Creation and Implementation of an Online Tool for Feedback on Resident Teaching: A Pilot Study.

OBJECTIVE: There are few assessments of the competence and growth of surgical residents as educators. We developed and piloted an observation-based feedback tool (FT) to provide residents direct feedback during a specific teaching session, as perceived by medical students (MS). We hypothesized that residents' performance would improve with frequent, low stakes, observation-based feedback. SETTING: This prospective study took place at an academic general surgery program. PARTICIPANTS: Focus groups of MS, surgical residents, and faculty informed FT development. MS completed the FT regarding resident teaching. DESIGN: The FT utilized 5 slider-bar ratings (0 to 100) about the teaching encounter and a checklist of 16 desirable teaching behaviors. QR codes and weekly email links were distributed for 12 months (6 clerkship blocks) to promote use. Residents were sent their results after each block. A survey after each block assessed motivation for use and gathered feedback on the FT. Descriptive statistics were used for analysis (medians, IQRs). Primary measures of performance were median of the slider-bar scores and the number of teaching behaviors. RESULTS: The FT was used 111 times; 37 of 46 residents were rated by up to 65 MS. The median rating on the slider-bars was 100 and the median number of desirable teaching behaviors was 12; there were no differences based on gender or PGY level. 10 residents had 5 or more FT observations during the year. Four residents had evaluations completed in 4 or more blocks and 19 residents had evaluations completed in at least 2 blocks. Over time, 13 residents had consistent slider-bar scores, 1 resident had higher scores, and 5 residents had lower scores (defined as a more than 5-point change from initial rating). Frequency of use of the FT decreased over time (38, 32, 9, 21, 7, 5 uses per block). The post-use survey was completed by 24 MS and 19 residents. Most common reasons for usage were interest in improving surgical learning environment, giving positive feedback (MS), and improving teaching skills (residents). Most common reasons for lack of usage from residents were "I did not think I taught enough to ask for feedback," "I forgot it existed," and "I did not know it existed." CONCLUSIONS: The FT did not lead to any meaningful improvement in resident scores over the course of the year. This may be due to overall high scores, suggesting that the components of the FT may require reevaluation. Additionally, decreased utilization of the instrument over time made it challenging to assess change in performance of specific residents, likely due to lack of awareness of the FT despite frequent reminders. Successful implementation of observation-based teaching assessments may require better integration with residency or clerkship objectives.

The use of core descriptors from the ENiGMA code study in recent literature: a systematic review.

AIM: The heterogeneity in data quality presented in studies regarding Crohn's anal fistula (CAF) limit extrapolation into clinical practice. The ENiGMA collaborators established a core descriptor set to standardize reporting of CAF. The aim of this work was to quantify the use of these descriptors in recent literature. METHOD: We completed a systematic review of PubMed and the Cochrane Library, extracting publications from the past 10 years specific to the clinical interventions and outcomes of CAF, and reported in line with PRISMA guidance. Each article was assessed for inclusion of ENiGMA descriptors. The median number of descriptors per publication was evaluated along with the overall frequency of each individual descriptor. Use of ENiGMA descriptors was compared between medical and procedural publications. RESULTS: Ninety publications were included. The median number of descriptors was 15 of 37; 16 descriptors were used in over half of the publications while 17 were used in fewer than a third. Descriptors were more frequently used in procedural (n = 16) than medical publications (n = 14) (p = 0.031). In procedural publications, eight descriptors were more frequently used including Faecal incontinence, Number of previous fistula interventions, Presence and severity of anorectal stenosis and Current proctitis. Medical publications were more likely to include Previous response to biological therapy and Duration and type of current course of biological therapy. CONCLUSION: With many descriptors being used infrequently and variations between medical and procedural literature, the colorectal community should assess the need for all 37 descriptors.

Eliminating Hands-Off Handoffs: Improvement in Perioperative Handoff Communication With a Multidisciplinary Tool Initiative.

