared to a subset of patients operated by a senior surgeon. Eighty-nine patients were included in the study. Forty patients were operated by fellow-1, 39 by fellow-2, and 10 patients by the senior surgeon. Demographic data of all patients between groups were homogeneous, with no difference in gender (p = 0.432), age (p = 0.92), stone volume (p = 0.78), puncture laterality (p = 0.755), and body mass index (p = 0.365). The mean puncture time was 7.5, 4, and 3.1min for fellow-1, fellow-2, and expert, respectively. The mean fluoroscopic screening time for the puncture was 10, 11, and 5.1s for fellow-1, fellow-2, and the expert, respectively. Stone cases, both fellows needed to complete 10 procedures to match the senior surgeon in the mean puncture time (p = 0.046); meanwhile, the fluoroscopic screening time was equal even before to complete 10 procedures. This study suggests that with the simplified biplanar (0-90º) puncture technique, the fluoroscopic screening time used in the learning process is brief. A novice fellow could require to complete ten cases to flatten the learning curve treating complex stone cases, and a flat learning curve is seen since the beginning when treating simple renal stones.

A dynamic multi-sector analysis of technological catch-up: The impact of technology cycle times, knowledge base complexity and variety

This article contributes to the ongoing debate about whether, how, and under what conditions latecomer countries can become producers of new technology and innovation, thereby catching up with technological leaders. Recent work on sectoral systems of innovation and in the evolutionary economics literature suggests that successful latecomers can move into new technological or industrial domains. They specialise in domains that present more frequent windows of opportunity, shorter technological cycles, flatter learning curves and easier access to relevant knowledge than others. This study investigates the role and significance of two hitherto neglected dimensions of technological regimes that might influence technological catch-up, namely, the degree of complexity and variety of an industry's knowledge base.The impact of technological variety and complexity on catch-up dynamics is tested in three industries – upstream oil/gas, wind power and solar energy – over the period from 1980 to 2016. First, we find that increased knowledge base complexity and related (as opposed to unrelated) variety play a substantial role by hindering the latecomers’ attempts to catch up with technological leaders within each industry. Second, we confirm that other dimensions of technological regime are relevant. Specifically, we find that the length of the technological cycle is important, although a nuanced picture emerges regarding the direction of its impact on catch-up when results are compared across the three industries. These results offer new insights into the technologies and industries in which latecomer countries can specialise in order to develop their innovation capacity.

A Structured, Microsurgical Training Curriculum Improves the Outcome in Lower Extremity Reconstruction Free Flap Residency Training: The Ludwigshafen Concept.

Risk stratification, economic pressure, and a flat learning curve make the realization and development of proper microsurgical skills and competences a challenging task in the daily clinical practice. In previous studies, we were able to show that microsurgical procedures, e.g., free flaps and replantations, are safe training procedures and teachable in daily clinical practice in view of certain issues of risk stratification. The present study aims to evaluate further improvements in terms of safety and complication rates for free flaps as a training procedure after introduction and continuous implementation of a structured in-house training curriculum for microsurgical skills and competences and a 24-hour free accessible microsurgical training facility for the plastic surgery resident. This retrospective comparative cohort study was conducted to review whether microsurgical skills for free flaps to the lower extremity can further be improved after implementation of the curriculum and a 24-hour accessible training facility. Therefore, we compared cohort A before (2009-2012) and B after (2014-2017) implementation. Patient demographics, procedural characteristics, and outcome parameters for free tissue transfer of the lower extremity were evaluated. The comparison of both cohorts showed a significantly reduced postoperative complication rate for cohort B (p <0.05). Furthermore, operation time was shorter, and the hospital stay could be significantly decreased (p <0.01). Workhorse flaps for plastic surgical training were the anterior lateral thigh (ALT) flap or the musculus latissimus dorsi (LD) flap. However, even more complex procedures with arteriovenous loops could be safely performed by plastic surgery residents under the supervision of the senior surgeon in exceptional cases. The implementation of a regularly held, microsurgical in-house training curriculum with 24-hour accessible training facility improves procedural and outcome parameters for free flaps to the lower extremity for surgical residents and is an elementary part of skills and competency training. However, risk stratification, repeated surgical exposure, expertise, and institutional infrastructures are essential and must be taken into consideration.

