Residents underestimate their robotic performance: evaluating resident robotic console participation time.

Lack of formal national robotic curriculum results in a void of knowledge regarding appropriate progression of autonomy in robotic general surgery training. One midwestern academic surgical training program has demonstrated that residents expect to independently operate more on the robotic console than they perceive themselves to do. As such, our study sought to evaluate expectations of residents and faculty regarding resident participation versus actual console participation time (CPT) at a community general surgery training program. We surveyed residents and faculty in two phases. Initially, participants were asked to reflect on their perceptions and expectations from the previous six months. The second phase included surveys (collected over six months) after individual cases with subjective estimation of participation versus CPT calculated by the Intuitive Surgical, Inc. MyIntuitive application. Using Mann-Whitney U-Test, we compared resident perceptions of CPT to actual CPT by case complexity and post-graduate year (PGY). Faculty (n = 7) estimated they allowed residents to complete a median of 26-50% of simple and 0-25% of complex cases in the six months prior to the study. They expected senior residents (PGY-4 and PGY-5) to complete more: 51-75% of simple and 26-50% of complex cases. Residents (n = 13), PGY-2-PGY-5, estimated they completed less than faculty perceived (0-25% of simple and 0-25% of complex cases). Sixty-six post-case (after partial colectomy, abdominoperoneal resection, low anterior resection, cholecystectomy, inguinal/ventral hernia repair, and others) surveys were completed. Residents estimated after any case that they had completed 26-50% of the case. However, once examining their MyIntuitive report, they actually completed 51-75% of the case (median). Residents, especially PGY-4 and 5, completed a higher percentage than estimated of robotic cases. Our study confirms that residents can and should complete more of (and increasingly complex) robotic cases throughout training, like the transition of autonomy in open and laparoscopic surgery.

Learning curve for robotic rectal cancer resection at a community-based teaching institution.

The surgical management of rectal cancer is shifting toward more widespread use of robotics across a spectrum of medical centers. There is evidence that the oncologic outcomes are equivalent to laparoscopic resections, and the post-operative outcomes may be improved. This study aims to evaluate the learning curve of robotic rectal cancer resections at a community-based teaching institution and evaluate clinical and oncologic outcomes. A retrospective review of consecutive robotic rectal cancer resections by a single surgeon was performed for a five-year period. The cumulative sum (CUSUM) for total operative time was calculated and plotted to establish a learning curve. The oncologic and post-operative outcomes for each phase were analyzed and compared. The CUSUM learning curve yielded two phases, the learning phase (cases 1-79) and the proficiency phase (cases 80-130). The median operative time was significantly lower in the proficiency phase. The type of neoadjuvant therapy used between the two groups was statistically different, with chemoradiation being the primary regimen in the learning phase and total neoadjuvant therapy being more common in the proficiency phase. Otherwise, oncologic and overall post-operative outcomes were not significantly different between the groups. Robotic rectal resections can be done in a community-based hospital system by trained surgeons with outcomes that are favorable and similar to larger institutions.

Metastasectomy for Stage IVA Colon Cancer: Does the Type of Treating Institution Make a Difference?

Treatment of metastatic colon cancer has evolved over time. More evidence has been emerging in recent years supporting metastasectomy in selected patients. We sought to elucidate whether the type of institution-community, comprehensive community, academic/research, and integrated cancer network-would have an effect on patient outcome, specifically those colon cancer patients with isolated liver metastasis. This retrospective cohort study queried the National Cancer Database (NCDB) from 2010 to 2014 for patients who were 18 years of age or older with stage IVA colon cancer with isolated liver metastasis. We then performed uni- and multivariate analyses comparing patients based on such factors as age, tumor characteristics, primary tumor location, rate of chemotherapy, and type of treating institution. Patients who came from regions of higher income, receiving chemotherapy, and presenting to an academic/research hospital were more likely to undergo metastasectomy. Median survival was longest at academic/community hospitals at 22.4 months, 6 to 7 months longer than the other three types of institutions. Factors positively affecting survival included receiving chemotherapy, presenting to an academic/research institution, and undergoing metastasectomy, all at P < .05. In our study, the rate of metastasectomy was more than double at academic/research institutions for those with stage IVA colon cancer with isolated liver metastasis. Prior studies have quoted a mere 4.1% synchronous colon resection and metastasectomy. Our findings suggest that we should maintain multidisciplinary approach to this complex disease process and that perhaps it is time for us to consider regionalization of care in treating metastatic colon cancer.