INTRODUCTION: Handoffs between the operating room (OR) and post-anesthesia care unit (PACU) require a high volume and quality of information to be transferred. This study aimed to improve perioperative communication with a handoff tool. METHODS: Perioperative staff at a quaternary care center was surveyed regarding perception of handoff quality, and OR to PACU handoffs were observed for structured criteria. A 25-item tool was implemented, and handoffs were similarly observed. Staff was then again surveyed. A multidisciplinary team led this initiative as a collaboration. RESULTS: After implementation, nursing reported improved perception of time spent (2.63-3.68, p = .02) and amount of information discussed (2.85-3.73, p = .05). Anesthesia also reported improved personal communication (3.69-4.43, p = .004), effectiveness of handoffs (3.43-3.82, p = .02), and amount of information discussed (4.26-4.76, p = .05). After implementation, observed patient information discussed during handoffs increased for both surgical and anesthesia team members. The frequency of complete and near-complete handoffs increased (40%-74%, p < .001). CONCLUSIONS: A structured handoff tool increased the amount of essential information reported during handoffs between the OR and PACU and increased team members' perception of handoffs.

Disparities in Clinical Trial Enrollment and Reporting in Rectal Cancer: A Systematic Review and Demographic Comparison to the National Cancer Database.

BACKGROUND: Cancer care guidelines based on clinical trial data in homogenous populations may not be applicable to all rectal cancer patients. The aim of this study was to evaluate whether patients enrolled in rectal cancer clinical trials (CTs) are representative of United States (U.S.) rectal cancer patients. METHODS: Prospective rectal cancer CTs from 2010 to 2019 in the United States were systematically reviewed. In trials with multiple arms reporting separate demographic variables, each arm was considered a separate CT group in the analysis. Demographic variables considered in the analysis were age, sex, race/ethnicity, facility location throughout the United States, rural vs urban geography, and facility type. Participant demographics from trial and the National Cancer Database (NCDB) participants were compared using chi-squared goodness of fit and one-sample t-test where applicable. RESULTS: Of 50 CT groups identified, 42 (82%) studies reported mean or median age. Trial participants were younger compared to NCDB patients (P < .001 all studies). All but three trials had fewer female patients than NCDB (48.2% female, P < .001). Less than half the CT groups reported on race or ethnicity. Eighteen out of 22 trials (82%) had a smaller percentage of Black patients and 4 out of 8 (50%) trials had fewer Hispanic or Spanish origin patients than the NCDB. No CTs reported comorbidities, socioeconomic factors, or education. CT primary sites were largely at academic centers and in urban areas. CONCLUSION: The present study supports the need for improved demographic representation and transparency in rectal cancer clinical trials.

Trends in Management of Anal Fissures.

BACKGROUND: It is unclear how patients with anal fissures are treated in real-world settings, particularly since patients may not see colorectal surgeons. This study describes trends in treatment with medical therapies (calcium-channel blockers [CCBs], nitroglycerin [NTG], and narcotics) and surgical treatments. METHODS: Cohorts were created within the TriNetX database platform using codes for anal fissures and surgical interventions. Demographics were compared between patients that received surgical intervention within 1 year of diagnosis, CCB or NTG within 1 year (or preoperatively), or narcotics within 30 days or postoperatively vs those who did not. RESULTS: 121,213 patients were included of which 4.0% had surgical intervention. Factors associated with surgical intervention were male sex (OR 1.40), White race (OR 1.17), and Hispanic ethnicity (OR 1.11). Male patients were more likely to undergo sphincterotomy (OR 1.49). Female (OR 1.27), non-Hispanic (OR 1.34), and White patients (OR 1.41) were more likely to have chemodenervation. Regarding nonoperatively managed patients, non-Hispanic (OR .91) and White patients (OR .89) were less likely to receive CCB/NTG. Male (OR 1.21), non-Hispanic (OR 1.08), and Black patients (OR 1.20) were more likely to receive narcotics. Male patients that required surgery were more likely to be prescribed CCB/NTG preoperatively (OR 1.27). Non-Hispanic surgical patients were more likely to receive narcotics (OR 1.84). DISCUSSION: Male fissure patients were more likely to undergo surgical intervention other than chemodenervation. Differences in the rates of surgery and medical therapy (especially narcotics) between races and ethnicities require exploration to enhance the care of patients with anal fissures.

