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1.
Surgery ; 166(5): 738-743, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31326184

RESUMO

BACKGROUND: Despite an increasing number of women in the field of surgery, bias regarding cognitive or technical ability may continue to affect the experience of female trainees differently than their male counterparts. This study examines the differences in the degree of operative autonomy given to female compared with male general surgery trainees. METHODS: A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice ("show and tell") to autonomous surgeon ("supervision only"). Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis. RESULTS: A total of 412 residents and 524 faculty from 14 general surgery training programs evaluated 8,900 cases over a 9-month period. Female residents received less autonomy from faculty than did male residents overall (P < .001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors, including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty sex, and training program environment, female residents still received less operative autonomy than their male counterparts. The greatest discrepancy was in the fourth year of training. CONCLUSION: There is a sex-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents' experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap.


Assuntos
Cirurgia Geral/educação , Internato e Residência/organização & administração , Salas Cirúrgicas/organização & administração , Autonomia Profissional , Cirurgiões/estatística & dados numéricos , Competência Clínica , Feminino , Identidade de Gênero , Cirurgia Geral/organização & administração , Cirurgia Geral/estatística & dados numéricos , Humanos , Internato e Residência/estatística & dados numéricos , Relações Interprofissionais , Masculino , Salas Cirúrgicas/estatística & dados numéricos , Fatores Sexuais , Cirurgiões/educação
2.
J Am Coll Surg ; 228(4): 547-556.e8, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30639302

RESUMO

BACKGROUND: Although diverting stomas have reduced anastomotic leak rates after sphincter-preserving proctectomy in some series, the effectiveness of routine diversion among a broad population of rectal cancer patients remains controversial. We hypothesized that routine temporary diversion is not associated with decreased rates of leak or reintervention in cancer patients at large undergoing sphincter-sparing procedures. STUDY DESIGN: The Florida State Inpatient Database (AHRQ, Healthcare Cost and Utilization Project) was queried for patients undergoing sphincter-preserving proctectomy for cancer (2005 to 2014). Matched cohorts defined by diversion status were created using propensity scores based on patient and hospital characteristics. Incidence of anastomotic leak, nonelective reintervention, and readmission were compared, and cumulative 90-day inpatient costs were calculated. RESULTS: Of 8,620 eligible sphincter-sparing proctectomy patients, 1,992 matched pairs were analyzed. Leak rates did not significantly vary between groups (4.5% vs 4.3%; p = 0.76), but diversion was associated with significantly higher odds of nonelective reintervention (2.37; 95% CI 1.90 to 2.96) and readmission (1.55; 95% CI 1.33 to 1.81) compared with undiverted patients. Median costs were higher among those diverted (US$21,325 vs US$15,050; p < 0.01). CONCLUSIONS: No association between diversion and anastomotic leak was found. However, temporary diversion was associated with increased incidence of nonelective reinterventions, readmissions, and higher costs. We therefore challenge the paradigm of routine diversion in rectal cancer operations. Additional study is needed to identify which patients would benefit most from diversion.

3.
J Surg Educ ; 76(3): 824-831, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30595474

RESUMO

OBJECTIVE: The "Surgery for Abdomino-thoracic ViolencE (SAVE)" animate lab engages surgical residents in the management of complex penetrating injuries. We hypothesized that residents will improve their understanding of the management of trauma patients and will perform skills that they have not previously performed in training. DESIGN: Pre- and postlab assessments were reviewed from surgical residents participating in the SAVE lab over 2 years (2017-2018). Residents of varying levels were grouped and reviewed "real-life" trauma scenarios with supplemental imaging. Seniors were tasked with creating injuries while juniors performed as primary surgeons under supervision. Each successive scenario increased in difficulty, from hollow viscus injury and solid organ disruption, to great vessel and cardiac injuries with the goal to "SAVE" the patient. Assessments included a pre- and postlab multiple-choice questionnaire of trauma management knowledge and a survey of completed technical skills. SETTING: Academic General Surgery residency program. PARTICIPANTS: General, Vascular, Urology, and Plastic Surgery PGY1 to PGY5 residents. RESULTS: One hundred and nineteen residents participated in the SAVE lab in 2017 and 2018. PGY1 to PGY4 residents showed significant improvement in knowledge of trauma management on matched pre- and postlab assessments. The most significant improvement was seen in the PGY1 and PGY2 residents, with scores increasing by 21% (p < 0.001) and 13% (p < 0.001), respectively. PGY1-3 residents had a significant increase in new technical skills acquisition. PGY5 residents showed no significant changes in either realm. CONCLUSIONS: The SAVE lab was effective in increasing junior surgical residents' technical skills as well as fund of knowledge related to complex trauma care. While seniors had previously performed most of these skills as reflected in their assessments, the SAVE lab provided a way for them to assume the role of team leader, guiding management of complex, and high acuity situations. Future endeavors include teamwork and leadership skills' assessment through the SAVE lab.

