A pilot trial of vaccination with Carcinoembryonic antigen and Her2/neu peptides in advanced colorectal cancer.

Checkpoint-blockade therapy (CBT) is approved for select colorectal cancer (CRC) patents, but additional immunotherapeutic options are needed. We hypothesized that vaccination with carcinoembryonic antigen (CEA) and Her2/neu (Her2) peptides would be immunogenic and well tolerated by participants with advanced CRC. A pilot clinical trial (NCT00091286) was conducted in HLA-A2+ or -A3+ Stage IIIC-IV CRC patients. Participants were vaccinated weekly with CEA and Her2 peptides plus tetanus peptide and GM-CSF emulsified in Montanide ISA-51 adjuvant for 3 weeks. Adverse events (AEs) were recorded per NIH Common Terminology Criteria for Adverse Events version 3. Immunogenicity was evaluated by interferon-gamma ELISpot assay of in vitro sensitized peripheral blood mononuclear cells and lymphocytes from the sentinel immunized node. Eleven participants were enrolled and treated; one was retrospectively found to be ineligible due to HLA type. All 11 participants were included in AEs and survival analyses, and the 10 eligible participants were evaluated for immunogenicity. All participants reported AEs: 82% were Grade 1-2, most commonly fatigue or injection site reactions. Two participants (18%) experienced treatment-related dose-limiting Grade 3 AEs; both were self-limiting. Immune responses to Her2 or CEA peptides were detected in 70% of participants. Median overall survival (OS) was 16 months; among those enrolled with no evidence of disease (n = 3), median OS was not reached after 10 years of follow-up. These data demonstrate that vaccination with CEA or Her2 peptides is well tolerated and immunogenic. Further study is warranted to assess potential clinical benefits of vaccination in advanced CRC either alone or in combination with CBT.

Readiness of US General Surgery Residents for Independent Practice.

OBJECTIVE: This study evaluates the current state of the General Surgery (GS) residency training model by investigating resident operative performance and autonomy. BACKGROUND: The American Board of Surgery has designated 132 procedures as being "Core" to the practice of GS. GS residents are expected to be able to safely and independently perform those procedures by the time they graduate. There is growing concern that not all residents achieve that standard. Lack of operative autonomy may play a role. METHODS: Attendings in 14 General Surgery programs were trained to use a) the 5-level System for Improving and Measuring Procedural Learning (SIMPL) Performance scale to assess resident readiness for independent practice and b) the 4-level Zwisch scale to assess the level of guidance (ie, autonomy) they provided to residents during specific procedures. Ratings were collected immediately after cases that involved a categorical GS resident. Data were analyzed using descriptive statistics and supplemented with Bayesian ordinal model-based estimation. RESULTS: A total of 444 attending surgeons rated 536 categorical residents after 10,130 procedures. Performance: from the first to the last year of training, the proportion of Performance ratings for Core procedures (n = 6931) at "Practice Ready" or above increased from 12.3% to 77.1%. The predicted probability that a typical trainee would be rated as Competent after performing an average Core procedure on an average complexity patient during the last week of residency training is 90.5% (95% CI: 85.7%-94%). This falls to 84.6% for more complex patients and to less than 80% for more difficult Core procedures. Autonomy: for all procedures, the proportion of Zwisch ratings indicating meaningful autonomy ("Passive Help" or "Supervision Only") increased from 15.1% to 65.7% from the first to the last year of training. For the Core procedures performed by residents in their final 6 months of training (cholecystectomy, inguinal/femoral hernia repair, appendectomy, ventral hernia repair, and partial colectomy), the proportion of Zwisch ratings (n = 357) indicating near-independence ("Supervision Only") was 33.3%. CONCLUSIONS: US General Surgery residents are not universally ready to independently perform Core procedures by the time they complete residency training. Progressive resident autonomy is also limited. It is unknown if the amount of autonomy residents do achieve is sufficient to ensure readiness for the entire spectrum of independent practice.