Development of a Competency Framework Defining Effective Surgical Educators.

OBJECTIVE: The objective of this study is to develop a practical framework of competencies and behaviors which define an effective surgical educator. DESIGN: A modified Delphi approach was used. A literature review and series of discussions with surgical education experts led to creation of a survey instrument which was sent to surgical faculty and trainees from a single academic institution. The results from this initial survey informed the creation of the subsequent survey instrument which was also sent to surgical faculty and trainees. Focus groups with surgical faculty and residents were conducted separately, transcribed, deidentified, and then evaluated for recurring themes. A competency framework was developed. SETTING: The surveys were administered and focus groups were conducted at the University Hospitals Cleveland Medical Center, a tertiary care academic institution. PARTICIPANTS: Residents, fellows, and faculty surgeons from the fields of general surgery, plastic surgery, vascular surgery, orthopedic surgery, otolaryngology, neurosurgery, and urology. RESULTS: There were 115 responses (31.3%) from 367 faculty surgeons, residents, and fellows invited to complete the initial survey examining 50 competencies. Eighteen competencies received a mean Likert score of at least 4 by both faculty and residents and were included in the subsequent survey instrument which was completed by 72 participants (19.6%). Focus groups were held separately with 6 faculty surgeons and 6 residents. Analysis of the survey results and focus group discussions identified several themes which informed the development of a competency framework consisting of 5 overarching competencies as well as 16 specific behaviors. CONCLUSIONS: A practical framework was developed consisting of 5 competencies and 16 behaviors which define an effective surgical educator. The 5 competencies are: 1) fosters psychological safety, 2) displays exemplary medical knowledge and patient care, 3) diagnoses the learner and adjusts teaching, 4) communicates thought process to trainee, and 5) displays learner-centeredness. Based on the competency framework, residency leadership may specifically tailor faculty development initiatives to improve surgical education programming.

Surgical Education: Disparities in Education May Impact the Quality and Likelihood of Completion of Training.

Female surgical trainees experience bias that begins at the preclinical stages of medical school, extending into their surgery clerkships, and then into their residency training. There are important implications in terms of training opportunities and career advancement, mentorship, sponsorship, and ultimately burnout. Childbearing and lactation also impact the experiences and perceptions of female trainees who have children. There are limited interventions that have improved the experience of women in surgical training. Mentorship appears to play an important role in ameliorating some of the negative consequences of the training environment and improving outcomes for women surgeons.

Primary Colorectal Tumor Location and Predictors for Metastasis to the Brain.

Introduction Although rectal cancer is thought to have a higher rate of metastasis to the brain compared with colon cancer, there is limited and contradictory data on the subject. This study aims to determine the prevalence of brain metastasis for colon and rectal cancers (CRC), and to explore associations and predictors of brain metastasis (BM). Methods The 2010-2016 National Cancer Database (NCDB) was queried for patients with stage IV CRC. Patients with missing data on site of metastasis and primary tumor location were excluded. Chi-square test was used for categorical data and multivariate logistic regression analysis was performed to evaluate the predictors of BM. Results Of 108,540 stage IV CRC patients, the prevalence of BM was 1.21% from the right colon, 1.29% from the left colon, and 1.59% from the rectal adenocarcinoma (p<0.001). The presence of lung, bone, and liver metastases were the strongest predictors for BM. Bone and lung metastases increased the odds for BM by 3.87 (95% CI: 3.36-4.46) and 3.38 (95% CI: 3.01-3.80), respectively while the presence of liver metastasis decreased odds for BM by 55% (OR: 0.45; 95% CI: 0.40-0.50). On multivariate analysis, primary tumor location was not predictive of BM. Discussion This study helps to characterize the prevalence and associations of BM from CRC using the NCDB. The correlation between BM and bone and lung metastases, along with negative association of liver metastasis further supports the hypothesis of systemic transmission of tumor cells. Further identification of predictors and correlations with BM may help guide surveillance among patients with advanced CRC.

