General Surgeon and Vascular Surgery in South Africa

Transcription

1 General Surgeon and Vascular Surgery in South Africa VASSA 2016 Kwa Maritane Thifheli Luvhengo Department of Surgery Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand

2 Layout Introduction. Comparison between general surgery training in vascular surgery: past versus current status. Challenges regarding general surgery exposure to vascular surgery. Consequences of current training in vascular surgery for general surgeons. The way forward.

3 UN Sustainable Development Goals 3.8 Achieve universal Health Coverage, including Financial risk protection. Access to quality essential health-care services. Access to safe, effective, quality and affordable medicines, and vaccines for all.

4 Access to quality essential health-care services Timeous Diagnosis. Treatment. Prevention.

5 Status of Vascular Surgery in Southern Africa Vascular surgery is highly technical. Shortage of vascular surgeons in RSA (around 50). A significant volume of vascular procedures is still performed by general surgeons. There is a disproportionate increase in volume of vascular work. Training of vascular surgeons cannot keep pace. Veller, Journal of Vascular Surgery 48: 84S-86S.

6 Historical General Surgery Units Doing everything which came through the door. Continuous exposure (4-5 years). Predominately trauma. Varicose vein surgery. Limited exposure Aneurysmal surgery. Bypass for occlusive disease. Balloon embolectomy.

7 Currently Subspecialty units. Not at all university departments. Limited time for rotation: 4-6 months. Not mandatory. Training not standardized. Ill-defined learning outcomes. Knowledge based examination.

8 Additional challenges Development of specialized units. Fast growth of vascular surgery. Information overload. Expansion of vascular fellowship programs. Rapid development of endovascular surgery. Less exposure to index open vascular procedures.

9 Index open vascular procedures Open AAA repair. Aorto-bifemoral bypass. Infra-inguinal bypass. Embolectomy.

10 Achilles heal: past versus present The Past Vertebral artery. The Present Knowledge. Right subclavian. Iliac vessels injury. All including repair of brachial artery! Ruptured AAA.

11 Quantity and Quality Are/should current and future general surgeons be allowed to perform index vascular procedures?

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13 At cross-road Review of vascular surgery training in general surgery. No exposure to vascular surgery. Vascular surgery as independent specialty. Trauma Surgery. Emergency General Surgery.

14 Benefits of exposing general surgery trainees to vascular surgery Peri-operative care of complex patients. Trauma Surgery. Emergency General Surgery. Complex non-vascular procedures Hepatobiliary Surgery. Transplant Surgery. Head and Neck Surgery.

15 Proposed solutions Link curriculum, training and assessment with specific learning outcomes.

16 The ideal: harmonization Appropriate curriculum. Appropriate training. Specific learning outcomes. Appropriate and standardized assessment.

17 Theoretical knowledge?

18 Which vascular procedures should a qualifying general surgeon be able to do? (Competencies) Amputations Below knee. Above knee. Acute arterial occlusion Embolectomy. Thrombosuction. Trauma Arterial injury (Carotid, subclavian, brachial, femoral and popliteal) Exposure. Repair. Harvesting of vein graft. Selection and use of prosthetic graft Fasciotomy. Dialysis access.

19 Minimum to be achieved for Index Vascular Procedures Procedure Observed Performed assisted Performed independently Fasciotomy BKA AKA Carotid endarterectomy Open AAA repair Aorto-bifemoral bypass 3 0 Embolectomy Dialysis access Infra-inguinal bypass

20 Volume challenge Twinning. Simulation. Advanced Vascular Surgery Skills Course. Wet cadavers.

21 Assessment Traditional Written Examination. Viva Voce. Simulation Standardized patient simulation (wet cadavers?). Computer-based simulation. Work-based assessment Case-based discussion (focus topics). Mini-clinical evaluation exercise. Direct observation of procedural skills (index procedures). Mini-peer assessment tool. Norcini and McKinley. Teaching and Teacher Education 2007; 23:

22 Vascular Society involvement in FCS (SA) Examinations FCS (SA) Part 1A Generic MCQs. No blueprint (for vascular). Currently: no contribution from VASSA. FCS (SA) Part 1B Blueprinted MCQs. Currently: minimal contribution from VASSA. FCS (SA) Part 2 Essay type questions. Currently: some involvement by VASSA.

23 FCS (SA) Part 2 Examination: Example 1 A 60-years-old man has undergone a hemicolectomy 8 weeks ago for a carcinoma. A week after commencing chemotherapy, he presents with pain and massive swelling of his left lower limb. There is a blister formation of the skin of the forefoot Describe in detail the clinical and radiologic methods to establish a diagnosis. [20] Describe the complications associated with that swollen lower limb. [20] Critically discuss the various treatment modalities for this condition. [20] Describe how you would perform a surgical thrombectomy with a Fogarty catheter in this patient. [20] How would you manage the tissue loss of the forefoot? [20]

24 FCS (SA) Part 2 Examination: Example 2 A 20-year-old male patient presented to a hospital emergency department 8 hours after a gunshot to the superficial femoral artery. His management included a fasciotomy and reverse saphenous vein repair i. Discuss the loco-regional and systemic complications related to revascularization. [30] ii. Discuss the indications for a fasciotomy. [20] iii. Discuss early graft failure. [20]

25 A 35-years-old male presents with end-stage renal failure. The nephrologist recommends haemodialysis within 48 hours a) Describe the technique and complications of inserting a permanent venous catheter in this patient. [30] b) Considering that dialysis may be required for decades in this patient, discuss the range of vascular access surgery options available. [20] c) Describe your technique of creating an arterio-venous fistula in this patient. [30] d) Discuss the complications of arterio-venous fistula. [20]

26 Assessment should extend beyond testing of knowledge to include both clinical and technical skills (Mitchell et al, Journal of Vascular Surgery 53:

27 Was V, Van der Vleuten, Shatzer J, et al. The Lancet 2001; 357:

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29 Van Bockel et al, Journal of Vascular Surgery 48: 69S-75S

30 Requirements Standardized/harmonized training. Guaranteed/achievable numbers. Funding (Simulation/Travel). Wet cadavers specimen. Probably an increase training time.

31 And, perhaps challenging the Amazing Race Rotation Breast and Endocrine Endoscopy GIT Minimal access Paediatric Surgery Trauma Vascular Duration 4 moths 4 months 4 months 4 months 4 months 4 months 4 months

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33 Thank you.