Trends and Outcomes of Synchronous Resection of Colorectal Metastasis in the Modern Era-Analysis of Targeted Hepatic NSQIP Database.

BACKGROUND: Previous studies using the NSQIP database to study hepatectomies lacked hepatic specific variables and outcomes. We used the targeted NSQIP hepatectomy database to examine the nationwide trend and the safety profile of synchronous liver and colorectal resection compared with hepatectomy alone for colorectal liver metastasis. METHODS: The targeted NSQIP hepatectomy database from 2014 was used to study patients who underwent hepatectomy for diagnosis of adenocarcinoma of the colon and rectum. RESULTS: Of the 3064 hepatic resections in the database, 1138 cases were performed for colorectal metastasis. Of these, 1040 were liver-alone surgery and 98 were synchronous liver and colorectal resection. Most (58.7%) patients received neoadjuvant therapy. The rate of neoadjuvant therapy, intraoperative ablation, biliary reconstruction, and the use of minimally invasive technique were similar between the two groups. The overall 30-d mortality in this cohort was low (1.1%). While the mortality rate in the synchronous group was similar to liver-only group (3.1% versus 0.9%, P = 0.077). The rate of liver failure (3.3% versus 4.1%, P = 0.722) and biliary leak (5.3% versus 9.6%, P = 0.084) were similar between the two groups. However, the rate of major complications was higher on multivariable analyses (25.5% versus 12.1%, OR 2.5, 95% CI 1.5-4.1, P < 0.001) for the synchronous group. CONCLUSIONS: Hepatic resection for colorectal metastasis in the modern era has low short-term mortality. While synchronous resection was associated with a higher incidence of major complications, liver-specific complications did not increase with synchronous resection.

Diagnosing colorectal medullary carcinoma: interobserver variability and clinicopathological implications.

Colorectal medullary carcinoma, recognized by the World Health Organization as a distinct histologic subtype, is commonly regarded as a specific entity with an improved prognosis and unique molecular pathogenesis. A fundamental but as yet unaddressed question, however, is whether it can be diagnosed reproducibly. In this study, by analyzing 80 colorectal adenocarcinomas whose dominant growth pattern was solid (thus encompassing medullary carcinoma and its mimics), we provided a detailed description of the morphological spectrum from "classic medullary histology" to nonmedullary poorly differentiated histologies and demonstrated significant overlapping between categories. By assessing a selected subset (n=30) that represented the spectrum of histologies, we showed that the interobserver agreement for diagnosing medullary carcinoma by using 2010 World Health Organization criteria was poor; the κ value among 5 gastrointestinal pathologists was only 0.157 (95% confidence interval, 0.127-0.263; P=.001). When we arbitrarily classified the entire cohort into "classic" and "indeterminate" medullary tumors (group 1, n=19; group 2, n=26, respectively) and nonmedullary poorly differentiated tumors (group 3, n=35), groups 1 and 2 were more likely to exhibit mismatch repair protein deficiency than group 3 (P<.001); however, improved survival could not be detected in either group compared with group 3. Our findings suggest that the diagnosis of medullary carcinoma, as currently applied, may only serve as a morphological descriptor indicating an increased likelihood of mismatch-repair deficiency. Additional evidence including a more objective classification system is needed before medullary carcinoma can be regarded as a distinct entity with prognostic relevance. Until such evidence becomes available, caution should be exercised when making this diagnosis, as well as when comparing results across different studies.

Developing a robotic colorectal cancer surgery program: understanding institutional and individual learning curves.