Adjuvant Chemotherapy Is Associated with Improved Survival for Stage III Colon Cancer When Initiated Beyond 8 Weeks.

BACKGROUND: The National Comprehensive Cancer Network (NCCN) guidelines recommend adjuvant chemotherapy (AC) within 6-8 weeks of surgical resection for patients with stage III colon cancer. However, postoperative complications or prolonged surgical recovery may affect the receipt of AC. The aim of this study was to assess the utility of AC for patients with prolonged postoperative recovery. METHODS: We queried the National Cancer Database (2010-2018) for patients with resected stage III colon cancer. Patients were categorized as having either normal or prolonged length of stay (PLOS: >7 days, 75th percentile). Multivariable Cox proportional hazard regression and logistic regressions were used to identify factors associated with overall survival and receipt of AC. RESULTS: Of the 113,387 patients included, 30,196 (26.6%) experienced PLOS. Of the 88,115 (77.7%) patients who received AC, 22,707 (25.8%) initiated AC more than 8 weeks after surgery. Patients with PLOS were less likely to receive AC (71.5% vs. 80.0%, OR: 0.72, 95%CI=0.70-0.75) and displayed inferior survival (75 vs. 116 months, HR: 1.39, 95%CI=1.36-1.43). Receipt of AC was also associated with patient factors such as high socioeconomic status, private insurance, and White race (p<0.05 for all). AC within and after 8 weeks of surgery was associated with improved survival for patients with both normal LOS and PLOS (normal LOS: <8 weeks HR: 0.56, 95% CI: 0.54-0.59, >8 weeks HR: 0.68, 95% CI: 0.65-0.71; PLOS: <8 weeks HR: 0.51, 95% CI: 0.48-0.54, >8 weeks HR: 0.63, 95% CI 0.60-0.67). AC was associated with significantly improved survival if initiated up to 15 weeks postoperatively (normal LOS: HR: 0.72, 95%CI=0.61-0.85; PLOS: HR: 0.75, 95%CI=0.62-0.90), and very few patients (<3.0%) initiated AC beyond this time. CONCLUSION: Receipt of AC for stage III colon cancer may be affected by surgical complications or otherwise prolonged recovery. Timely and even delayed AC (>8 weeks) are both associated with improved overall survival. These findings highlight the importance of delivering guideline-based systemic therapies, even after complicated surgical recovery.

Factors Associated with Receipt of Adjuvant Chemotherapy in Stage II Colon Cancer.

BACKGROUND: The benefits of chemotherapy in stage II colon cancer remain unclear, but it is recommended for high-risk stage II disease. Which patients receive chemotherapy and its impact on survival remains undetermined. METHODS: The National Cancer Database was surveyed between 2004 and 2016 for stage II colon cancer patients. Patients were categorized as high- or average-risk as defined by the National Comprehensive Cancer Network. The demographic characteristics of high- and average-risk patients who did and did not receive chemotherapy were compared using univariate and multivariable analyses. The survival of high- and average-risk patients was compared based on receipt of chemotherapy with Cox hazard ratios and Kaplan-Meier curves. RESULTS: Overall, 84,424 patients met the inclusion criteria. A total of 34,868 patients were high-risk and 49,556 were average-risk. In high-risk patients, the risk factors for not receiving chemotherapy included increasing age, distance from the treatment facility, Charlson-Deyo score, and lack of insurance. In average-risk patients, factors associated with receipt of chemotherapy were decreasing age, distance from the treatment facility, Charlson-Deyo score, and non-academic association of the treatment facility. In both, chemotherapy was significantly associated with increased survival on the Kaplan-Meier curve. In the Cox hazard ratio, only high-risk patients benefited from chemotherapy (hazard ratio 1.183, confidence interval 1.116-1.254). CONCLUSIONS: Factors associated with not receiving chemotherapy in high-risk stage II colon cancers included increasing age, medical comorbidities, increasing distance from the treatment facility, and lack of insurance. Chemotherapy is associated with improved overall survival in high-risk patients.

An analysis of publications originating from abstracts presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Meeting.

