A novel approach to assessing technical competence of colorectal surgery residents: the development and evaluation of the Colorectal Objective Structured Assessment of Technical Skill (COSATS).

OBJECTIVE: To develop and evaluate an objective method of technical skills assessment for graduating subspecialists in colorectal (CR) surgery-the Colorectal Objective Structured Assessment of Technical Skill (COSATS). BACKGROUND: It may be reasonable for the public to assume that surgeons certified as competent have had their technical skills assessed. However, technical skill, despite being the hallmark of a surgeon, is not directly assessed at the time of certification by surgical boards. METHODS: A procedure-based, multistation technical skills examination was developed to reflect a sample of the range of skills necessary for CR surgical practice. These consisted of bench, virtual reality, and cadaveric models. Reliability and construct validity were evaluated by comparing 10 graduating CR residents with 10 graduating general surgery (GS) residents from across North America. Expert CR surgeons, blinded to level of training, evaluated performance using a task-specific checklist and a global rating scale. The mean global rating score was used as the overall examination score and a passing score was set at "borderline competent for CR practice." RESULTS: The global rating scale demonstrated acceptable interstation reliability (0.69) for a homogeneous group of examinees. Both the overall checklist and global rating scores effectively discriminated between CR and GS residents (P < 0.01), with 27% of the variance attributed to level of training. Nine CR residents but only 3 GS residents were deemed competent. CONCLUSIONS: The Colorectal Objective Structured Assessment of Technical Skill effectively discriminated between CR and GS residents. With further validation, the Colorectal Objective Structured Assessment of Technical Skill could be incorporated into the colorectal board examination where it would be the first attempt of a surgical specialty to formally assess technical skill at the time of certification.

The american society of colon and rectal surgeons and surgical education: what does your society do for you?

Since its inception in 1899, the American Society of Colon and Rectal Surgeons (ASCRS) has been actively providing support for the education of its members specializing in colon and rectal surgery, general surgeons, surgical residents, and medical students. With new developments in surgical education, the ASCRS continues to offer educational tools and activities tailored to meet acquisition of medical knowledge and technical skills in an ongoing fashion throughout surgeons' careers, foster high-quality patient care, and promote the integration of the core competencies of communication skills, professionalism, system-based practice and practice-based learning, and improvement in daily practice. These tools and activities are presented in this article.

Career decisions and the structure of training: an American Board Of Colon and Rectal Surgery survey of colorectal residents.

OBJECTIVE: To investigate potential impacts of restructuring general surgery training on colorectal (CR) surgery recruitment and expertise. SUMMARY BACKGROUND DATA: In response to the American Surgical Association Blue Ribbon Committee report on surgical education (2004), the American Board of Colon and Rectal Surgery, working with the Accreditation Council for Graduate Medical Education and American Board of Surgery, established a committee (2006) to review residency training curricula and study new pathways to certification as a CR surgeon. To address concerns related to shortened general surgery residency, the American Board of Colon and Rectal Surgery committee surveyed recent, current, and entering CR residents on the timing and factors associated with their career choice and opinions regarding restructuring. METHODS: A 10-item, online survey of 189 CR surgeons enrolled in the class years of 2005, 2006, and 2007 was administered and analyzed May to July 2007. RESULTS: One hundred forty-five CR residents responded (77%); results were consistent across class years and types of general surgery training program. Seventy percent of respondents had rotated onto a CR service by the end of their PGY-2 year. Most identified CR as a career interest in their PGY-3 or PGY-4 year. Overall interest in CR surgery, the influence of CR mentors and teachers, and positive exposure to CR as PGY-3, PGY-4, or PGY-5 residents were the top cited factors influencing choice decisions. Respondents were opposed to restructuring by a 2:1 ratio, primarily because of concerns about inadequate training and lack of time to develop technical expertise. CONCLUSIONS: Shortening general surgery residency would not necessarily limit exposure to CR rotations and mentors unless such rotations are cut. The details of proposed restructuring are critical.

Reliability and validity of key feature cases for the self-assessment of colon and rectal surgeons.

OBJECTIVE: The purpose of this study was to determine the reliability and validity of the scores from "key feature" cases in the self-assessment of colon and rectal surgeons. BACKGROUND: Key feature (KF) cases specifically focus on the assessment of the unique challenges, critical decisions, and difficult aspects of the identification and management of clinical problems in practice. KF cases have been used to assess medical students and residents but rarely for specialists. METHODS: Responses from all 256 participants taking the American Society of Colon and Rectal Surgeons (ASCRS) Colon and Rectal Surgery Educational Program (CARSEP) V Self-assessment Examination (SAE) from 1997 to 2002 were scored and analyzed, including score reliability, item analysis for the factual (50 multiple-choice questions (MCQ)) and applied (9 KF cases) knowledge portions of the SAE, and the effect of examination preparation, examination setting, specialization, Board certification, and clinical experience on scores. RESULTS: The reliability (Cronbach alpha) of the scores for the MCQ and KF components was 0.97 and 0.95, respectively. The applied KF component of the SAE was more difficult than the factual MCQ component (0.52 versus 0.80, P < 0.001). Mean item discrimination (upper-lower groups) was 0.59 and 0.66 for the MCQ and KF components, respectively. Taking the test at the annual meeting was harder than at home (0.41 versus 0.81, P < 0.001). Content-related validity evidence for the KF cases was supported by mapping KF cases onto the examination blueprint and by judgments from expert colorectal surgeons about the challenging and critical nature of the KFs used. Construct validity of the KF cases was supported by incremental performance related to types of practice (general, anorectal, and colorectal), levels and types of Board certification, and years of clinical experience. CONCLUSIONS: The self-assessment of surgical specialists, in this case colorectal surgeons, using KF cases is possible and yielded reliable and valid scores.

