The Impact of Prolonged Chemotherapy to Surgery Interval and Neoadjuvant Radiotherapy on Pathological Complete Response and Overall Survival in Pancreatic Cancer Patients.

BACKGROUND: We aimed to study the impact of neoadjuvant chemotherapy to surgery (NCT-S) interval and neoadjuvant radiotherapy (NRT) on pathological complete response (pCR) and overall survival (OS) in pancreatic cancer (pancreatic ductal adenocarcinoma [PDAC]). METHODS: National Cancer Data Base (NCDB)-pancreatectomy patients who underwent NCT/NRT were included. The NCT-S interval was divided into time quintiles in weeks: 8 to 11, 12 to 14, 15 to 19, 20 to 29, and >29 weeks. RESULTS: A total of 2093 patients with NCT were included with median follow-up of 74 months and 71% NRT. The pCR rate was 2.1% with higher median OS compared with non-pCR (41 vs 19 months, P = .03). The pCR rate increased with longer NCT-S interval (quintiles: 1%, 1.6%, 1.7%, 3%, and 6%, P < .001, respectively). In logistic regression, NRT (odds ratio [OR] = 2.5, 95% confidence interval [CI]: 1.1-6.1, P = .03) and NCT-S >29 weeks (OR = 6.1, 95% CI = 2.02-18.50, P < .001) were predictive of increased pCR. The prolonged NCT-S interval and pCR were independent predictors of OS, whereas NRT was not. CONCLUSIONS: Longer NCT-S interval and pCR were independent predictors of improved OS in patients with PDAC. The NRT predicted increased pCR but not OS.

Robotic Cholecystectomy Is a Safe Educational Alternative to Laparoscopic Cholecystectomy During General Surgical Training: A Pilot Study.

OBJECTIVE: The role of robotic surgery in general surgery (GS) continues to expand. Several programs have integrated robotic-based simulators and models into surgical education; however, residents' robotic experience in the operating room is currently limited. We sought to assess the safety and feasibility of robotic cholecystectomy (RC) when independently performed by GS chief residents. METHODS: From June 2016 to October 2018, RC and laparoscopic cholecystectomies (LC) performed independently by chief residents on a resident staff surgical service were prospectively included. Patient demographics, intraoperative variables, and postoperative complications were analyzed and compared between both cohorts. RESULTS: A total of 20 RC and 70 LC were included. Patient characteristics, indications for surgery, and comorbidities were similar in both groups. RC was more likely to be performed electively (95% vs. 17.1%, p < 0.001). No difference in operative time, estimated blood loss, intraoperative bile duct injury, or conversion to open was observed. Patients undergoing LC had an overall longer mean length of hospital stay (2.7 days ± 2.1 vs. 0.8 days ± 0.4, p < 0.001); however, length of hospital stay was similar between RC and LC performed electively (p = 0.946). No difference in postoperative complications and 30-day readmission was observed. CONCLUSIONS: RC can be safely and independently performed by GS residents with similar outcomes as LC. Efforts should be directed toward creating a platform to bridge competent simulator skills into safe performance in the operating suite. The integration of robotic training into the core GS curriculum should be encouraged.

Interpretation of Basic Clinical Images: How Are Surgical Residents Performing Compared to Other Trainees?

BACKGROUND: During medical training students, residents, and fellows learn how to accurately interpret basic radiographic images. This skill is mostly utilized by physicians in the acute and critical care settings. It is unclear whether surgical residents' interpretation skills differ from that of other trainees. METHODS: A 30-question online quiz was developed to evaluate trainees' skills in interpreting images using various radiologic modalities. The participating cohort included (1) medical students (MS), (2) general surgery residents (GST), internal medicine residents and fellows (IMT), and radiology trainees (RT). The impact of residency specialty and level of training on performance was evaluated. RESULTS: A total of 69 postgraduate trainees and 19 MS enrolled in the online quiz. The average score was 67.6% (±16.6). GST scored higher than IMT (74.2% ± 10.7% vs. 67.9% ± 11.3%, p = 0.038); however, they were equally proficient to RT. MS had the lowest interpretation accuracy rates compared to postgraduate trainees (57.4% ± 16.8%, p < 0.001). On different radiographic modalities, junior GST performance was comparable to MS, JR-IMT, and Junior Radiology Trainees (JR-RT). On computed tomography (CT) body, GST (83.1% ± 15.7%) scored higher than IMT (70.3% ± 17.7%, p = 0.026) and MS (61.7% ± 23.4%, p < 0.001). Similar findings were demonstrated on ultrasound modality. A difference in performance was not evident for X-rays, CT head, and tubes/lines localization images. CONCLUSIONS: GST were able to correctly interpret 74.2% of basic clinical images. Although superior in the evaluation of pathologies seen on CT body and ultrasound, GST have comparable performance to other trainees in X-rays, tube/line localization images, and CT head. Integration of radiology education in surgical training may enhance performance and potentially improve patient care.