Does Anastomotic Leak Contribute to High Failure-to-rescue Rates?

OBJECTIVE: Our aim was to evaluate failure-to-rescue (FTR) after anastomotic leak (AL) in colectomy patients. BACKGROUND: In the era of pay for performance, it is imperative that we understand the quality measures under which we are scrutinized. FTR has been proposed as a marker of surgical quality. We investigated the role of complications in FTR rates in colectomy patients. METHODS: Patients who underwent nonemergent colectomy from 2012 to 2013 were identified from the The American College of Surgeons National Quality Improvement Program (ACS NSQIP database). Mortality after AL was assessed and stratified in relation to mortality after other postoperative complications. χ and logistic regression analysis were used to assess the effect of AL on mortality. RESULTS: We identified 30,101 patients who met inclusion criteria, 1127 suffered an AL (3.7%). FTR was increased in patients with AL compared with those without AL (6% vs 1%, P < 0.001). The mortality rate after leak was similar to mortality after other major complications. Independent risk factors for death after AL included older age (odds ratio [OR] 3.140; 95% confidence interval [CI], 1.744-5.651), cancer diagnosis (OR 2.032; 95% CI, 1.177-3.507), and open approach (OR 2.124; 95% CI, 1.194-3.776) while preoperative bowel preparation was protective (OR 0.563; 95% CI, 0.328-0.969). CONCLUSIONS: AL is a common complication after colectomy with a relatively high FTR rate. As hospitals are penalized for not reaching specific rates of FTR, we must better understand these complex relationships to improve quality and safety of patient care.

Evaluating the effectiveness of a mock oral educational program.

BACKGROUND: To obtain board certification, the American Board of Surgery requires graduates of general surgery training programs to pass both the written qualifying examination (QE) and the oral certifying examination (CE). In 2015, the pass rates for the QE and CE were 80% and 77%, respectively. In the 2011-2012 academic year, the University of Wisconsin instituted a mandatory, faculty-led, monthly CE preparation educational program (CE prep) as a supplement to their existing annual mock oral examination. We hypothesized that the implementation of these sessions would improve the first-time pass rate for residents taking the ABS CE at our institution. Secondary outcomes studied were QE pass rate, correlation with American Board of Surgery In-Training Examination (ABSITE) and mock oral examination scores, cost, and type of study materials used, perception of examination difficulty, and applicant preparedness. METHODS: A sixteen question survey was sent to 57 of 59 residents who attended the University of Wisconsin between the years of 2007 and 2015. Email addresses for two former residents could not be located. De-identified data for the ABSITE and first-time pass rates for the QE and CE examination were retrospectively collected and analyzed along with survey results. Statistical analysis was performed using SPSS version 22 (IBM Corp., Armonk, NY). P values < 0.05 were considered significant. RESULTS: Survey response rate was 77.2%. Of the residents who have attempted the CE, first-time pass rate was 76.0% (19 of 25) before the implementation of the formal CE Prep and 100% (22 of 22) after (P = 0.025). Absolute ABSITE score, and mock oral annual examination grades were significantly improved after the CE Prep was initiated (P values < 0.001 and 0.003, respectively), however, ABSITE percentile was not significantly different (P = 0.415). ABSITE raw score and percentile, as well as mock oral annual examination scores were significantly associated with passing the QE (0.032, 0.027, and 0.020, respectively), whereas mock oral annual examination scores alone were associated with passing the CE (P = 0.001). Survey results showed that residents perceived the CE to be easier than the annual mock oral after the institution of the CE prep course (P = 0.036), however, there was no difference in their perception of preparedness. Overall, applicants felt extremely prepared for the CE (4.70 ± 0.5, Likert scale 1-5). CONCLUSIONS: Formal educational programs instituted during residency can improve resident performance on the ABS certifying examination. The institution of a formal, faculty-led monthly CE preparation educational program at the University of Wisconsin has significantly improved the first-time pass rate for the ABS CE. Mock oral annual examination scores were also significantly improved. Furthermore, ABSITE scores correlate with QE pass rates, and mock oral annual examination scores correlate with pass rates for both QE and CE.