Clostridium difficile colitis.

Clostridium difficile enterocolitis is endemic in most modern hospitals. The spectrum of clinical presentation varies from the asymptomatic carrier state to fulminant colitis with toxic megacolon and perforation. Highly toxigenic and lethal strains of C. difficile have emerged worldwide. Medical treatment consists of discontinuing the precipitating antibiotic, supportive measures and bowel rest, and antibiotic treatment with metronidazole or vancomycin. Surgical treatment may be necessary in cases of fulminant disease. Subtotal colectomy with end ileostomy is the operation of choice.

Colonoscopy in the elderly: low risk, low yield in asymptomatic patients.

PURPOSE: Current colonoscopy guidelines do not address the issue of when to stop performing screening and surveillance colonoscopy in the elderly. We reviewed our experience and results of colonoscopy in patients aged 80 years and older to assess the risks and diagnostic yield in this population. METHODS: We reviewed retrospectively the endoscopic and pathologic reports from consecutive colonoscopies performed on patients aged 80 years and older at a single, high-volume endoscopy center between August 1999 and May 2003. Patient characteristics, indications for examination, findings at colonoscopy, and complications were recorded and analyzed. RESULTS: A total of1,199 colonoscopic examinations were performed on 1,112 patients. Average age was 83.1 (range, 80-100) years. Male:female distribution was 1:1.7. Leading exclusive indications for colonoscopy included: polyp surveillance, 227 (19 percent); altered bowel habits, 168 (14 percent); iron-deficiency anemia, 132 (11 percent); and cancer follow-up, 108 (9 percent). Eighty-six examinations (7 percent) were performed solely for an indication of colorectal cancer screening. Twenty-two percent of patients had more than one indication for colonoscopy. Forty-five malignancies were found (3.7 percent). No cancers were found in the screening group, and two malignancies (0.7 percent) were detected in patients undergoing colonoscopy for polyp surveillance. There were eight (0.6 percent) reported major complications. CONCLUSIONS: Colonoscopy can be performed safely in patients aged 80 years and older. However, the diagnostic yield is low, particularly in patients undergoing routine screening or surveillance examinations. Colonoscopy should for the most part be limited to elderly patients with symptoms or specific clinical findings.

Education: a career of teaching in colon and rectal surgery.

The past 25 years have seen a revolution in the way surgery is learned, taught, and practiced. This revolution has increased the need for surgical educators to adapt surgical educational strategies to the modern practice environment. The purposes of this article are (1) to describe the impact of recent and upcoming changes in surgical education, (2) to explore the benefits of participating in surgical education activities both for academic surgeons and for surgeons in private practice, and (3) to review some of the avenues available to surgeons wishing to become involved or build a career in surgical education.

Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure.

PURPOSE: Neoadjuvant radiation therapy has been used increasingly to downstage rectal cancer and decrease local recurrence. Despite its efficacy, preoperative radiation therapy may inhibit healing and contribute to wound complications. This study was designed to evaluate perineal wound complications after abdominoperineal resection. METHODS: The clinical records of a consecutive series of patients who underwent abdominoperineal resection for rectal carcinoma between 1988 and 2002 were reviewed. Demographic data, disease stage, and use of preoperative radiation therapy were recorded. Major wound complications included delayed wound healing (>1 month), wound infection requiring drainage/debridement, or reoperation. RESULTS: A total of 160 patients underwent abdominoperineal resection with primary closure of the perineal wound (mean age, 63 +/- 12 years); 117 (73 percent) patients received preoperative radiation therapy; 114 received radiation therapy for rectal cancer (radiation therapy + chemotherapy = 107, radiation therapy alone = 7); 3 received radiation therapy for other pelvic malignancies. Median radiation dose was 5,040 (range, 900-5,400) cGY. Overall wound complication rate was 41 percent. Major wound complication rate was 35 percent. Delayed healing was the most common complication (24 percent), followed by infection (10 percent). Radiation therapy increased the risk of any wound complication (47 vs. 23 percent; P = 0.005), risk of a major wound complication (41 vs. 19 percent; P = 0.021), and risk of infection (14 vs. 0 percent; P = 0.015). Risk of wound complications did not correlate with age, gender, disease stage, smoking, or diabetes. CONCLUSIONS: Wound complications are frequent after abdominoperineal resection and primary closure of the perineum. Preoperative radiation therapy doubles the rate of total and major perineal wound complications. Alternatives to primary perineal closure should be considered, particularly after radiation therapy.

