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Introduction: Colonoscopy adverse events (AEs) are commonly underreported and standardised reporting is rarely used. We aimed to investigate AEs associated with colonoscopy in a real world setting, using the American Society of Gastrointestinal Endoscopy (ASGE) lexicon. Methods: This retrospective cohort study of AEs related to outpatient colonoscopies performed in the North Denmark Region from 2015 to 2018 identified AEs from readmission within eight days or death within 30 days of colonoscopy. AEs were investigated in electronic health records and categorised, attributed and graded according to the ASGE lexicon. Results: Of 49,445 colonoscopies performed, 1141 were potentially associated with AEs (23.07‰). Electronic health record review left 489 AEs attributed to colonoscopy (9.9‰); categorised as cardiovascular (0.65‰), pulmonary (0.36‰), thromboembolic (0.10‰), instrumental incl. perforations (0.99‰), bleeding (3.07‰), infection (0.87‰), drug reactions (0.04‰), pain (2.00‰), integument (damage to skin/bones) (0.34‰) and other (1.62‰) AEs. Ten (0.20‰) AEs were fatal, but only one was procedure related (perforation). All shearing force perforations occurred in the sigmoid colon. Most polypectomy perforations occurred in the caecum (60%). Conclusions: Colonoscopy carries important procedure and non-procedure related risks. Non-procedure related AEs are likely underreported. Better attention to patients with pre-existing diseases and further colonoscopist training may lower AE rates. A standardised colonoscopy AE reporting system is warranted.

INTRODUCTION: In Denmark, quality-improvement initiatives aimed at providing a better colonoscopy service are few. The primary objective of this study was to improve colonoscopy quality at Aalborg University Hospital, Denmark, using structured training programmes. The secondary aim was to introduce a system for individual colonoscopist performance monitoring.METHODS: We conducted a colonoscopy-quality pilot study covering two major quality performance indicators: caecum intubation rate (CIR) and polyp detection rate (PDR). The pilot study was followed by colonoscopy training programmes offering experienced colonoscopists colonoscopy skills upgrading, polypectomy and train-the-trainers courses taught by English experts. Junior doctors completed a 20-day module-based colonoscopy-training programme. A regional individual colonoscopy quality-reporting system was developed as a supplementary file within the electronic health records.RESULTS: The CIR increased from 87.1% to 92.1% (p less-than 0.001) and the PDR from 33.7% to 41.7% (p less-than 0.001) in the course of the structured training programme. Multivariable analysis adjusting for patient sex, patient age and colonoscopy indication showed a significant increase in CIR (p less-than 0.001), but not in PDR (p = 0.19). The colonoscopy quality reporting system was introduced and now provides biannual feedback to all colonoscopists.CONCLUSIONS: Quality-improvement initiatives may lead to an improved CIR and possibly PDR. Nationwide training programmes and performance monitoring should be implemented to further improve and monitor colonoscopy quality.FUNDING: none.TRIAL REGISTRATION: not relevant.

Relatively little evidence about the validity threats in open-book multiple-choice tests exist. The aim of this study was to examine validity aspects relating to gener-alization, extrapolation and decision of a multiple-choice test of medical knowledge with aids (open-book and internet access). The theoretical framework was modern validity theory, and the study was designed as a ‘known groups com-parison’ study. Test performances of three known groups of test takers hypothe-sized to have different knowledge levels of the test content were compared, and analysis of pass/fail decisions was used to examine implications of decisions based on test scores. Results indicated that it was possible to discriminate between expert and non-expert test taker groups even with the access to aids. In contrast, an inde-fensible passing score was found to be the largest potential threat to test validity. Relatively little evidence about the validity threats in open-book multiple-choice tests exist. The aim of this study was to examine validity aspects relating to gener-alization, extrapolation and decision of a multiple-choice test of medical knowledge with aids (open-book and internet access). The theoretical framework was modern validity theory, and the study was designed as a ‘known groups com-parison’ study. Test performances of three known groups of test takers hypothe-sized to have different knowledge levels of the test content were compared, and analysis of pass/fail decisions was used to examine implications of decisions based on test scores. Results indicated that it was possible to discriminate between expert and non-expert test taker groups even with the access to aids. In contrast, an inde-fensible passing score was found to be the largest potential threat to test validity.

Objectives: New working time directives reduce the available training hours for futuresurgeons. Laparoscopic training must be more efficient, and deliberate clinical operative training within a short time-frame (module based training) might help achieve this goal. This study set out to measure the effect of such a module based training programme for surgical trainees applied to laparoscopic cholecystectomy. Method: Randomized controlled trial in Danish surgical training hospitals. Thirty-five Danish surgical specialty trainees (registrars) were randomized to either module based training including performance of 20 procedures within 4-8 weeks or standard clinical training. The laparoscopic cholecystectomies were videotaped and blindly rated by three professors/consultants using the validated tool: Global Objective Assessment of Laparoscopic Skills (GOALS). Results: Data show a significant effect of the module based training program on technical skills compared to standard training at one year follow-up despite equal number of performed procedures in the two groups (p=0.010). Due to a large number of drop-outs only ten participants completed the study with the required number of videotaped operations. Inter-rater reliability showed Cronbach’s alpha=0.37. Conclusions: Only few trainees completed the study and inter-rater reliability was low, which highlight some of the challenges in educational randomized studies. Despite this, module based training showed promising effect as an efficient method in clinical skills training of surgical registrars.

