Impact of integrated programs on general surgery operative volume.

BACKGROUND: Integrated residencies are now commonplace, co-existing with categorical general surgery residencies. The purpose of this study was to define the impact of integrated programs on categorical general surgery operative volume. METHODS: Case logs from categorical general, integrated plastics, vascular, and thoracic surgery residents from a single institution from 2008 to 2016 were collected and analyzed. RESULTS: Integrated residents have increased the number of cases they perform that would have previously been general surgery resident cases from 11 in 2009-2010 to 1392 in 2015-2016. Despite this, there was no detrimental effect on total major cases of graduating chief residents. CONCLUSIONS: Multiple integrated programs can co-exist with a general surgery program through careful collaboration and thoughtful consideration to longitudinal needs of individual trainees. As additional programs continue to be created, both integrated and categorical program directors must continue to collaborate to insure the integrity of training for all residents.

Is our residency program successful? Structuring an outcomes assessment system as a component of program evaluation.

OBJECTIVE: In an attempt to better define the success of our residency program with regard to resident development, we committed to develop an ongoing assessment of residency performance and devised an outcomes assessment system. DESIGN: We describe the process and structure that we used to construct an outcomes assessment system. We discuss the process we used to discern whether or not our program is successful as well as offer tips on what data to collect and track should other residency programs decide to devise a similar outcomes assessment database. CONCLUSION: Taking time to "step back" to take inventory of a residency program and ensure year over year and at the end of training residents have developed and matured as planned is an educationally sound practice. Structuring an outcomes assessment system like the one that we discuss here can aid program directors with this important task.

Robotic distal pancreatectomy: cost effective?

BACKGROUND: Minimally invasive techniques and even robotics in pancreaticobiliary surgery are being used increasingly. Cost-effectiveness is a practical burden associated with the introduction of surgical innovation. This study compares the costs and the outcomes of open, laparoscopic, and robotic distal pancreatectomies. We hypothesized that robotic distal pancreatectomy is cost-effective. METHODS: Between August 2008 and August 2009, 77 distal pancreatectomies were performed at a single academic medical center. A retrospective analysis of prospectively collected data on demographics, short-term outcomes, and direct cost was performed. RESULTS: Thirty-two open distal pancreatectomies, 28 laparoscopic distal pancreatectomies, and 17 robotic distal pancreatectomies were performed. Age, American Society of Anesthesia preoperative risk score, and specimen length were similar. Indications for laparoscopic distal pancreatectomies and robotic distal pancreatectomies included more cystic neoplasms (49%) and fewer malignancies (29%) versus open distal pancreatectomies (16% and 47%). Spleen preservation occurred in 65% robotic distal pancreatectomies versus 12% and 29% in open distal pancreatectomies and laparoscopic distal pancreatectomies (P < .05). The operative time averaged 298 minutes in robotic distal pancreatectomies versus 245 and 222 minutes in open distal pancreatectomies and laparoscopic distal pancreatectomies (P < .05). Blood loss and morbidity were similar with no mortality. The length of stay was 4 days in robotic distal pancreatectomies versus 8 and 6 in open distal pancreatectomies and laparoscopic distal pancreatectomies (P < .05). The total cost was $10,588 in robotic distal pancreatectomies versus $16,059 and $12,986 in open distal pancreatectomies and laparoscopic distal pancreatectomies. CONCLUSION: These data suggest direct hospital costs are comparable among all groups. They suggest a shorter length of stay in robotic versus laparoscopic or open approaches. Finally, spleen and vessel preservation rates may improve with a robotic approach at the expense of increased operative time. In summary, robotic distal pancreatectomy is safe and cost effective in selected cases.

Incorporating an HPB fellowship does not diminish surgical residents' HPB experience in a high-volume training centre.

BACKGROUND: Surgical residency training is evolving, and trainees who wish to practice hepato-pancreato-biliary (HPB) surgery in the future will be required to obtain advanced training. As this paradigm evolves, it is crucial that HPB fellowship incorporation into an established surgical residency programme does not diminish surgical residents' exposure to complex HPB procedures. We hypothesized that incorporation of a HPB fellowship in a high-volume clinical training programme would not detract from residents' HPB experience. METHODS: Resident operative case logs and HPB fellow case logs were reviewed. Resident exposure to complex HPB procedures for 3 years prior to and 3 years after fellowship incorporation were compared. RESULTS: No significant changes in surgical resident exposure to liver and pancreatic resection were seen between the two time periods. Surgical resident exposure to complex biliary procedures decreased in the 3 years after HPB fellowship incorporation (P= 0.003); however, exceeded the national average in each year except 2006. Graduating residents' overall HPB experience was unchanged in the 3 years prior to and after incorporating an HPB fellow. Expansion of HPB volume was a critical part of successful HPB fellowship implementation. DISCUSSION: An HPB fellowship programme can be incorporated into a high-volume clinical training programme without detracting from resident HPB experience. Individual training programmes should carefully assess their capability to provide an adequate clinical experience for fellows without diminishing resident exposure to complex HPB procedures.