IMPORTANCE: Robotic colorectal resection continues to gain in popularity. However, limited data are available regarding how surgeons gain competency and institutions develop programs. OBJECTIVE: To determine the number of cases required for establishing a robotic colorectal cancer surgery program. DESIGN: Retrospective review. SETTING: Cancer center. PATIENTS: We reviewed 418 robotic-assisted resections for colorectal adenocarcinoma from January 1, 2009, to December 31, 2014, by surgeons at a single institution. The individual surgeon's and institutional learning curve were examined. The earliest adopter, Surgeon 1, had the highest volume. Surgeons 2-4 were later adopters. Surgeon 5 joined the group with robotic experience. INTERVENTIONS: A cumulative summation technique (CUSUM) was used to construct learning curves and define the number of cases required for the initial learning phase. Perioperative variables were analyzed across learning phases. MAIN OUTCOME MEASURE: Case numbers for each stage of the learning curve. RESULTS: The earliest adopter, Surgeon 1, performed 203 cases. CUSUM analysis of surgeons' experience defined three learning phases, the first requiring 74 cases. Later adopters required 23-30 cases for their initial learning phase. For Surgeon 1, operative time decreased from 250 to 213.6 min from phase 1-3 (P = 0.008), with no significant changes in intraoperative complication or leak rate. For Surgeons 2-4, operative time decreased from 418 to 361.9 min across the two phases (P = 0.004). Their intraoperative complication rate decreased from 7.8 to 0 % (P = 0.03); the leak rate was not significantly different (9.1 vs. 1.5 %, P = 0.07), though it may be underpowered given the small number of events. CONCLUSIONS: Our data suggest that establishing a robotic colorectal cancer surgery program requires approximately 75 cases. Once a program is well established, the learning curve is shorter and surgeons require fewer cases (25-30) to reach proficiency. These data suggest that the institutional learning curve extends beyond a single surgeon's learning experience.

Abdominal metastases from colorectal cancer: intraperitoneal therapy.

Patients with peritoneal metastasis from colorectal cancer represent a distinct subset with regional disease rather than systemic disease. They often have poorer survival outcomes with systemic chemotherapy. Optimal cytoreductive surgery and intraperitoneal chemotherapy (IPC) offers such patients a more directed therapy with improved survival. In this review, we discuss the diagnosis, evaluation and classification, as well as rational for treatment of peritoneal carcinomatosis (PC) secondary to colorectal cancer.

Technique of last resort: characteristics of patients undergoing open surgery in the laparoscopic era.

BACKGROUND: The utilization rates for minimally invasive colorectal resection techniques (MICR) continue to increase. In some centers MICR methods are the preferred approach, however, open methods continue to be utilized for select patients. In this study, the profile and short-term outcomes of open colorectal resection (CR) and MICR patients are determined and compared. METHODS: A retrospective review of patients who underwent elective CR over 11 years at two institutions was performed. The MICR group contained both laparoscopic-assisted and hand-assisted cases. The past medical and surgical histories, indications, operations performed, and short-term outcomes were assessed. The Charlson co-morbidity index (CMI) was used to assess risk. RESULTS: During the study period 1080 patients underwent CR (Open, 141; MICR, 939). As judged by the CMI, there were more high-risk patients (score ≥2) in the Open group (34.38%) versus MICR (22.11%) p = 0.0029. Significantly more open patients had prior abdominal surgery and specifically CRs (Open, 15.60% vs. MICR, 2.13%, p < 0.001). Intraoperative transfusion (Open 25.7%; MICR 6.8%, p < 0.001) and diversion (25.53 vs. 11.50%, p < 0.001) were more common in the Open group. Not surprisingly, recovery of bowel function and length of stay were longer for the Open group. The overall complication rate was also higher for the Open patients (p < 0.001). CONCLUSION: When MICR is the procedure of choice, patients selected for Open CR are higher risk and more complex as judged by the CMI and past operative history. Not surprisingly, this translates into a longer length of stay, higher rates of transfusion, diversion, and complications. This disparity in patients undergoing CRs makes direct comparison of MICR and Open resection outcomes not reasonable.

Predictors of mortality after emergency colectomy for Clostridium difficile colitis: an analysis of ACS-NSQIP.