An internet-based survey among Danish doctors specializing in diagnostic radiology revealed differences with respect to the length of internships at regional and university hospitals as well as the educational environment. The university hospitals were generally evaluated to have the best educational facilities except within practical skills. Therefore, it seems necessary to optimize the educational environment at regional hospitals, especially within medical expertise and scientific skills which are key elements regarding continuous development and quality assurance within radiology.

OBJECTIVES: Evaluation of surgical training in Denmark is competency based with no requirement for a specific number of procedures. This may affect monitoring of surgical progress adversely and cause an underestimation of the time needed to acquire surgical competencies. We investigated the number of common surgical procedures performed by trainees. Trainees' and consultants' expectations from the training program were also investigated.DESIGN AND PARTICIPANTS: A questionnaire was sent to all 115 surgical trainees in Denmark. We asked how many common surgical procedures the trainees had performed during their postgraduate training, whether self-reported procedural confidence was achieved during their training, and whether their training expectations were met. Another questionnaire dealt with the consultants' expectations of the surgical training.RESULTS: The total number of common surgical procedures (Lichtenstein hernia repair, appendectomy, laparoscopic appendectomy, and laparoscopic cholecystectomy) that were performed varied between trainees. One group performed few common procedures during training. A low number in 1 procedure correlated with a similar pattern in other procedures. Approximately one-third did not perform common elective procedures independently until their fifth year. Consultants and trainees viewed training differently.CONCLUSIONS: Our study reveals no common trend in the numbers and types of procedures performed during training. The number of procedures seems to reflect the individual trainee and a local tradition rather than the particular training program. An informal competency-based assessment system with lack of quantitative requirements evidently involves a risk of skewness in training.

PURPOSE: Lichtenstein hernia repair is a common surgical procedure and one of the first procedures performed by a surgical trainee. However, formal assessment tools developed for this procedure are few and sparsely validated. The aim of this study was to determine the reliability and validity of an assessment tool designed to measure surgical skills in Lichtenstein hernia repair.METHODS: Key issues were identified through a focus group interview. On this basis, an assessment tool with eight items was designed. Ten surgeons and surgical trainees were video recorded while performing Lichtenstein hernia repair, (four experts, three intermediates, and three novices). The videos were blindly and individually assessed by three raters (surgical consultants) using the assessment tool. Based on these assessments, validity and reliability were explored.RESULTS: The internal consistency of the items was high (Cronbach's alpha = 0.97). The inter-rater reliability was very good with an intra-class correlation coefficient (ICC) = 0.93. Generalizability analysis showed a coefficient above 0.8 even with one rater. The coefficient improved to 0.92 if three raters were used. One-way analysis of variance found a significant difference between the three groups which indicates construct validity, p < 0.001.CONCLUSIONS: Lichtenstein hernia repair skills can be assessed blindly by a single rater in a reliable and valid fashion with the new procedure-specific assessment tool. We recommend this tool for future assessment of trainees performing Lichtenstein hernia repair to ensure that the objectives of competency-based surgical training are met.

Incisional hernia following laparotomy remains an important problem. Laparoscopic repair has become the method of choice in recent years. The present article presents the outcome of laparoscopic incisional hernia mesh repair at Viborg Hospital in the years 2003-2006.We retrospectively identified 114 patients who had undergone laparoscopic hernia repair during the relevant period. The patients received a questionnaire regarding satisfaction, pain and recurrence. Patients reporting any inconvenience were offered a consultation.Among the 114 included patients, ten procedures were converted to open laparotomy, six of which were converted due to recognized bowel injury. One case of bowel injury was managed laparoscopically. One case of bowel injury was recognized during reoperation the following day. Another four patients experienced reoperations for other reasons, mainly bleeding. The mean hospital stay was one day. A total of 12 patients had a recurrent hernia. The mean follow-up was 14 months.We conclude that laparoscopic incisional hernia repair is a useful surgical procedure with short hospital stay and high patient satisfaction. There is, however, a certain risk of bowel injury associated with this procedure.

Ingestion of small foreign bodies is common in children, and usually does not cause any harm to the gastrointestinal tract. But ingestion of multiple magnets can be hazardous because of the strong attraction of the magnets through the bowel wall, which may lead to bowel wall necrosis and perforation. We describe the case of a 6-year-old autistic boy who swallowed 4 magnets which led to bowel obstruction and 8 small perforations. It is important to be aware of this potential risk if children ingest small magnetic toys.