BACKGROUND: Research presentation has benefits, including CV building, networking, and collaboration. A measurable standard for achievement is publication in a peer-reviewed journal. Expectations regarding the likelihood of publication are unknown for studies presented at a national surgical scientific meeting. This study aims to evaluate predictors of manuscript publication arising from abstracts presented at a national surgical scientific meeting. METHODS: Abstracts presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Meeting 2019 were reviewed. Identification of published manuscripts was completed using MedLine, Embase, and Google Scholar 28 months after the presentation to allow for time for publication. Factors evaluated for association with publication included author and abstract measures. Descriptive analyses and multivariable statistics were performed. RESULTS: 724 abstracts (160 podiums, 564 posters) were included. Of the podium presentations, 128 (80%) were published in a median of 4 months after the presentation. On univariable and multivariable analyses, there was no association between publication and abstract topic, gender, degree, number of publications, or H-indices of first and senior authors. 154 (27.3%) poster presentations were published with a median of 13 months. On univariable analysis, there was a statistically significant difference regarding the abstract topic (p = 0.015) and senior author degree (p = 0.01) between published and unpublished posters. Multivariable analysis demonstrated that colorectal surgery (OR 2.52; CI 1.02-6.23) and metabolic/obesity (OR 2.53; CI 1.09-5.84) are associated with an increased odd of publication. There was an inverse association with female senior authors (OR 0.53; CI 0.29-0.98), while additional degrees (e.g., doctorate and/or master's degree) of the senior authors were associated with an increased publication rate (OR 1.80; CI 1.00-3.22). CONCLUSION: 80% of podiums but only 27% of posters were ultimately published. While some predictors of poster publication were noted, it is unclear if these are why these projects fail to publish. Future research is warranted to determine if there are effective strategies to increase poster publication rates.

The Presence of Implicit Gender Bias in Colon and Rectal Surgery Residency Letters of Recommendation.