4.
Dis Colon Rectum ; 61(12): 1403-1409, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30308525

RESUMO

BACKGROUND: Thoracic epidural analgesia has been shown to be an effective method of pain control. The utility of epidural analgesia as part of an enhanced recovery after surgery protocol is debatable. OBJECTIVE: This study aimed to determine if the use of thoracic epidural analgesia in an enhanced recovery after surgery protocol decreases hospital length of stay or inpatient opioid consumption after elective colorectal resection. DESIGN: This is a single-institution retrospective cohort study. SETTINGS: The study was performed at a high-volume, tertiary care center in the Midwest. An institutional database was used to identify patients. PATIENTS: All patients undergoing elective transabdominal colon or rectal resection by board-certified colon and rectal surgeons from 2013 to 2017 were included. MAIN OUTCOME MEASURES: The main outcome was length of stay. The secondary outcome was oral morphine milligram equivalents consumed during the first 48 hours. RESULTS: There were 1006 patients (n = 815 epidural, 191 no epidural) included. All patients received multimodal analgesia with opioid-sparing agents. Univariate analysis demonstrated no difference in length of stay between those who received thoracic epidural analgesia and those who did not (median, 4 vs 5 days; p = 0.16), which was substantiated by multivariable linear regression. Subgroup analysis showed that the addition of epidural analgesia resulted in no difference in length of stay regardless of an open (n = 362; p = 0.66) or minimally invasive (n = 644; p = 0.46) approach. Opioid consumption data were available after 2015 (n = 497 patients). Univariate analysis demonstrated no difference in morphine milligram equivalents consumed in the first 48 hours between patients who received epidural analgesia and those who did not (median, 135 vs 110 oral morphine milligram equivalents; p = 0.35). This was also confirmed by multivariable linear regression. LIMITATIONS: The retrospective observational design was a limitation of this study. CONCLUSION: The use of thoracic epidural analgesia within an enhanced recovery after surgery protocol was not found to be associated with a reduction in length of stay or morphine milligram equivalents consumed within the first 48 hours. We cannot recommend routine use of thoracic epidural analgesia within enhanced recovery after surgery protocols. See Video Abstract at http://links.lww.com/DCR/A765.


Assuntos
Analgésicos Opioides/uso terapêutico , Anestesia Epidural , Colo/cirurgia , Tempo de Internação , Reto/cirurgia , Idoso , Anestésicos Locais , Bupivacaína , Protocolos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Recuperação de Função Fisiológica , Estudos Retrospectivos , Vértebras Torácicas
5.
Int J Colorectal Dis ; 33(10): 1453-1459, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30076441

RESUMO

PURPOSE: Pelvic floor abnormalities often affect multiple organs. The incidence of concomitant uterine/vaginal prolapse with rectal prolapse is at least 38%. For these patients, addition of sacrocolpopexy to rectopexy may be appropriate. Our aim was to determine if addition of sacrocolpopexy to rectopexy increases the procedural morbidity over rectopexy alone. METHODS: We utilized the ACS-NSQIP database to examine female patients who underwent rectopexy from 2005 to 2014. We compared patients who had a combined procedure (sacrocolpopexy and rectopexy) to those who had rectopexy alone. Thirty-day morbidity was compared and a multivariable model constructed to determine predictors of complications. RESULTS: Three thousand six hundred patients underwent rectopexy; 3394 had rectopexy alone while 206 underwent a combined procedure with the addition of sacrocolpopexy. Use of the combined procedure increased significantly from 2.6 to 7.7%. Overall morbidity did not differ between groups (14.8% rectopexy alone vs. 13.6% combined procedure, p = 0.65). Significant predictors of morbidity included addition of resection to a rectopexy procedure, elevated BMI, smoking, wound class, and ASA class. After controlling for these and other patient factors, the addition of sacrocolpopexy to rectopexy did not increase overall morbidity (OR 1.00, p = 0.98). CONCLUSIONS: There is no difference in operative morbidity when adding sacrocolpopexy to a rectopexy procedure. Despite a modest increase in utilization of combined procedures over time, the overall rate remains low. These findings support the practice of multidisciplinary evaluation of patients presenting with rectal prolapse, with the goal of offering concurrent surgical correction for all compartments affected by pelvic organ prolapse disorders.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Prolapso de Órgão Pélvico/cirurgia , Feminino , Humanos , Laparoscopia , Pessoa de Meia-Idade , Diafragma da Pelve , Prolapso Retal/cirurgia , Resultado do Tratamento , Prolapso Uterino/cirurgia
6.
Surgery ; 164(5): 1117-1123, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30149939