Remediation practices for surgery residents.

BACKGROUND: This study sought to determine to what extent surgery programs are remediating residents who fail to achieve competency and to offer remediation strategies. METHODS: A web-based survey was e-mailed to 253 program directors of all US surgery residency programs. Questions were asked about remediation and probation practices for residents failing to meet the competencies. RESULTS: Programs seem to struggle the least with knowing how to remediate medical knowledge and patient care deficits and struggle more with professionalism and interpersonal communication skills. Most programs have no remediation methods in place for systems-based practice and practice-based learning and improvement deficits. CONCLUSIONS: Surgery residency programs are cognizant of the reality that some residents perform unsatisfactorily. Most have remediation plans for residents and understand that a process needs to be in place. Remediation methods tend to vary depending on the deficit and are devised tailored to the resident's needs.

Practice-based learning and improvement: a curriculum in continuous quality improvement for surgery residents.

HYPOTHESIS: Surgery residents can learn continuous quality improvement (CQI) principles within a structured curriculum and propose quality improvement projects. DESIGN: Curriculum within a surgical residency program. SETTING: A university surgical residency program with multiple hospital training sites. PARTICIPANTS: Fifteen surgical residents during the dedicated research year. INTERVENTION: A curriculum in CQI that focuses on devising a quality improvement project. MAIN OUTCOME MEASURES: Resident self-reported attitudes about quality improvement and implementation of resident-initiated quality improvement projects. RESULTS: Resident survey data demonstrated an improvement in knowledge, self-efficacy, and experiences within CQI. Fifteen individual residents, within smaller teams, created 4 quality improvement projects worthy of implementation. CONCLUSIONS: A structured CQI curriculum can be successfully integrated into a general surgery residency program. Residents can learn the skill of constructing CQI project ideas within the framework of the plan-do-study-act cycle. Residents are eager to make improvements in their local system of residency. By giving them the tools to critically investigate systems improvement and a much needed ear to hear their concerns and suggestions for improvement, we found ways to potentially enhance patient care and developed ideas to improve the education of future surgeons. In doing so, we provided the residents with "buy-in" into their residency program, while addressing the competency of practice-based learning and improvement required by the Accreditation Council for Graduate Medical Education for resident education.

Frequency of biliary complications after laparoscopic cholecystectomy detected by ERCP: experience at a large tertiary referral center.

BACKGROUND: Laparoscopic cholecystectomy has a higher incidence of bile-duct injuries than open cholecystectomy. Although a learning curve phenomenon was attributed to biliary injuries early after its introduction, we were interested in trends in biliary injury rates over time as laparoscopic cholecystectomy has become a mature technology. OBJECTIVE: To analyze the frequency and anatomic distribution of bile-duct injuries referred after laparoscopic cholecystectomy over a 10-year period. DESIGN: Retrospective, case-series. SETTING: Tertiary, referral hepatobiliary unit. PATIENTS: Referrals to ERCP unit for diagnosis and treatment of biliary injuries after laparoscopic cholecystectomy. INTERVENTION: ERCP to diagnose level and severity of bile duct injury. MAIN OUTCOME MEASUREMENTS: Type and anatomy of bile-duct injury, reason for cholecystectomy, mean time between injury and diagnosis, presenting symptoms, ratio of bile-duct injuries diagnosed over total ERCPs done per year. RESULTS: There were 87 bile-duct leaks, 28 leaks with stones, 51 strictures, and 17 complete duct transactions. The bile-duct injury rate calculated per 100 ERCPs per year was 0.84 (1994), 0.99 (1995), 1.36 (1996), 1.41 (1997), 1.03 (1998), 1.31 (1999), 0.84 (2000), 0.75 (2001), 1.15 (2002), and 0.94 (2003). LIMITATIONS: Single institution, retrospective analysis, unknown denominator of cholecystectomies done in referral area per year to calculate true bile-duct injury rate. CONCLUSIONS: Static incidence in frequency, anatomic distribution, and rate per 100 ERCPs per year of postcholecystectomy bile-duct injuries at a tertiary referral hepatobiliary unit over a 10-year period of observation.