OBJECTIVE: To evaluate clinical factors associated with mortality in emergency colectomies performed for Clostridium difficile colitis. BACKGROUND: The incidence and mortality from C difficile colitis is on the rise. Emergent colectomy performed for C difficile colitis is associated with a high mortality. METHODS: The ACS-NSQIP database from 2005 to 2010 was used to study emergently performed open colectomies for a primary diagnosis of C difficile colitis on the International Classification of Diseases, Ninth Revision. Preoperative, intraoperative, and postoperative factors were noted and compared between survivors and nonsurvivors. We performed multivariate stepwise binomial logistic regression analyses to study clinical factors that may be associated with 30-day mortality. RESULTS: The overall mortality for this cohort was 33% (111/335) with a median time to death of 8 days. On average, survivors were discharged on postoperative day 24. On multivariate analysis, those aged 80 years or older were associated with a ninefold increase in the odds of mortality [95% confidence interval (CI): 3.0-13.0]. Other factors associated with increased mortality were preoperative shock (OR=2.8, 95% CI: 1.6-5.4), preoperative dialysis dependence (OR=2.3, 95% CI: 1.1-4.8), chronic obstructive pulmonary disease (OR=3.7, 95% CI: 2.0-7.1), and wound class III (OR=2.1, 95% CI: 3.0-13). Thrombocytopenia (platelet count < 150×10(3)/mm(3)), coagulopathy (International Normalized Ratio>2.0), and renal insufficiency (blood urea nitrogen>40 mg/dL) were associated with a higher mortality as well. CONCLUSIONS: This is the largest series of colectomies performed for C difficile colitis in the literature. We identified several preoperative clinical risk factors that were associated with increased postoperative mortality. These findings may be useful in selecting appropriate patients for surgical intervention and may help to define a population where surgery may not be beneficial.

Feasibility and analgesic efficacy of the transversus abdominis plane block after single-port laparoscopy in patients having bariatric surgery.

PURPOSE: The transversus abdominis plane (TAP) block is a technique increasingly used for analgesia after surgery on the anterior abdominal wall. We undertook this study to determine the feasibility and analgesic efficacy of ultrasound-guided TAP blocks in morbidly obese patients. We describe the dermatomal spread of local anesthetic in TAP blocks administered, and test the hypothesis that TAP blocks decrease visual analog scale (VAS) scores. PATIENTS AND METHODS: After ethics committee approval and informed consent, 35 patients with body mass index >35 undergoing single-port sleeve gastrectomy (SPSG) were enrolled. All patients received balanced general anesthesia, followed by intravenous patient-controlled analgesia (IV-PCA; hydromorphone) postoperatively; all reported VAS >3 upon arrival to the recovery room. From the cohort of 35 patients having single-port laparoscopy (SPL), a sealed envelope method was used to randomly select ten patients to the TAP group and 25 patients to the control group. The ten patients in the TAP group received ultrasound-guided TAP blocks with 30 mL of 0.2% Ropivacaine injected bilaterally. The dermatomal distribution of the sensory block (by pinprick test) was recorded. VAS scores for the first 24 hours after surgery and opioid use were compared between the IV-PCA+TAP block and IV-PCA only groups. RESULTS: Sensory block ranged from T5-L1. Mean VAS pain scores decreased from 8 ± 2 to 4 ± 3 (P=0.04) within 30 minutes of TAP block administration. Compared with patients given IV-PCA only, significantly fewer patients who received TAP block had moderate or severe pain (VAS 4-10) after block administration at 6 hours and 12 hours post-surgery. However, cumulative consumption of hydromorphone at 24 hours after SPSG surgery was similar for both groups. CONCLUSION: Ultrasound-guided TAP blocks in morbidly obese patients are feasible and result in satisfactory analgesia following SPSG in the immediate postoperative period.

The incidence of trocar-site hernia in minimally invasive bariatric surgery: a comparison of multi versus single-port laparoscopy.