Perioperative and oncological outcomes of abdominoperineal resection in the prone position vs the classic lithotomy position: A systematic review with meta-analysis.

BACKGROUND AND OBJECTIVES: This study is a systematic review with meta-analysis designed to compare the perioperative and oncological outcomes of the abdominoperineal resection (APR) carried out in the prone jack-knife position (P-APR) vs the classic lithotomy position (C-APR). METHODS: We conducted an electronic search through PubMed utilizing the PRISMA guidelines. We included all randomized and nonrandomized studies which allowed for comparative analysis between the two groups. Research that focused on and analyzed the extralevator abdominal excision were excluded. Pooled variables and number of events were analyzed using the random-effect model. RESULTS: The final analysis included seven nonrandomized retrospective cohorts encompassing 1663 patients. P-APR was associated with decreased operative time (OT) (DM, -43.8 minutes; P < 0.01) and estimated blood loss (EBL) (DM, 86.9 mL; P < 0.01). There were no observed differences regarding perineal wound infections (PWI) (odds ratio [OR], 0.36; P = 0.18), intraoperative perforation of rectum (IOP) (OR, 0.98; P = 0.97), circumferential resection margin (CRM) positivity (OR, 1.02; P = 0.98) or 5-year LR (OR, 1.00; P = 0.99). CONCLUSION: The prone approach for APR is associated with decreased EBL and OT, although not with any change in the incidence of PWI or IOP. Moreover, surgical positioning per se does not appear to affect the CRM positivity rates or LR rate.

The Role of Completion Lymphadenectomy in Positive Regional Lymph Nodes in Melanoma: A Meta-analysis.

BACKGROUND: The optimal management of melanoma with positive sentinel lymph node (SLN) remains unclear. Completion lymph node dissection (CLND) only yields additional positive non-SLN in 20% of cases and its benefits on survival remains debatable. METHODS: An online database search of Medline was performed; key bibliographies were reviewed. Studies comparing outcomes after CLND versus observation were included. Odds ratios (ORs) with the corresponding 95% confidence intervals (CIs) by random fixed effects models of pooled data were calculated. The primary endpoints were disease-free survival (DFS), melanoma-specific survival (MSS), and overall survival (OS). RESULTS: Search strategy yielded 117 publications. Twelve studies were selected for inclusion, comprising 7966 SLN-positive patients. Among these patients, 5306 (66.6%) subjects underwent CLND and 2660 (33.4%) patients were observed. Median Breslow thickness and ulceration were similar between groups (2.8 ± 0.6 mm versus 2.5 ± 0.8 mm, P = 0.721; and 38.8% versus 37.2%, P = 0.136, CLND versus observation, respectively). CLND was associated with statistically significant improved 3-y (71.0% versus 66.2%, OR 0.82, 95% CI 0.69-0.97, P = 0.02) and 5-y DFS (48.3% versus 47.8%, OR 0.75, 95% CI 0.59-0.96, P = 0.02) compared with observation. However, no difference was demonstrated in 3-y MSS (83.7% versus 84.7%, OR 1.09, 95% CI 0.88-1.35, P = 0.41), 5-y MSS (68.4% versus 69.8%, OR 1.02, 95% CI 0.88-1.19, P = 0.78), or OS (68.2% versus 78.9%, OR 0.93, 95% CI 0.55-1.57, P = 0.78). CONCLUSIONS: Based on this large-scale analysis, CLND improved both 3- and 5-y DFS, possibly because of increased rates of local control; however, this did not translate in improved MSS or OS. Efforts toward the identification of molecular markers associated with poor outcomes in SLN-positive patients who undergo observation are warranted.

Is hepatic resection better than transarterial chemoembolization in hepatocellular carcinoma with portal vein tumor thrombosis?