Pancreaticoduodenectomy: a 20-year experience in 516 patients.

HYPOTHESIS: Pancreaticoduodenectomy (PD) is a safe procedure for a variety of periampullary conditions. DESIGN: Retrospective review of a prospectively collected database. SETTING: Academic tertiary care hospital. PATIENTS: A total of 516 consecutive patients who underwent PD. MAIN OUTCOME MEASURES: Patient outcomes and survival factors. RESULTS: Pathological examination demonstrated 57% periampullary cancers, 22% chronic pancreatitis, 12% cystic neoplasms, 4% islet cell neoplasms, and 5% other. Fifty-one percent of patients underwent pylorus preservation. Median operating time was 5 hours; blood loss, 1300 mL; and transfusion requirement, 1.5 U. Postoperative complications occurred in 43% of patients, including cardiopulmonary events (15%), fistula (9%), delayed gastric emptying (7%), and sepsis (6%). Additional surgery was required in 3% of patients, most commonly because of bleeding. Perioperative mortality was 3.9% overall but only 1.8% in patients with chronic pancreatitis; 25% of patients who died had preoperative complications associated with their periampullary condition. Three-year survival was 15% after resection for pancreatic cancer, 42% for duodenal cancer, 53% for ampullary cancer, and 62% for bile duct cancer. Univariate predictors of long-term survival in patients with periampullary adenocarcinoma included elevated glucose levels, liver function test results, abnormal tumor markers, blood loss, transfusion requirement, type of operation, and pathologic findings (periampullary adenocarcinoma type, differentiation, and margin and node status). Multivariate predictors were serum total bilirubin level, blood loss, operation type, diagnosis, and lymph node status. CONCLUSIONS: Pancreaticoduodenectomy continues to be associated with considerable morbidity. With careful patient selection, PD can be performed safely. Long-term survival in patients with periampullary adenocarcinoma can be predicted by preoperative laboratory values, intraoperative factors, and pathologic findings.

Wall stent-enhanced lateral pancreaticojejunostomy for small-duct pancreatitis.

HYPOTHESIS: The purpose of this study was to see if a small (<7 mm) pancreatic duct could be dilated to an acceptable diameter, allowing lateral pancreaticojejunostomy to decompress the pancreatic duct and relieve pain, while preserving pancreatic endocrine and exocrine function. DESIGN: Patients with chronic pancreatitis who had a small main pancreatic duct underwent progressive trans-ampullary dilation of the duct and subsequent placement of an expandable metallic wall stent (wallstent; Boston Scientific Microvasive Division, Natick, Mass). Approximately 14 days later, a lateral pancreaticojejunostomy was done. SETTING: A 400-bed university referral center hospital in an urban setting. PATIENTS: Thirty-five patients were selected from a large group with chronic pancreatitis. Thirty-one had pancreas divisum. All patients had undergone transendoscopic sphincterotomies and stenting before being accepted into the study. All had endoscopic retrograde cholangiopancreatography-proven chronic pancreatitis, and all ducts were observed to be 7 mm or smaller. INTERVENTIONS: Patients were selected after endoscopic sphincterotomy and stenting failed. Progressive transendoscopic duct dilation with plastic stents was carried out, and a 10-mm expandable metallic wall stent was placed prior to surgical decompression. Lateral pancreaticojejunostomy was performed. MAIN OUTCOME MEASURES: Patients were observed for pain relief, postoperative symptoms, analgesic use, glucose intolerance, and quality of life. All patients were seen or contacted by telephone, and their results were recorded. RESULTS: There were no operative deaths, but 26% of patients had complications. Seventy-one percent of patients reported that their pain was better than preoperatively. Three patients had subsequent pancreatic surgery. No new cases of diabetes occurred except in the 2 patients who underwent total pancreatectomy. CONCLUSIONS: In general, most patients feel that their lives were improved by the procedure. A quarter of the patients no longer take narcotics, and many have been able to resume a relatively normal lifestyle. Although this procedure is not a panacea for all patients with chronic pancreatitis and a nondilated duct, it is a reasonable alternative to resection.