Predicting residual rectal adenocarcinoma in the surgical specimen after preoperative brachytherapy with endoscopic ultrasound.

BACKGROUND AND STUDY AIMS: A novel brachytherapy (BT) protocol evaluated at McGill University has shown promise in terms of downstaging and achieving high tumour sterilization rates in rectal cancer. Endoscopic ultrasound (EUS) has emerged as the imaging modality of choice for local staging of rectal cancer. However, external beam radiotherapy appears to decrease the accuracy of EUS from 85% to 40%. The aim of the present study was to prospectively evaluate the accuracy of EUS in assessing the response of rectal cancer to BT. PATIENTS AND METHODS: Thirty-three patients with locally advanced (stage T2 or T3) operable rectal carcinomas were included in an experimental protocol involving a novel conformal technique, using three-dimensional planning, to administer high-dose rate preoperative BT. The 18 patients who were able to have a post-BT EUS exam arranged within two weeks before surgery (eg, four to eight weeks post-BT) were included in this study. Tumour (T)- and lymph node (N)-staging on radial EUS, as well as interpretation of the residual tumour, were assessed prospectively. Pathologists were blinded to the post-BT EUS results. RESULTS: The mean age was 70 years (SD +/- 11; range, 52 to 93 years) and 78% of the patients were male. Pre-BT EUS indicated that 16 patients (89%) were stage T3, and two were stage T2. Five patients (28%) had positive nodes (N1) by ultrasound. With BT, the mean maximal wall thickness on EUS decreased from 14 mm to 9.4 mm (P<0.001). At the time of surgery, seven of the 18 patients (39%) had no detectable tumour in the resected specimen; one had carcinoma in situ, one was stage T1, one was stage T2, and eight were stage T3. Eleven patients (61%) underwent an abdominoperineal resection, including four of the 11 (36%) with no ultimate evidence of residual carcinoma. Eight patients (44%) were node-positive. The sensitivity, specificity, and positive and negative predictive values of post-BT EUS in predicting residual tumour were 82%, 29%, 64% and 50%, respectively. The post-BT EUS accurately predicted the T-stage in eight (44%) patients; most errors were due to overstaging. CONCLUSIONS: Rectal cancer T-staging by EUS post-BT is inaccurate, and although it appears sensitive in predicting the presence or absence of residual tumor in rectal adenocarcinoma after preoperative BT, the low predictive values in this setting limit its utility at this time.

Conformal preoperative endorectal brachytherapy treatment for locally advanced rectal cancer: early results of a phase I/II study.

PURPOSE: Downstaging rectal carcinoma by preoperative radiotherapy decreases local recurrence, and recent phase II studies suggest that, in the lower one-third lesions, sphincter-preserving surgery can be considered. The purpose of the current study was to assess the efficacy and the toxicity of endorectal high dose-rate brachytherapy as a preoperative downstaging treatment modality. METHODS: Patients with newly diagnosed invasive rectal adenocarcinoma, T2 to very early T4, operable tumors were eligible. A dose of 26 Gy was given over four consecutive daily treatments of 6.5 Gy prescribed at the tumor radial margin using endorectal brachytherapy with high dose-rate delivery system. Surgery as planned initially was done four to eight weeks later to allow for tumor downstaging. Patients found to have pathologic positive nodes received postoperative external beam (45 Gy/25 fractions) to the pelvis and systemic 5-fluorouracil-leucovorin chemotherapy. RESULTS: Forty-nine patients entered the study. Tumors were in the lower one-third in 24 patients, middle one-third in 22, and upper one-third in 3. With preoperative endorectal ultrasound and magnetic resonance imaging, the clinical staging of the tumors was: 3 T2, 42 T3, 4 T4, and 16 N1-2. Acute toxicity related to brachytherapy was limited to a moderate proctitis (Radiation Therapy Oncology Group acute toxicity scoring system, Grade 2) in all patients, with two patients with tumors extending into the anal canal having Grade 3 dermatitis. Forty-seven patients underwent surgery. Two patients refused their operation based on a normal endoscopic rectal ultrasound after treatment. A complete clinical response was obtained in 32 of 47 (68 percent) patients with 32 percent pathologically pT0N0-1, and 36 percent had only residual microfoci of carcinoma. The surgical approaches did not yield more complications than expected. CONCLUSION: Preoperative high dose-rate endorectal brachytherapy seems to be safe, because acute toxicity was mainly local, with moderate proctitis (Grade 2) and occasional dermatitis (Grade 3) for very low tumors. Finally, this modality, by providing high rate of tumor downstaging and downsizing especially for patients with lesions in the lower one-third of the rectum, represents a definite potential for sphincter-preserving surgery for investigation in future studies.