BACKGROUND: The management of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) remains controversial. We compared the outcomes of hepatic resection (HR) and transarterial chemoembolization (TACE). METHODS: Comprehensive online databases search was performed. Comparative studies measuring survival in HCC patients with PVTT undergoing HR versus TACE were included. Pooled risk ratios with corresponding 95% confidence intervals (CI) were calculated for overall survival (OS) at 1, 3, and 5 years. Study quality and heterogeneity was assessed. RESULTS: Six studies comprising 1,320 patients were included. HR was done in 526 (39.8%) patients and TACE in 794 (60.2%) patients. Meta-analysis of all included studies showed improved OS in HR compared to TACE patients at 1-year (OR: 1.49, 95% CI: 1.16-1.92, P=0.002), 3-year (OR: 3.33, 95% CI: 1.55-7.12, P=0.002) and 5-year (OR: 3.91, 95% CI: 1.42-10.77, P=0.008). Survival benefit conferred by HR was 7-33 months. This benefit was mostly noted in tumors with PVTT types I and II and those with single lesions. Age, ECOG status, and STROBE score did not contribute to differences in survival. CONCLUSIONS: Long-term survival outcomes of HCC with PVTT are superior in patients undergoing hepatectomy compared to TACE. Further experience with randomized clinical trials may be warranted to confirm these findings.

Fully robotic total pancreatectomy: technical aspects and outcomes.

Robotic total pancreatectomy (RTP) is a novel surgical approach currently performed by a select group of skilled surgeons. As robotic approaches to pancreatic surgery increase worldwide, rates of RTP are expected to increase. However, the standard technique is still evolving and several technical problems still require evaluation. Here, we describe our approach in a stepwise fashion and discuss solutions to overcome technical difficulties.

Impact of Chemoradiation-to-Surgery Interval on Pathological Complete Response and Short- and Long-Term Overall Survival in Esophageal Cancer Patients.

BACKGROUND: The impact of the neoadjuvant chemoradiation-to-surgery (CRT-S) interval in patients with esophageal cancer is not clear. We aimed to determine the relationship between CRT-S interval and pathological complete response rate (pCR) and overall survival (OS). METHODS: National Cancer Data Base patients with CRT followed by surgery were studied. CRT-S interval was studied as a continuous (weeks) and categorical variable (quintiles: 15-37, 38-45, 46-53, 54-64, and 65-90 days, with n = 1016, 1063, 1081, 1083, and 938 patients, respectively). RESULTS: A total of 5181 patients were included; 81% had adenocarcinoma. There was a significant increase of pCR rate across quintiles (18%, 21%, 24%, 25%, and 29%, p < 0.001) and per week increase of CRT-S interval [odds ratio (OR) 1.11, p < 0.001]. The 90-day mortality increased as CRT-S increased across quintiles (5.7%, 6.2%, 6.8%, 8.5%, and 8.2%, p = 0.02) and through weeks (OR 1.05, p = 0.03). Mean OS across CRT-S quintiles was 36.4, 35.1, 33.9, 33.2, and 30.7 months, respectively. Multivariate Cox regression showed significantly worse OS per week increase in CRT-S interval [hazard ratio (HR) 1.02, p = 0.02], especially among the last quintile (CRT-S = 65-90 days: HR 1.2, p = 0.009). The squamous cell carcinoma (SCC) and pCR groups had similar OS across CTR-S intervals. CONCLUSIONS: Despite the higher pCR rate with longer CRT-S interval, surgery is optimal less than 65 days after CRT to avoid worse 90-day mortality and achieve better OS. In patients with SCC and those with pCR, prolonged CRT-S interval had no impact on OS. Further studies are needed to consolidate our findings.

A large national comparative study of clinicopathological features and long-term survivals between esophageal gastrointestinal stromal tumor and leiomyosarcoma.

BACKGROUND: Esophageal gastrointestinal stromal tumors (E-GIST) and leiomyosarcoma (E-LMS) are rare tumors. Previous studies are limited to small number of patients. We sought to study these two tumors using a large national database. METHODS: The National Cancer Data Base 2004-2014 was queried for patients with E-GIST and E-LMS. The primary outcome was overall survival (OS). Univariate and multivariable Cox regression models were used to investigate OS predictors. RESULTS: We found 141 E-GIST and 38 E-LMS patients, with esophagectomy and systemic treatment rate of 55% and 49% for E-GIST and 50% and 26% for E-LMS. The 5-year OS of E-GIST and E-LMS were 62% and 23%, respectively, p < 0.001. In multivariable analysis, young age, tumor <10 cm, esophagectomy, and E-GIST were associated with superior OS. There was a higher median and mean OS with neoadjuvant vs. upfront surgery for E-GIST group (98 and 111 vs 79 and 80 months). CONCLUSION: E E-GIST has superior OS compared to E-LMS. Esophagectomy is the cornerstone treatment modality. Further studies are needed to evaluate the role of neoadjuvant therapy in E-GIST patients.