Short-term outcomes of minimally invasive versus open colectomy for colon cancer.

BACKGROUND: Laparoscopic and open approaches to colon resection have equivalent long-term outcomes and oncologic integrity for the treatment of colon cancer. Differences in short-term outcomes should therefore help to guide surgeons in their choice of operation. We hypothesized that minimally invasive colectomy is associated with superior short-term outcomes compared to traditional open colectomy in the setting of colon cancer. MATERIALS AND METHODS: Patients undergoing nonemergent colectomy for colon cancer in 2012 and 2013 were selected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted colectomy participant use file. Patients were divided into two cohorts based on operative approach-open versus minimally invasive surgery (MIS). Univariate, multivariate, and propensity-adjusted multivariate analyses were performed to compare postoperative outcomes between the two groups. RESULTS: A total of 11,031 patients were identified for inclusion in the study, with an overall MIS rate of 65.3% (n = 7200). On both univariate and multivariate analysis, MIS approach was associated with fewer postoperative complications and lower mortality. In the risk-adjusted multivariate analysis, MIS approach was associated with an odds ratio of 0.598 for any postoperative morbidity compared to open (P < 0.001). CONCLUSIONS: This retrospective study of patients undergoing colectomy for colon cancer demonstrates significantly improved outcomes associated with a MIS approach, even when controlling for baseline differences in illness severity. When feasible, minimally invasive colectomy should be considered gold standard for the surgical treatment of colon cancer.

Rural Surgery--A Crisis in Wisconsin.

Recruitment of general surgeons to practice in rural environments is challenging. We believe that innovative training programs focusing on the specific needs and experiences of rural surgical practice can play an important role in addressing this clinical workforce issue. For practical reasons, our program will start out small, but if 50 centers around the nation were to establish a similar rural track, we could see a substantial collective impact over time. We hope our new program will serve as a model for the development of other university-based residency training programs with similar opportunities. We are grateful to have received state funding to support the development and early implementation of this program (see Table). We commend the state for understanding the importance of primary care surgery, and we look forward to measuring and reporting the impact of our rural training program on rural surgical care in Wisconsin.

Postoperative complications in patients with rectal cancer are associated with delays in chemotherapy that lead to worse disease-free and overall survival.

OBJECTIVE: The objective of this study was to identify the risk factors for delays in chemotherapy after rectal cancer surgery and evaluate the effects of delayed therapy on long-term outcomes. We also sought to clarify what time frame should be used to define delayed adjuvant chemotherapy. BACKGROUND: Postoperative complications have been found to influence the timing of chemotherapy in patients with colon cancer. Delays in chemotherapy have been shown to be associated with worse overall and disease-free survival in patients with colorectal cancer, although the timing of delay has not been agreed upon in the literature. STUDY DESIGN: We performed a retrospective review of a prospectively maintained rectal cancer database. Univariate analysis was used to identify risk factors for delayed chemotherapy. Kaplan-Meier curves were generated to compare overall and disease-free survival in patients based on complications and timing of chemotherapy. SETTINGS: This study was performed at the University of Wisconsin Hospital, Madison, Wisconsin, between 1995 and 2012. PATIENTS: Patients with rectal cancer who underwent proctectomy with curative intent were included in this study. OUTCOME MEASURES: Timing of chemotherapy, 30-day complications, and 30-day readmissions were the main outcome measures. RESULTS: Postoperative complications and 30-day readmissions were associated with delays in chemotherapy ≥8 weeks after surgery. Patients who received chemotherapy ≥8 weeks postoperatively were found to have worse local and distant recurrence rates and worse overall survival in comparison with patients who received chemotherapy within 8 weeks of surgery. LIMITATIONS: The limitations of this study include its retrospective nature and that it was performed at a single institution. CONCLUSIONS: We found complications and readmissions to be risk factors for delayed chemotherapy. Patients who received therapy ≥8 weeks postoperatively had worse disease-free and overall survival.