RESUMO

BACKGROUND: Accurate risk assessment before surgery is complex and hampered by behavioral factors. Underutilized risk-based decision-support tools may counteract these barriers. The purpose of this study was to identify perceptions of and barriers to the use of surgical risk-assessment tools and assess the importance of data framing as a barrier to adoption in surgical trainees. METHODS: We distributed a survey and risk assessment activity to surgical trainees at four training institutions. The primary outcomes of this study were descriptive risk assessment practices currently performed by residents, identifiable influences and obstacles to adoption, and the variability of preference sets when comparing modified System Usability Scores of a current risk calculator to a purpose-built calculator revision. Risk calculator comparison responses were compared with simple and multivariable regression to identify predictors for preferentiality. RESULTS: We collected responses from 124 surgical residents (39% response rate). Participants endorsed familiarity with direct verbal communication (100%), sketch diagrams (87%), and brochures (59%). The most contemporary risk communication frameworks, such as best-worst case scenario framing (38%), case-specific risk calculators (43%), and all-procedure calculators (52%) were the least familiar. Usage favored traditional models of communication with only 26% of residents regularly using a strategy other than direct verbal discussion or anatomic sketch diagrams. Barriers limiting routine use included lack of electronic and clinical workflow integration. The mean modified System Usability Scores domain scores were widely dispersed for all domains, and no domain demonstrated one calculator's superiority over another. CONCLUSION: Risk assessment tools are underutilized by trainees. Of importance, preference sets of clinicians appear to be unpredictable and may benefit more from a customizable, bespoke approach.


Assuntos
Tomada de Decisão Clínica/métodos , Técnicas de Apoio para a Decisão , Cirurgia Geral/educação , Internato e Residência/estatística & dados numéricos , Cuidados Pré-Operatórios/métodos , Adulto , Competência Clínica/estatística & dados numéricos , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/estatística & dados numéricos , Medição de Risco/métodos , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/educação , Inquéritos e Questionários/estatística & dados numéricos
7.
Surgery ; 164(3): 566-570, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29929754

RESUMO

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.


Assuntos
Competência Clínica , Cirurgia Geral/educação , Internato e Residência , Autonomia Profissional , Atitude do Pessoal de Saúde , Tomada de Decisões , Humanos
8.
J Gastrointest Surg ; 22(8): 1477-1487, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29663303

RESUMO

BACKGROUND: Management of low rectal cancer continues to be a challenge, and decision making regarding the need for an abdominoperineal resection (APR) in patients with low-lying tumors is complicated. Furthermore, choices need to be made regarding need for modification of the surgical approach based on tumor anatomy and patient goals. DISCUSSION: In this article, we address patient selection, preoperative planning, and intraoperative technique required to perform the three types of abdominoperineal resections for rectal cancer: extrasphincteric, extralevator, and intersphincteric. Attention is paid not only to traditional oncologic outcomes such as recurrence and survival but also to patient-reported outcomes and quality of life.