The Role of Surgical Resection for Stage IV Gastric Cancer With Synchronous Hepatic Metastasis.

BACKGROUND: With improved responses to chemotherapy and targeted treatments, the role of surgery in metastatic gastric cancer (MGC) to the liver needs to be revisited. We sought to examine whether surgical resection is associated with improvement of long-term survival. METHODS: The National Cancer Database was queried for MGC to the liver (2010-2014). Survival analysis was performed to compare the effect of gastrectomy and perioperative chemotherapy (G-CT) to palliative chemotherapy (PCT) alone. RESULTS: We identified 3175 patients with MGC to the liver. Most patients (94%, n = 2979) were treated with PCT, whereas 6% (n = 196 patients) underwent G-CT. Overall survival improved in patients treated with G-CT compared to PCT alone (16 versus 9.7 mo, P < 0.001). In patients undergoing G-CT, neoadjuvant chemotherapy was associated with increased overall survival compared to adjuvant chemotherapy (18.9 versus 14.8 mo, P = 0.011). Hazards of death significantly decreased with gastrectomy (hazard ratio [HR]: 0.53, 95% confidence interval [CI]: 0.44-0.63, P < 0.001). Negative prognostic factors included advanced age (HR: 1.10, 95% CI: 1.06-1.14, P < 0.001), treatment at nonacademic institution (HR: 1.23, 95% CI: 1.13-1.33, P < 0.001), and poorly differentiated grade (HR: 1.54, 95% CI: 1.17-2.03, P < 0.001). CONCLUSIONS: G-CT is associated with improved survival in patients with gastric cancer and synchronous liver metastasis. Further experience with well-designed prospective trials may be warranted to confirm these findings.

Multidisciplinary team approach in the management of popliteal artery injury.

Popliteal artery injuries (PAIs) remain a challenging entity and carry the greatest risk of limb loss among traumatic lower extremity vascular injuries. Operative management of traumatic popliteal vascular injuries continues to evolve. Improved diagnostic imaging and the introduction of endovascular techniques offered alternative modalities to traditional surgical management. Despite major efforts in establishing protocols and guidelines in the management of vascular trauma, optimal strategies of traumatic PAIs are still under investigation. Herein, we discussed the role of multidisciplinary team, involving trauma and endovascular surgeons, emergency department personnel, and interventional radiologists in the management of complex PAIs.

Long-term Quality of Life and Gastrointestinal Functional Outcomes After Pancreaticoduodenectomy.

OBJECTIVE: To perform a comprehensive assessment of long-term quality of life (QOL) and gastrointestinal (GI) function in patients following pancreaticoduodenectomy (PD). SUMMARY OF BACKGROUND DATA: Survival after PD has greatly improved and thus has resulted in a larger population of survivors, yet long-term QOL and GI function after PD is largely unknown. METHODS: Patients were identified from a global online support group. QOL was measured using the Short Form-36, while GI function was assessed using the Gastrointestinal Symptom Rating Scale. QOL and GI function were analyzed across subgroups based on time after PD. QOL was compared with preoperative measurements and with established values of a general healthy population (GHP). Multivariate linear regression was used to identify predictors of QOL. RESULTS: Of the 7605 members of the online support group, 1102 responded to the questionnaire with 927 responders meeting inclusion criteria. Seven hundred seventeen (77.3%) of these responders underwent PD for malignancy. Mean age was 57 ±â€Š12 years and 327 (35%) were male. At the time of survey, patients were 2.0 (0.7, 4.3) years out from surgery, with a maximum 30.7-year response following PD. Emotional and physical domains of QOL improved with time and surpassed preoperative levels between 6 months and 1 year after PD (both P < 0.001). Each GI symptom worsened over time (all P < 0.001). Independent predictors of general QOL in long-term survivors (> 5 years) included total GSRS score [ß = -1.70 (-1.91, -1.50)], female sex [ß = 3.58 (0.67, 6.46)], and being a cancer survivor [ß = 3.93 (0.60, 7.25)]. CONCLUSIONS: Long-term QOL following PD improves over time, however never approaches that of a GHP. GI dysfunction persists in long-term survivors and is an independent predictor of poor QOL. Long-term physical, psychosocial, and GI functional support after PD is encouraged.