Visceral obesity is associated with outcomes of total mesorectal excision for rectal adenocarcinoma.

BACKGROUND AND OBJECTIVES: General obesity, measured by the body mass index (BMI), increases the technical difficulty of total mesorectal excision (TME) but does not affect oncologic outcomes. The purpose of this study is to compare visceral and general obesity as predictors of outcomes of TME for rectal adenocarcinoma. METHODS: Adult patients undergoing TME for rectal adenocarcinoma were retrospectively identified. Preoperative computed tomography scans were used to measure abdominal circumference (AC), visceral (VFA), and subcutaneous fat area (SFA). BMI, AC, VFA, SFA, total fat area (TFA, sum of VFA and SFA), and VFA/SFA ratio were examined for association with operative, postoperative, oncologic, and survival outcomes in a univariate analysis model. RESULTS: Between 1999 and 2009, 113 patients met inclusion criteria. Increasing VFA and VFA/SFA ratio were associated with reduced lymph node retrieval (P = 0.03 and P = 0.009, respectively). The association between increasing VFA/SFA ratio with delayed resumption of oral intake (P = 0.05) and prolonged overall survival (P = 0.003) were also significant. Increasing BMI was associated with improved overall (P = 0.02) but not disease-free survival (P = 0.14). CONCLUSION: Visceral obesity, measured by VFA/SFA ratio, is a better predictor of postoperative, oncologic, and survival outcomes after TME for rectal adenocarcinoma than general obesity measured by the BMI.

Comparable postoperative morbidity and mortality after laparoscopic and open emergent restorative colectomy: outcomes from the ACS NSQIP.

BACKGROUND: Laparoscopic surgery is safe and effective in the management of common abdominal emergencies. However, there is currently a lack of data about its use for emergency colorectal surgery. We hypothesized that laparoscopy can improve the postoperative outcomes of emergency restorative colon resection. METHODS: Adult patients undergoing emergent open and laparoscopic colon resection with primary anastomosis were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database for the years 2005 to 2008 inclusive. Demographic and operative characteristics, laboratory values, and postoperative outcomes were compared between patients undergoing laparoscopic and open colon resection using univariate analyses, multivariate logistic regression, and propensity score analyses. RESULTS: A total of 341 laparoscopic (9.6 %) and 3211 (90.4 %) open colon resections were included. Patients undergoing laparoscopic surgery had a significantly lower prevalence of co-morbidities and better postoperative outcomes. On multivariate analysis, laparoscopic surgery was an independent predictor of a longer operating time (p < 0.001) and shorter total (p = 0.013) and postoperative (p = 0.004) hospital stays, but it did not affect the need for intraoperative blood transfusion (p = 0.488), the 30-day reoperation rates (p = 0.969), or mortality (p = 0.417). After adjusted propensity score analysis, postoperative morbidity (p = 0.833) and mortality (p = 0.568) were comparable in patients undergoing laparoscopic and open surgery. CONCLUSIONS: On a national scale, laparoscopic emergent colon resections are being performed in a small number of patients, who have favorable co-morbidity characteristics and improved postoperative outcomes. Laparoscopic emergent colon resection with primary anastomosis has postoperative morbidity and mortality rates comparable to those seen with the open approach, and it reduces the total and postoperative length of hospital stay.

Optimizing surgical care of colon cancer in the older adult population.