BACKGROUND: Selection for colorectal surgery residency relies on letters of recommendation for assessment of candidates' strengths and weaknesses. It is unclear whether this process incorporates implicit gender bias. OBJECTIVE: This study aimed to assess the presence of gender bias in letters of recommendation for colorectal surgery residency. DESIGN: Mixed methods assessment of the characteristics described within the blinded letters of the 2019 application cycle to a single academic residency. SETTINGS: Academic medical center. PATIENTS: Blinded letters from the 2019 colorectal surgery residency application cycle. INTERVENTIONS: Characteristics of the letters were qualitatively and quantitatively analyzed. MAIN OUTCOME MEASURES: Association of gender with the presence of descriptors within the letters. RESULTS: A total of 111 applicants, 409 letter writers, and 658 letters were analyzed. Forty-three percent of applicants were female. Female and male applicants had an equal mean number of positive (5.4 vs 5.8; p = 0.10) and negative (0.5 vs 0.4; p = 0.07) attributes represented. Female applicants were more likely to be described as having poor academic skills (6.0 vs 3.4%; p = 0.04) and possessing negative leadership qualities (5.2% vs 1.4%; p < 0.01) than male applicants. Male applicants were more likely to be described as kind (36.6% vs 28.3%; p = 0.03), curious (16.4% vs 9.2%; p = 0.01), possessing positive academic skills (33.7% vs 20.0%; p < 0.01), and possessing positive teaching skills (23.5% vs 17.0%; p = 0.04). LIMITATIONS: This study analyzed a single year of applications to an academic center and may not be generalizable. CONCLUSIONS: There are differences in the qualities used to describe female versus male applicants in colorectal surgery residency application letters of recommendation. Female applicants were more often described in negative academic terms and possessing negative leadership qualities. Males were more likely to be described as kind, curious, academically impressive, and possessing good teaching skills. The field may benefit from educational initiatives to reduce implicit gender bias in letters of recommendation. See Video Abstract at http://links.lww.com/DCR/C191 . LA PRESENCIA DE SESGO DE GNERO IMPLCITO EN LAS CARTAS DE RECOMENDACIN DE RESIDENCIA EN CIRUGA DE COLON Y RECTO: ANTECEDENTES:La selección para la residencia en cirugía colorrectal se basa en cartas de recomendación para la evaluación subjetiva de las fortalezas y debilidades de los candidatos. No está claro si este proceso incorpora un sesgo de género implícito.OBJETIVO:Evaluar la presencia de sesgo de género en las cartas de recomendación para la residencia en cirugía colorrectal.DISEÑO:Evaluación de métodos mixtos de las características descritas dentro de las cartas selladas del ciclo de solicitud de 2019 a una sola residencia académica.ENTORNO CLÍNICO:Centro médico académico.PACIENTES:Cartas selladas del ciclo de solicitud de residencia en cirugía colorrectal de 2019.INTERVENCIONES:Las características de las cartas se determinaron utilizando medidas cualitativas y cuantitativas.PRINCIPALES MEDIDAS DE VALORACIÓN:Asociación del género con la presencia de descriptores dentro de las cartas.RESULTADOS:Hubo 111 solicitantes, 409 escritores de cartas y se analizaron 658 cartas. El 43% de los solicitantes eran mujeres. Los solicitantes masculinos y femeninos tenían el mismo promedio de atributos positivos (5,4 frente a 5,8; p = 0,10) y negativos (0,5 frente a 0,4; p = 0,07) representados. Las solicitantes femeninas tenían más probabilidades de ser descritas como con deficientes habilidades académicas (6,0 frente a 3,4%, p = 0,04) y poseían cualidades de liderazgo negativas (5,2% frente a 1,4%; p < 0,01) en comparacion con los solicitantes masculinos. Los solicitantes masculinos tenían más probabilidades de ser descritos como amables (36,6 % frente a 28,3%; p = 0,03), curiosos (16,4% frente a 9,2%; p = 0,01), que poseían habilidades académicas positivas (33,7 % frente a 20,0%; p < 0,01), y habilidades docentes positivas (23,5% vs 17,0%; p = 0,04).LIMITACIONES:Este estudio analizó un solo año de solicitudes a un centro académico y puede no ser generalizable.CONCLUSIÓN:Existen diferencias en las cualidades utilizadas para describir a los solicitantes femeninos versus masculinos en las cartas de recomendación de solicitud de residencia en cirugía colorrectal. Las candidatas femeninas se describieron con mayor frecuencia en términos académicos negativos y poseían cualidades de liderazgo negativas. Los hombres eran más propensos a ser descritos como amables, curiosos, académicamente impresionantes y con buenas habilidades docentes. El campo puede beneficiarse de iniciativas educativas para reducir el sesgo de género implícito en las cartas de recomendación. Consulte Video Resumen en http://links.lww.com/DCR/C191 . (Traducción-Dr. Ingrid Melo ).

Sarcopenia in Patients With Rectal Adenocarcinoma: An Opportunity for Preoperative Rehabilitation.

BACKGROUND: Sarcopenia, defined as low skeletal muscle mass, affects up to 60% of rectal adenocarcinoma patients receiving neoadjuvant chemoradiation (NACRT), with negative impact on patient outcomes. Identifying modifiable risk factors may decrease morbidity and mortality. METHODS: A retrospective review of rectal cancer patients from a single academic center from 2006 to 2020 was performed. Sixty-nine patients with pre- and post-NACRT CT imaging were included. Skeletal muscle index (SMI) was calculated as total L3 skeletal muscle divided by height squared. Sarcopenia thresholds were 52.4 cm2/m2 for men and 38.5 cm2/m2 for women. Student T-test, chi-square test, multivariable regression, and multivariable Cox hazard analysis were performed. RESULTS: 62.3% of patients lost SMI from pre- to post-NACRT imaging, with a mean change of -7.8% (±19.9%). Eleven (15.9%) patients were sarcopenic at presentation, increasing to 20 (29.0%) following NACRT. Mean SMI decreased from 49.0 cm2/m2 (95% CI: 42.0 cm2/m2-56.0 cm2/m2) to 38.2 cm2/m2 (95% CI: 33.6 cm2/m2-42.9 cm2/m2) (P = .003). Pre-NACRT sarcopenia correlated with post-NACRT sarcopenia (OR 20.6, P = .002). Percent decrease in SMI was associated with a 5% increased mortality risk. CONCLUSION: The presence of sarcopenia at diagnosis and its association with post-NACRT sarcopenia suggests an opportunity for a high-impact intervention.

Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons.

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.

Not All Patients With Locally Advanced Rectal Cancer Benefit From Neoadjuvant Therapy.

BACKGROUND: While neoadjuvant combined modality therapy (NA-CMT) is beneficial for most patients with locally advanced rectal cancer some patients may experience disease progression during treatment. The purpose of this study is to identify characteristics associated with progression during NA-CMT. METHODS: A single institution retrospective review of patients with stage II-III rectal cancer receiving NA-CMT was conducted from 2008-2019. Patients with incomplete or unknown NA-CMT treatment and those who received chemotherapy in addition to NA-CMT were excluded. Initial staging MRI was compared to post-operative pathology to determine progression. Definitions: responders (complete response or regression) and non-responders (stable disease or progression). RESULTS: 156 patients were included: 25 (16.1%) complete responders, 79 (50.6%) had evidence of regression, 34 (21.8%) were stable non-responders, and 18 (11.5%) were progressors. Those who progressed had worse overall survival. Factors associated with non-responders included black race (OR 4.5, 95% CI: 1.10-18.7) and increasing distance from the anal verge (OR 1.2, 95% CI: .2-2.9). Distance from the anal verge was determined via MRI. Recurrence was significantly more common among non-responders (15, 30.61%) when compared to responders (14, 13.46%), P = .012. CONCLUSION: Patients who progress despite NA-CMT have overall worse survival compared to patients who do respond. While this study failed to identify modifiable or predictive risk factors for progression, the multivariate logistic regression model suggests that race and tumor biology may play a role in progression. Future studies should focus on early identification of patients who may not benefit from NA-CMT in an effort to develop alternative treatment algorithms.

Standardized Letter of Recommendation: Can Everyone Be Awesome?

OBJECTIVE: Standardized letters of recommendation (SLOR) are hypothesized to decrease bias and provide consistent domains for evaluation. However, their ability to differentiate among applicants is unknown. The utilization and functionality of SLOR and the impact of SLOR domain rating on matching for colon and rectal surgery (CRS) residency applicants have yet to be assessed. DESIGN: Descriptive statistics and bivariate analysis were employed. Applicants were categorized into 3 groups; Top-tier(TT): applicants rated 100% Excellent/Very Good; Mid-Tier(MT) applicants rated 80-99% Excellent/Very Good; and Non-Top Tier(NTT) applicants rated <80% Excellent/Very Good. SETTING: University of Hospitals Cleveland Medical Center. PARTICIPANTS: SLORs submitted to a single colorectal surgery residency in 2019 were analyzed RESULTS: A total of 101 applicants were included, 54 (53.5%) of the applicants were male. 75 (74.2%) applicants who applied to our residency matched into a CRS residency, compared to the national rate of 66%. Of the 101 applicants with SLOR, 54 (53.5%) were categorized as TT, 26 (25.7%) as MT, and 21(20.8%) as NTT. The univariable analysis demonstrated a statistically significant difference in research experience (p=0.029) and match status (p=0.01) between applicant tiers. There were no statistically significant differences between applicant-tier and demographics, foreign medical graduates (FMG), H-indices, ABSITE scores, type of residency, preliminary year, completing an unaccredited CRS, and applicants with an additional degree. On multivariable analysis age (OR=0.65; CI=0.48-0.87) and FMG applicants (OR=0.05; CI=0.01-0.44) were inversely associated with successfully matching. Compared to TT applicants, MT (OR=0.07; CI=0.01-0.57) and NTT (OR=0.04; CI=0.01-0.34) applicants were inversely associated with a successful match. Individuals who completed research prior to residency but after medical school was associated with successfully matching (p=0.009). CONCLUSIONS: The presence of MT and NTT ratings is associated with failure to match and may represent an area of concern for CRS programs rather than a tool to discern differences between candidates.