Assuntos
Recidiva Local de Neoplasia , Seleção de Pacientes , Protectomia/métodos , Neoplasias Retais/cirurgia , Abdome/cirurgia , Medicina Baseada em Evidências , Humanos , Margens de Excisão , Períneo/cirurgia , Protectomia/efeitos adversos , Qualidade de Vida , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/patologia , Taxa de Sobrevida
9.
J Surg Res ; 225: 142-147, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29605024

RESUMO

BACKGROUND: In 2012, the American Society of Colon and Rectal Surgeons published the Rectal Cancer Surgery Checklist, a consensus document listing 25 essential elements of care for all patients undergoing radical surgery for rectal cancer. The authors herein examine checklist adherence in a mature, multisurgeon specialty academic practice. MATERIALS AND METHODS: A retrospective medical record review of patients undergoing elective radical resection for rectal adenocarcinoma over a 23-mo period was conducted. Checklists were completed post hoc for each patient, and these results were tabulated to determine levels of compliance. Subgroup analyses by compliance and experience levels of the treating surgeon were performed. RESULTS: A total of 161 patients underwent resection, demonstrating a median completion rate of 84% per patient. Poor compliance was noted consistently in documenting baseline sexual function (0%), multidisciplinary discussion of treatment plans (16.8%), pelvic nerve identification (8.7%) and leak testing (52.9%), and radial margin status reporting (57.5%). Junior surgeons achieved higher rates of compliance and were more likely to restage after neoadjuvant therapy (67.9% versus 29.4%, P < 0.001), discuss patients at tumor board (31.3% versus 13.2%, P = 0.014), and document leak testing (86.7% versus 47.2%, P = 0.005) compared with senior surgeons. CONCLUSIONS: Checklist compliance within a high-volume, specialty academic practice remains varied. Only surgeon experience level was significantly associated with high checklist compliance. Junior surgeons achieved greater compliance with certain items, particularly those that reinforce decision-making. Further efforts to standardize rectal cancer care should focus on checklist implementation, targeted surgeon outreach, and assessment of checklist compliance correlation to clinical outcomes.


Assuntos
Adenocarcinoma/cirurgia , Benchmarking/estatística & dados numéricos , Fidelidade a Diretrizes/estatística & dados numéricos , Cuidados Pré-Operatórios/normas , Neoplasias Retais/cirurgia , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/patologia , Idoso , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/diagnóstico , Fístula Anastomótica/etiologia , Lista de Checagem/normas , Lista de Checagem/estatística & dados numéricos , Competência Clínica/estatística & dados numéricos , Tomada de Decisão Clínica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Estadiamento de Neoplasias , Cuidados Pré-Operatórios/estatística & dados numéricos , Neoplasias Retais/tratamento farmacológico , Neoplasias Retais/patologia , Reto/cirurgia , Estudos Retrospectivos
10.
J Am Coll Surg ; 226(4): 425-431, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29309940

RESUMO

BACKGROUND: The Flexibility in Surgical Training (FIST) consortium project was designed to evaluate the feasibility and resident outcomes of optional subspecialty-focused training within general surgery residency training. STUDY DESIGN: After approval by the American Board of Surgery, R4 and R5 residents were permitted to customize up to 12 of the final 24 months of residency for early tracking into 1 of 9 subspecialty tracks. A prospective IRB-approved study was designed across 7 institutions to evaluate the impact of this option on operative experience, in-service exam (American Board of Surgery In-Training Examination [ABSITE]) and ACGME milestone performance, and resident and program director (PD) perceptions. The FIST residents were compared with chief residents before FIST initiation (controls) as well as residents during the study period who did not participate in FIST (no specialization track, NonS). RESULTS: From 2013 to 2017, 122 of 214 chief residents (57%) completed a FIST subspecialty track. There were no differences in median ABSITE scores between FIST, NonS residents, and controls. The ACGME milestones at the end of the R5 year favored the FIST residents in 13 of 16 milestones compared with NonS. Case logs demonstrated an increase in track-specific cases compared with NonS residents. Resident and PD surveys reported a generally favorable experience with FIST. CONCLUSIONS: In this prospective study, FIST is a feasible option in participating institutions. All FIST residents, regardless of track, met requirements for ABS Board eligibility, despite modifications to rotations and case experience. Future studies will assess the impact of FIST on ABS exam results and fellowship success.