OBJECTIVE: We have undertaken the current study to evaluate factors that correlate with postoperative complications in older patients undergoing surgery for colon cancer. PATIENTS AND METHODS: The database of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) from years 2005 to 2008 was accessed. Patients age 65 and older were included according to Current Procedural Terminology and International Classification of Disease-9 codes. Preoperative and operative variables were examined and postoperative complications assessed using a combination of univariate and multivariate statistical models. Propensity score matching was used to control for nonrandomization of the database. RESULTS: We found that patients undergoing laparoscopic (n = 2113) and open (n = 3801) surgery for the diagnosis of colon cancer were similar in age and gender. However, patients undergoing laparoscopic surgery were generally at lower risk for developing postoperative complications (16.1% vs. 25.4%, P < 0.005). Statistical models controlling for preoperative and operative variables demonstrated patients with elevated body mass index (odds ratio [OR] = 1.26), a history of chronic obstructive pulmonary disease (OR = 1.63), over age 85 (OR = 1.35), a surgery lasting longer than 4 hours (OR = 1.48), or having undergone an open operation (OR = 1.53) to have increased risk for developing postoperative complications. Propensity score match analysis confirmed these results. CONCLUSIONS: Identification of preoperative factors that predispose patients to postoperative complications could allow for the institution of protocols that may decrease these events. Furthermore, expanding the role of laparoscopy in the treatment of older patients with colon cancer may decrease rates of postoperative complications.

Laparoscopy improves short-term outcomes after surgery for diverticular disease.

BACKGROUND & AIMS: Observational studies and small randomized controlled trials have shown that the use of laparoscopy in colon resection for diverticular disease is feasible and results in fewer complications. We analyzed data from a large, prospectively maintained, multicenter database (National Surgical Quality Initiative Program) to determine whether the use of laparoscopy in the elective treatment of diverticular disease decreases rates of complications compared with open surgery, independent of preoperative comorbid factors. METHODS: The analysis included data from 6970 patients who underwent elective surgeries for diverticular disease from 2005 to 2008. Patients with diverticular disease were identified by International Classification of Diseases, 9th revision codes and then categorized into open or laparoscopic groups based on Current Procedural Terminology codes. Preoperative, intraoperative, and postoperative data were analyzed to determine factors associated with increased risk for postoperative complications. RESULTS: Data were analyzed from 3468 patients who underwent open surgery and 3502 patients who underwent laparoscopic procedures. After correcting for probability of morbidity, American Society of Anesthesiology class, and ostomy creation, overall complications (including superficial surgical site infections, deep incisional surgical site infections, sepsis, and septic shock) occurred with significantly lower incidence among patients who underwent laparoscopic procedures compared with those who received open operations. CONCLUSIONS: The use of laparoscopy for treating diverticular disease, in the absence of absolute contraindications, results in fewer postoperative complications compared with open surgery.

Body mass index does not affect postoperative morbidity and oncologic outcomes of total mesorectal excision for rectal adenocarcinoma.

INTRODUCTION: Obesity adds to the technical difficulty of colorectal surgery and is a risk factor for postoperative complications. We hypothesized that obese patients have increased morbidity and poor oncologic outcomes after proctectomy for rectal adenocarcinoma. METHODS: Adult patients undergoing total mesorectal excision (TME) for rectal adenocarcinoma at a tertiary referral center were retrospectively identified from a prospectively maintained database. Operative characteristics, postoperative complication rates, and oncologic outcomes were compared in patients with BMI > or = 30 kg/m(2) and BMI < 30 kg/m(2). RESULTS: Between 1997 and 2009, 254 patients underwent proctectomy for rectal adenocarcinoma, of whom 27% were obese. There were no significant differences in demographics, comorbidities or preoperative oncologic characteristics between obese and nonobese groups. Patients with BMI > or = 30 kg/m(2) had longer operative times (p = 0.04) and higher intraoperative blood loss (p < 0.001) but comparable postoperative complication rates (p = 0.80), number of lymph nodes retrieved (p = 0.57), margin-negative resections (p = 0.44), and disease-free survival (p = 0.11). Obese patients had longer overall survival (p = 0.05). Tumor stage was the only variable associated with disease-free (p < 0.001) and overall survival (p < 0.001). CONCLUSION: Despite increased technical difficulty of resection, obesity does not increase the risk of postoperative morbidity or adversely affect oncologic outcomes after total mesorectal excision of rectal adenocarcinoma.