INTRODUCTION: Single-port laparoscopy (SPL) employs a 1.5- to 2.5-cm incision at the umbilicus for the placement of a single working port. We hypothesized that the longer incision created by SPL compared with multiport laparoscopy may increase the incidence of trocar-site hernias. We examined our experience with SPL in bariatric operations. METHODS: There were 734 laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding procedures performed at our institution between 2001 and 2011. Fifty-eight patients were lost to follow-up or had a short duration of follow-up (<1 month). Of the remaining 676 cases, 163 were performed via SPL. All laparoscopic wounds created by trocar size greater than 12 mm were closed with absorbable suture. RESULTS: Patient demographics of the SPL group and the multiport group were similar in terms of age, gender, and comorbidities. The average body mass index (BMI) of the SPL group was lower than the multiport group (43.5 ± 5.3 vs. 45.8 ± 7.7, p < 0.01). The mean follow-up for the SPL group was 11 months versus 24 months for the multiport group. There were three trocar-site hernias out of 513 cases in the multiport compared to one hernia out of 163 cases in the SPL group (0.6 vs. 0.6 %, p = 0.967). All trocar-site hernias occurred at the 15-mm port site. The median time to hernia occurrence for the multiport group was 13 months (range, 1-18). In the SPL group, the hernia occurred at 8 months. On multivariate analysis, age, BMI, SPL, procedure type, and the postoperative weight loss were not associated with the development of trocar-site hernias. CONCLUSIONS: SPL did not increase the rate of trocar-site hernia in this series. A low rate of trocar-site hernia can be achieved with the use of SPL in bariatric surgery.

Outcomes of laparoscopic Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding in adolescents.

BACKGROUND: The goal of this study is to compare the outcomes of laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in obese adolescents. METHODS: We performed a retrospective review of all adolescents between the ages of 15 and 19 who underwent LAGB or LRYGB at our university affiliated Bariatric Center of Excellence from 2002 to 2011. Postsurgical weight loss at 1, 3, 6, 12, 18, and 24 months was noted and expressed as percentage of excess weight loss (% EWL). RESULTS: Thirty-two patients underwent LRYGB and 23 underwent LAGB. The LAGB group was younger (18.6 ± 0.6 versus 17.2 ± 1.5) than the LRYGB group. Other preoperative demographic factors including body mass index, gender, ethnicity, and comorbidities were similar between the two groups. The average % EWL was superior in the LRYGB group compared to the LAGB group at all time points studied (p < 0.05), although at 2-year follow-up, only 16% (5/32) LRYGB and 30% (7/23) LAGB patients were available for follow-up. Three patients with type II diabetes mellitus underwent LRYGB and all experienced remission of their diabetes. The number of complications requiring interventions was similar between the two groups. CONCLUSIONS: In our study, adolescents undergoing LRYGB achieved superior weight loss compared to LAGB in the short-term follow-up. The complication rate for LAGB was similar compared to LRYGB. More studies are needed to monitor the long-term effects of these operations on adolescents before definitive recommendations can be made.

Dynamic GATA factor interplay at a multicomponent regulatory region of the GATA-2 locus.

Given the simplicity of the DNA sequence that mediates binding of GATA transcription factors, GATA motifs reside throughout chromosomal DNA. However, chromatin immunoprecipitation analysis has revealed that GATA-1 discriminates exquisitely among these sites. GATA-2 selectively occupies the -2.8-kilobase (kb) region of the GATA-2 locus in the active state despite there being numerous GATA motifs throughout the locus. The GATA-1-mediated displacement of GATA-2 is tightly coupled to repression of GATA-2 transcription. We have used high resolution chromatin immunoprecipitation to show that GATA-1 and GATA-2 occupy two additional regions, -3.9 and -1.8 kb of the GATA-2 locus. GATA-1 and GATA-2 had distinct preferences for occupancy at these regions, with GATA-1 and GATA-2 occupancy highest at the -3.9- and -1.8-kb regions, respectively. Activation of an estrogen receptor fusion to GATA-1 (ER-GATA-1) induced similar kinetics of ER-GATA-1 occupancy and GATA-2 displacement at the sites. In the transcriptionally active state, DNase I hypersensitive sites (HSs) were detected at the -3.9- and -1.8-kb regions, with a weak HS at the -2.8-kb region. Whereas ER-GATA-1-instigated repression abolished the -1.8-kb HS, the -3.9-kb HS persisted in the repressed state. Transient transfection analysis provided evidence that the -3.9-kb region functions distinctly from the -2.8- and -1.8-kb regions. We propose that GATA-2 transcription is regulated via the collective actions of complexes assembled at the -2.8- and -1.8-kb regions, which share similar properties, and through a qualitatively distinct activity of the -3.9-kb complex.