Autogenous hepatic tissue transplantation into the omentum in a novel ectopic liver regeneration murine model.

BACKGROUND: Liver regeneration involves hyperplasia and hypertrophy of hepatic cells. The capacity of macroscopic liver tissue to regenerate in ectopic sites is unknown. We aim to develop a novel in vivo model of ectopic liver survivability and regeneration and assess its functionality. METHODS: Adult male Sprague-Dawley rats (n = 23) were divided into four groups: (1) single-stage (SS) group, wedge liver resection was performed, and the parenchyma was directly implanted into the omentum; (2) double-stage (DS) group, omentum pedicle was transposed over the left hepatic lobe followed by wedge liver resection along with omental flap; (3) Biogel + DS group, rats received intraperitoneal injection of inert polymer particles prior to DS; (4) Biogel + DS + portal vein ligation (PVL) group, Biogel + DS rats underwent subsequent PVL. Hepatobiliary iminodiacetic acid scintigraphy assessed bile excretion from ectopic hepatic implants. RESULTS: Histologically, the scores of necrosis (P < 0.001) and fibrosis (P = 0.004) were significantly improved in rats undergoing DS procedure (groups 2, 3, and 4) compared with the SS group. Biogel rats (Biogel + DS and Biogel + DS + PVL) demonstrated statistically increased scores of bile duct neoformation (P = 0.002) compared to those without the particles (SS and DS). Scintigraphy demonstrated similar uptake of radiotracer by ectopic hepatic implants in groups 2, 3, and 4. CONCLUSIONS: Omental transposition provided adequate microcirculation for proliferation of ectopic hepatic cells after liver resection. Inert polymers enhanced the regeneration by promoting differentiation of new bile ducts. The ectopic hepatic implants showed preserved function on scintigraphy. This model provides insights into the capacity of liver parenchyma to regenerate in ectopic sites and the potential as therapeutic target for cell therapy in end-stage liver disease.

Effectiveness and feasibility of robotic gastric neurostimulator placement in patients with refractory gastroparesis.

Gastric neurostimulation (GNS) with Enterra® therapy device (Medtronic, Minneapolis, MN) appears as the last resort for patients with refractory gastroparesis. Currently, the device has Humanitarian Use status by Food and Drug Administration, thereby requiring further investigation. We aim to describe its feasibility and clinical outcomes using robotic technique. From June 2014 to September 2016, 15 consecutive patients underwent robotic insertion of Enterra® device. Patient demographics, comorbidities, and clinical outcomes including mortality, length of stay, readmission rates, reoperation and complications were retrospectively collected. Patients were also assessed based on a validated 14-point questionnaire regarding satisfaction with the operation, quality of life and symptomatic relief. Mean age was 41.6 years ± 13.8 and there were 11 females (73.3%). No mortality was reported. The annual hospital admissions were reduced after GNS (2.5 ± 4.1 vs. 3.6 ± 4.4, p = 0.004). The frequency of bloating (p = 0.029) and severity of emesis (p = 0.038), early satiety (p = 0.042) and bloating (p = 0.031) were reduced after GNS. The severity and frequency total scores were also improved after GNS (12.6 ± 1.4 vs. 18.1 ± 2.7, p = 0.008 and 12.9 ± 2.2 vs. 16.1 ± 1.1, p = 0.016, respectively). This is the first report describing the clinical experience with robotic insertion of GNS device. This approach is safe and feasible and seems to have similar long-term outcomes as laparoscopic technique. Potential advantages to robotic technique include enhanced dexterity and suturing of the device within gastric wall. Further experience with large prospective studies and randomized clinical trials may be warranted.