Laparoscopy decreases postoperative complication rates after abdominal colectomy: results from the national surgical quality improvement program.

OBJECTIVE: Compare outcomes of non-emergent laparoscopic to open colon surgery. BACKGROUND: Laparoscopy has revolutionized much of gastrointestinal surgery. Colon and rectal surgery has seen drastic changes with many of the abdominal operations being performed laparoscopically. However, data comparing recovery and complications in patients undergoing laparoscopic and open colon surgery has shown only slight benefits for laparoscopy. Given the large benefits of laparoscopy in most gastrointestinal surgical procedures, this outcome is surprising. We, therefore, have set out to test the hypothesis that laparoscopic approaches decreases postoperative complications. METHODS: We have undertaken a review of the database maintained by the American College of Surgeon's National Surgical Quality Improvement Program. We have identified 8660 patients who met inclusion criteria for this study. Postoperative complication data were collected for patients undergoing laparoscopic or open colon surgery. Using a combination of univariate and multivariate analyses we evaluated for statistical significance. RESULTS: We found that laparoscopy decreased overall complications as well as individual complications. We found a decreased length of stay as well as a decreased risk for postoperative complications in the elderly. We found that laparoscopy decreased complication rate independent of the probability of morbidity statistic. CONCLUSIONS: When controlled for probability of morbidity, laparoscopy decreases the rate of postoperative complications. Given the equivalent outcomes of laparoscopic approaches, we conclude that laparoscopy should be offered to all patients who lack an absolute contraindication for laparoscopic surgery.

Laparoscopic restorative proctocolectomy with ileal S-pouch.

PURPOSE: Restorative proctocolectomy has revolutionized the surgical management of ulcerative colitis and familial polyposis syndromes. Though now evolved to include laparoscopy, this approach has not included alternative pouch designs such as ileal S-pouch reconstruction. This comparative analysis evaluated the combination of laparoscopic-assisted total proctocolectomy with an ileal S-pouch design. METHODS: One hundred fifty-six (65 laparoscopic-assisted) total proctocolectomy and ileal S-pouch-anal anastomosis procedures performed between 2003 to 2007 were identified from a prospective surgical database. Operative time, length of incision, length of hospital stay, complications, and return of bowel function were examined. A cost analysis including preoperative through postoperative hospital stay and operating room and postanesthesia care unit costs was performed. RESULTS: The laparoscopic-assisted total proctocolectomy and ileal S-pouch-anal anastomosis procedures were performed for ulcerative colitis in 60 cases and familial adenomatous polyposis in the remaining 5 patients. Four conversions to open technique occurred (6 percent). Comparing laparoscopic and open procedures, the laparoscopic approach took longer to perform than the open technique (mean 451 minutes vs. 347 minutes open; P < 0.001). The mean hospital stay was 6.3 days in the laparoscopic group vs. 8.2 days in the open group (P < 0.001). A detailed cost analysis revealed similar overall costs between the laparoscopic ($18,700) and open approaches ($18,500). CONCLUSION: Use of a laparoscopic total proctocolectomy with ileal S-pouch-anal anastomosis reconstruction minimizes incision size and shortens hospital stay. At a teaching academic institution, the laparoscopic approach requires longer operative times yet a negligible cost disadvantage.

Cutaneous metastases in patients with rectal cancer: a report of six cases.

Cutaneous metastases from rectal cancer are rare manifestations of disseminated disease and uniformly represent dismal survival. A retrospective review of six patients with rectal cancer metastatic to the dermis was performed. The diagnosis of rectal cancer was made concurrently with the diagnosis of the dermal metastases in all six patients. A 100 per cent histopathologic concordance existed between the tissue of the dermal metastases and primary rectal tumor. The progression of systemic metastatic disease was the cause of death in 83.3 per cent of patients (5/6). No patient survived more than 7 months from the time of diagnosis. Recognition of suspicious skin lesions as possible harbingers of undiagnosed visceral malignancy is important in managing patients both with and without a history of previous cancer.