Ab externo device for the treatment of glaucoma: direct flow from the anterior chamber to the ocular surface.

A new microinvasive glaucoma surgery device, the Beacon Aqueous Microshunt (BAM), drains aqueous humor directly from the anterior chamber to the surface of the eye vs draining to enclosed spaces within the eye, where outflow resistance, including the episcleral venous pressure, might limit drainage effectiveness. The BAM has a 0.030 mm × 0.048 mm channel and provides a fixed resistance. For implantation, a 1.40 mm wide transcorneal incision into the anterior chamber was created with a posterolimbal outer placement under topical anesthesia. The surgery was easy to execute and had a flat learning curve. Preliminary and early experience have shown success with lowering intraocular pressure immediately postoperatively. In conclusion, the BAM offers a promising minimally invasive surgical procedure.

The Learning Curve for Transurethral Resection of Bladder Tumour: How Many is Enough to be Independent, Safe and Effective Surgeon?

Transurethral resection of the bladder tumour (TURBT) is one the most common urological procedures. It is also one the fundamental surgeries performed by residents. The learning curve (LC) for TUR has never been analysed. The aim of the study was to analyse the learning curve of TURBT in a residency setting. This retrospective multicentre analysis of prospectively maintained databases enrolled 993 consecutive TURBTs performed by 10 urology residents in 3 academic institutions. Study end-points were as follows: the absence of muscularis propria in a specimen, any intra- or postoperative surgical complication and 3-month recurrence-free survival. With increasing experience, residents operated more complex cases defined by higher rate of large, multifocal or high-risk tumours. In the same time, surgery time, postoperative catheterization time and hospital stay became shorter. An improvement has been noticed regarding the muscularis propria sampling and 3-month recurrence-free survival, but not regarding the risk of surgical complications. Evident improvement in study end-points was noticed after 101 operations; surgeons achieved the best clinical outcomes after performing 170 procedures, whereas the poorest results for the first 45 operations. TURBT has a flat LC with 100 cases being the absolute minimum for a resident in training to achieve acceptable oncological and surgical outcomes.

Clinical Outcomes of Collagenase Injections During a Surgeon’s Initial Learning Phase

Purpose Collagenase Clostridium histolyticum (CCH) has increasingly been used to treat Dupuytren contracture since its Food and Drug Administration approval in 2010. One concern among practitioners is the learning curve of this new technique. This study characterizes success and complication rates for surgeons with no prior experience with CCH treatment. Methods We recruited 10 hand and upper-extremity surgeons for this study. Retrospective clinical records were reviewed for the first 10 CCH injections by each surgeon. Preinjection, postmanipulation, and 30- to 90-day follow-up measurements were recorded, along with any complications. Finally, provider opinions regarding CCH for Dupuytren contracture were collected. Results There were 100 CCH injections in 100 fingers: 42 with isolated metacarpophalangeal contractures, 24 with isolated proximal interphalangeal contractures, and 34 with both metacarpophalangeal and proximal interphalangeal contractures. At 30- to 90-day follow-up, 61.4% of primary joints demonstrated improvement of contracture to within 0° to 5° degrees from full extension, 85.2% showed greater than 50% reduction in contracture, and 12 patients were lost to follow-up. Trend analysis suggested a flat initial learning curve. Complications occurred in 33 cases and included skin tears (31) and lymphadenopathy (4). No tendon ruptures were observed. All surgeons were either satisfied or extremely satisfied with CCH and continued using it in their practices. Conclusions Clinical results achieved from practitioners' early injections mirrored success and surgeon satisfaction rates previously reported in the literature. However, complication rates were higher than those in initial clinical trials but similar to later studies that used local anesthesia during manipulation. Trends in clinical outcomes among the first 10 injections suggest an initially flat learning curve for CCH. Practitioners' opinions of CCH remained favorable after early use. Type of study/level of evidence Therapeutic III.