Assuntos
Cirurgia Geral/educação , Internato e Residência/organização & administração , Atitude do Pessoal de Saúde , Competência Clínica , Currículo , Estudos de Viabilidade , Humanos , Estudos Prospectivos , Inquéritos e Questionários , Estados Unidos , Carga de Trabalho
11.
J Surg Educ ; 74(6): e51-e54, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28756968

RESUMO

OBJECTIVE: Fundamentals of laparoscopic surgery (FLS) was developed by the Society of American Gastrointestinal and Endoscopic Surgeons to teach the physiology, fundamental knowledge, and technical skills required for basic laparoscopic surgery. We hypothesize that residents are doing more laparoscopic surgery earlier in residency, and therefore would benefit from an earlier assessment of basic laparoscopic skills. Here, we examine FLS test results and ACGME case logs to determine whether it is practical to administer FLS earlier in residency. DESIGN: FLS test results were reviewed for the 42 residents completing FLS between July 2011 and July 2016. ACGME case logs for current and former residents were reviewed for laparoscopic cases logged by each postgraduate year. Basic and complex laparoscopic cases were determined by ACGME General Surgery Defined Category and Minimums Report. Descriptive statistics were used for analysis. SETTING: Academic general surgery residency, Washington University in St. Louis School of Medicine. PARTICIPANTS: Current and former general surgery residents. RESULTS: A total of 42 residents took and passed FLS between July 2011 and July 2016. All residents successfully passed the FLS knowledge and skills examinations on the first attempt regardless of their postgraduate year (PGY 3n = 13, PGY 4n = 15, and PGY 5n = 14). Total laparoscopic case volume has increased over time. Residents who graduated in 2012 or 2013 completed 229 laparoscopic cases compared to 267 laparoscopic cases for those who graduated from 2014 to 2016 (p = 0.02). Additionally, current residents completed more laparoscopic cases in the first 2 years of residency than residents who graduated from 2012 to 2016 (median current = 38; former = 22; p < 0.001). Examining laparoscopic case numbers for current residents by PGY demonstrated that the number of total and complex laparoscopic cases increased in each of the first 3 years of residency with the largest increase occurring between the PGY 2 and PGY 3 years. In the PGY 4 and PGY 5 years, most laparoscopic cases were complex. CONCLUSION: Increased use of laparoscopic surgery has led to a corresponding increase in laparoscopic case volume among general surgery residents. We would advocate for FLS testing to serve as an early assessment of laparoscopic knowledge and skill and should be performed before a significant increase in complex laparoscopic surgery during training.


Assuntos
Competência Clínica , Educação de Pós-Graduação em Medicina/métodos , Cirurgia Geral/ética , Laparoscopia/educação , Laparoscopia/normas , Educação Baseada em Competências , Feminino , Humanos , Internato e Residência/métodos , Masculino , Estudos Retrospectivos , Sociedades Médicas/normas , Estados Unidos
12.
J Am Coll Surg ; 225(4): 465-471, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28690206

RESUMO

BACKGROUND: Surgical site infections (SSI) are a common complication after colorectal surgery. An infection prevention bundle (IPB) was implemented to improve outcomes. STUDY DESIGN: A standardized IPB that included the administration of oral antibiotics with a mechanical bowel preparation, preoperative shower with chlorhexidine, hair removal and skin preparation in holding, antibiotic wound irrigation, and a "clean-closure" protocol was implemented in January 2013. Data from the American College of Surgeons NSQIP were analyzed at a single academic institution to compare pre-IPB and post-IPB SSI rates. In January 2014, a prospective database was implemented to determine compliance with individual IPB elements and their effect on outcomes. RESULTS: For the 24 months pre-IPB, the overall SSI rate was 19.7%. During the 30 months after IPB implementation, the SSI rate decreased to 8.2% (p < 0.0001). A subset of 307 patients was identified in both NSQIP and our prospective compliance databases. Elements of IPB associated with decreased SSI rates included preoperative shower with chlorhexidine (4.6% vs 16.2%; p = 0.005), oral antibiotics (3.4% vs 15.4%; p < 0.001), and mechanical bowel preparation (4.4% vs 14.3%; p = 0.008). Patients who received a full bowel preparation of both oral antibiotics and a mechanical bowel preparation had a 2.7% SSI rate compared with 15.8% for all others (p < 0.001). On multivariate analysis, full bowel preparation was independently associated with significantly fewer SSI (adjusted odds ratio 0.2; 95% CI 0.1 to 0.9; p = 0.006). CONCLUSIONS: Implementation of an IPB was successful in decreasing SSI rates in colorectal surgery patients. The combination of oral antibiotics with a mechanical bowel preparation was the strongest predictor of decreased SSI.