Examining the Impact of Using the SIMPL Application on Feedback in Surgical Education.

OBJECTIVE: The System for Improving and Measuring Procedural Learning (SIMPL) smartphone application allows physicians to provide dictated feedback to surgical residents. The impact of this novel feedback medium on the quality of feedback is unknown. Our objective was to compare the delivery and quality of best-case operative performance feedback given via SIMPL to feedback given in-person. DESIGN: We collected operative performance feedback given both in-person and via SIMPL from surgeons to residents over 6 weeks. Feedback transcripts were coded using Verbal Response Modes speech acts taxonomy to compare the delivery of feedback. We evaluated quality of feedback using a validated resident survey and third-party assessment form. SETTING: University of Wisconsin School of Medicine and Public Health, a large academic medical institution. PARTICIPANTS: Four surgical attendings and 9 general surgery residents. RESULTS: Nineteen SIMPL and 18 in-person feedback encounters were evaluated. Feedback via SIMPL was more directive (containing thoughts, perceptions, evaluations of resident behavior, or advice) and contained more presumptuous utterances (in which the physician reflected on and assessed resident performance or offered suggestions for improvement) than in-person feedback (p = 0.01). The resident survey showed no significant difference between the quality of feedback given via SIMPL and in-person (p = 0.07). The mean score was 47.74 (SD = 3.00) for SIMPL feedback and 45.33 (SD = 4.77) for in-person feedback, with a total possible score of 50. Third-party assessment showed no significant difference between the quality of feedback given via SIMPL and in-person (p = 0.486). The mean score was 23.40 (SD = 3.75) for SIMPL feedback and 22.25 (SD = 5.94) for in-person feedback, with a total possible score of 30. CONCLUSIONS: Although feedback given via SIMPL was more direct and based on the attendings' perspectives, the quality of the feedback did not differ significantly. Use of the dictation feature of SIMPL to deliver resident operative performance feedback is a reasonable alternative to in-person feedback.

Clinically Competent and Fiscally at Risk: Impact of Debt and Financial Parameters on the Surgical Resident.

BACKGROUND: While the costs of medical training continue to increase, surgeon income and personal financial decisions may be challenged to manage this expanding debt burden. We sought to characterize the financial liability, assets, income, and debt of surgical residents, and evaluate the necessity for additional financial training. STUDY DESIGN: All surgical trainees at a single academic center completed a detailed survey. Questions focused on issues related to debt, equity, cash flow, financial education, and fiscal parameters. Responses were used to calculate debt-to-asset and debt-to-income ratios. Predictors of moderate risk debt-to-asset ratio (0.5 to 0.9), high risk debt-to-asset ratio (≥0.9), and high risk debt-to-income ratio (>0.4) were evaluated. All analyses were performed in SPSS v.21. RESULTS: One hundred five trainees completed the survey (80% response rate), with 38% of respondents reporting greater than $200,000 in educational debt. Overall, 82% of respondents had a moderate or high risk debt-to-asset ratio. Residency program, year, sex, and perception of financial knowledge did not correlate with high risk debt-to-asset ratio. Residents with high debt-to-asset ratios were more likely to have a high level of concern about debt (52% vs 0%, p < 0.001) when compared with residents who had low debt-to-asset ratios. The majority (79%) of respondents felt strongly that inclusion of additional financial training in residency education is a critical need. CONCLUSIONS: In a climate of increasingly delayed financial gratification, surgical trainees are on critically unstable financial footing. There is a major gap in current surgical education that requires reassessment for the long-term financial health of residents.

Is the operative autonomy granted to a resident consistent with operative performance quality.