Outcomes of Laparoscopic Hiatal Hernia Repair in Nine Bariatric Patients with Prior Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) may exacerbate gastroesophageal reflux disease (GERD) in patients with a hiatal hernia (HH). Surgical repair may be needed, however prior LSG precludes standard HH repair with fundoplication. METHODS: We retrospectively reviewed our experience with bariatric patients with prior LSG undergoing laparoscopic HH repair from August 2010 to July 2016. Patient demographics and outcomes including mortality, length of stay (LOS), readmission rates, reoperation, and complications were described. A validated 13-point questionnaire was used to determine symptomatic relief, weight loss, and overall satisfaction. RESULTS: A total of nine consecutive patients with prior LSG underwent HH repair and were included in the analysis. Repair was performed using Bio-A Gore® mesh (W.L Gore Inc., Newark, DE) in six (66.7%) cases and posterior cruroplasty in three (33.3%) patients. Heartburn was significantly decreased at 1 year (1.4 ± 0.9 vs. 2.6 ± 0.9, p = 0.031), and 78% of patients reported some degree of symptomatic relief after HH repair. CONCLUSIONS: Laparoscopic HH repair offers a safe and feasible approach in the management of persistent GERD after LSG in well-selected bariatric patients. Larger prospective studies are warranted to investigate the effectiveness of HH repair in this population as 22% of our patients did not demonstrate postoperative symptomatic improvement.

The Impact of Surgeon Volume on Outcomes After Pancreaticoduodenectomy: a Meta-analysis.

BACKGROUND: Despite significant improvement in operative mortality rates following pancreaticoduodenectomy (PD), morbidity remains high. Outcomes following PD may be improved in high-volume centers and with high-volume surgeons. We sought to evaluate the association between surgeon experience and postoperative outcomes after PD. METHODS: An online database search of MEDLINE and EMBASE was performed; key bibliographies were reviewed. Studies comparing operative outcomes of high-volume surgeon (HVS) and low-volume surgeon (LVS) performing PD were included. Odds ratios with the corresponding 95% confidence intervals (CI) by random fixed effects models of pooled data were calculated. Definition of HVS varied among the studies, ranging from 6 to >20 PD/year. The primary endpoint was 30-day mortality, and secondary outcomes were complication rates, length of stay (LOS), hospital costs, and readmission rates. Study quality was assessed using STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria. RESULTS: Search strategy yielded 360 publications. Eleven studies met the inclusion criteria comprising 36,449 patients. Among these patients, 12,512 (34.3%) PDs were performed by HVS and 23,937 (65.7%) by LVS. Meta-analysis of included studies showed that HVS had significantly lower mortality rates than LVS (2.4 vs. 6.7%, OR 2.88; 95% CI 2.51-3.27, p < 0.001). They also had significantly lower overall complication rates (36.3 vs. 50.3%, OR 1.71; 95% CI 1.62-1.81, p < 0.001), hospital costs (range $10,818-141,322 vs. $12,114-198,678, OR 0.13; 95% CI 0.07-0.19, p < 0.001), and LOS (range 11-35 vs. 14-38 days, OR 2.86; 95% CI 2.03-3.68, p < 0.001). CONCLUSIONS: HVS performing PD have significantly better outcomes than LVS in terms of decreased mortality, morbidity, LOS, and hospital costs. Efforts toward increased regionalization of care should be discussed. Consensus regarding definition of HVS needs to be undertaken.

Utilisation of radiology rotations in ACGME-accredited general surgery programmes.

BACKGROUND: General surgery (GS) residents are often required to provide immediate preliminary interpretations of radiological images, especially in critical situations. It is unclear whether residents in Accreditation Council for Graduate Medical Education-accredited GS programmes receive sufficient radiological training to deliver adequate patient care. OBJECTIVES: Determine the utilisation of radiology rotations (RR) during GS residency. METHODS: Between February and March 2015, a pilot voluntary 19-item survey was electronically distributed to GS programme directors (PDs) regarding the availability and value of a RR during GS training. RESULTS: A total of 234 PDs received the questionnaire and the response rate was 36.8% (n=86). Sixty-five (77.4%) PDs expected their trainees to interpret imaging studies in the acute setting; however, only 8.3% of programmes had a dedicated RR. RRs are more prevalent among community-based than university-based programmes (71.4% vs 27.9% p=0.003). The implementation of a RR may be limited due to insufficient number of GS residents in the department (p=0.002). 75.4% of PDs expect GS residents to confirm their findings with a radiologist. In those programmes with RR, most PDs (85.7%) believed that a dedicated rotation improved GS residents' understanding of radiological imaging. CONCLUSION: The majority of PDs are currently not confident that GS residents are capable of interpreting radiological imaging independently; however, the implementation of a mandatory RR in GS residency curriculum yet seems to be controversial. Given the expectation of PDs and the continued need to improve patient care, the integration of a dedicated RR in GS training should be encouraged.