BACKGROUND: We investigated attending surgeon decisions regarding resident operative autonomy, including situations where operative autonomy was discordant with performance quality. METHODS: Attending surgeons assessed operative performance and documented operative autonomy granted to residents from 14 general surgery residency programs. Concordance between performance and autonomy was defined as "practice ready performance/meaningfully autonomous" or "not practice ready/not meaningfully autonomous." Discordant circumstances were practice ready/not meaningfully autonomous or not practice ready/meaningfully autonomous. Resident training level, patient-related case complexity, procedure complexity, and procedure commonality were investigated to determine impact on autonomy. RESULTS: A total of 8,798 assessments were collected from 429 unique surgeons assessing 496 unique residents. Practice-ready and exceptional performances were 20 times more likely to be performed under meaningfully autonomous conditions than were other performances. Meaningful autonomy occurred most often with high-volume, easy and common cases, and less complex procedures. Eighty percent of assessments were concordant (38% practice ready/meaningfully autonomous and 42% not practice ready/not meaningfully autonomous). Most discordant assessments (13.8%) were not practice ready/meaningfully autonomous. For fifth-year residents, practice ready/not meaningfully autonomous ratings (9.7%) were more frequent than not practice ready/meaningfully autonomous ratings (7.5%). Ten surgeons (2.3%) failed to afford residents meaningful autonomy on any occasion. CONCLUSION: Resident operative performance quality is the most important determinant in attending surgeon decisions regarding resident autonomy.

Efficacy of protocol implementation on incidence of wound infection in colorectal operations.

BACKGROUND: We reported previously a 26% incidence of surgical site infection (SSI) in patients undergoing elective colorectal resection. Multiple risk factors have been identified, including obesity, improper administration of prophylactic antibiotics, hypothermia, and poor glycemic control. We hypothesized that implementation of a multidisciplinary wound management protocol targeting these risk factors would reduce the incidence of SSI. STUDY DESIGN: Previously reported baseline data were collected from February 2000 to January 2002. Beginning September 2004, the protocol was implemented, including appropriate administration of prophylactic antibiotics 0 to 60 minutes before incision, continued antibiotic administration for < or = 24 hours postoperatively, maintenance of intraoperative normothermia (> 36 degrees C), improved glycemic control (goal <200 mg/dL 48 hours postoperatively) in diabetic patients, and placement of penrose drains in the subcutaneous space of patients with a body mass index > or = 25. Data were collected on patients undergoing elective colorectal resection from January 2005 to August 2005 and compared with baseline. RESULTS: One hundred seventy-five and 132 patients during the baseline and study periods, respectively, met criteria for inclusion. Compliance with administration of prophylactic antibiotics increased from 68% to 91% (p < or = 0.0001), and compliance with cessation within 24 hours increased from 71% to 93% (p < or = 0.0001). Compliance with normothermia increased from 64% to 71% (p = 0.25). Incidence of SSI fell from 25.6% to 15.9% (p < or = 0.05). CONCLUSIONS: After implementation of a multidisciplinary wound-management protocol, incidence of SSI improved 39%. These results demonstrate that compliance with a prospectively designed protocol for perioperative care can effectively reduce operative morbidity in patients undergoing colorectal operations.

Resident training in a teaching hospital: How do attendings teach in the real operative environment?

BACKGROUND: The study aim was to explore the nature of intraoperative education and its interaction with the environment where surgical education occurs. METHODS: Video and audio recording captured teaching interactions between colorectal surgeons and general surgery residents during laparoscopic segmental colectomies. Cases and collected data were analyzed for teaching behaviors and workflow disruptions. Flow disruptions (FDs) are considered deviations from natural case progression. RESULTS: Across 10 cases (20.4 operative hours), attendings spent 11.2 hours (54.7%) teaching, using directing (M = 250.1), and confirming (M = 236.1) most. FDs occurred 410 times, accounting for 4.4 hours of case time (21.57%). Teaching occurred with FD events for 2.4 hours (22.2%), whereas 77.8% of teaching happened outside FD occurrence. Teaching methods shifted from active to passive during FD events to compensate for patient safety. CONCLUSIONS: Understanding how FDs impact operative learning will inform faculty development in managing interruptions and improve its integration into resident education.