Assuntos
Antibioticoprofilaxia , Catárticos/uso terapêutico , Doenças do Colo/cirurgia , Cuidados Pré-Operatórios , Doenças Retais/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Administração Oral , Adulto , Idoso , Antibacterianos/administração & dosagem , Protocolos Clínicos , Feminino , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Infecção da Ferida Cirúrgica/epidemiologia , Irrigação Terapêutica
13.
Ann Surg ; 266(4): 582-594, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28742711

RESUMO

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.


Assuntos
Competência Clínica , Cirurgia Geral/educação , Internato e Residência/normas , Autonomia Profissional , Educação Baseada em Competências , Avaliação Educacional/normas , Feedback Formativo , Cirurgia Geral/normas , Humanos , Estudos Prospectivos , Estados Unidos
14.
Surg Clin North Am ; 97(3): 605-625, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28501250

RESUMO

Awareness of hereditary colorectal cancer syndromes is important to facilitate their identification because affected patients are at increased risk for early onset, synchronous, and metachronous colorectal malignancies, and certain extracolonic malignancies depending on the syndrome. Identification of an affected individual allows for screening and early interventions for patients and their at-risk kindred. Genetic counseling and testing is important to the care of these patients. As knowledge of the genetic basis of these syndromes grows, unique genotype-phenotype profiles allow clinicians to tailor surveillance and treatment strategies based on individual risk.


Assuntos
Pólipos do Colo/genética , Neoplasias Colorretais/genética , Síndromes Neoplásicas Hereditárias/genética , Polipose Adenomatosa do Colo/genética , Pólipos do Colo/cirurgia , Neoplasias Colorretais/prevenção & controle , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais Hereditárias sem Polipose/genética , DNA Glicosilases/genética , Testes Genéticos , Humanos , Mutação
15.
Ann Surg Oncol ; 24(5): 1195-1201, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28050726

RESUMO

PURPOSE: Anorectal gastrointestinal stromal tumors (GISTs) are exceedingly rare, and management remains controversial in regard to local resection (LR) and preoperative chemotherapy. METHODS: The National Cancer Data Base was queried from 1998 to 2012 for cases of GIST resection in the rectum or anus. Patient demographics, type of surgery (LR vs. radical excision [RE]), short-term outcomes, and overall survival (OS) were analyzed. Preoperative chemotherapy was recorded following the US FDA approval of imatinib in 2002. RESULTS: Overall, 333 patients with resection of anorectal GISTs were included. Mean age at presentation was 62.3 years (range 22-90), and median tumor size was 4.0 cm (interquartile range 2.2-7.0). Five-year OS for all patients was 77.6%. In a multivariable survival analysis, only age and tumor size >5 cm (hazard ratio 2.48, 95% confidence interval 1.50-4.01; p = 0.004) were associated with increased mortality. One hundred and sixty-three (49.0%) patients underwent LR, compared with 158 (47.4%) who underwent RE. For tumors smaller than 5 cm, no difference in 5-year survival by surgical approach was observed (LR 82.3% vs. RE 82.6%; p = 0.71). Fifty-nine patients (17.7%) received preoperative chemotherapy; for patients undergoing RE with tumors >5 cm, there was decreased mortality in the group who received preoperative chemotherapy (5-year OS with chemotherapy 79.2% vs. no chemotherapy 51.2%; p = 0.03). CONCLUSIONS: Size is the most important determinant in survival following resection. Local excision is common, with resection split between LR and RE. For smaller tumors, LR may be adequate therapy. Preoperative chemotherapy may result in improved survival for large tumors treated with radical resection, but the data are imperfect.


Assuntos
Neoplasias do Ânus/tratamento farmacológico , Neoplasias do Ânus/cirurgia , Tumores do Estroma Gastrointestinal/tratamento farmacológico , Tumores do Estroma Gastrointestinal/cirurgia , Neoplasias Retais/tratamento farmacológico , Neoplasias Retais/cirurgia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/uso terapêutico , Neoplasias do Ânus/mortalidade , Neoplasias do Ânus/patologia , Quimioterapia Adjuvante , Feminino , Tumores do Estroma Gastrointestinal/mortalidade , Tumores do Estroma Gastrointestinal/patologia , Humanos , Mesilato de Imatinib/uso terapêutico , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Neoplasias Retais/mortalidade , Neoplasias Retais/patologia , Taxa de Sobrevida , Carga Tumoral , Estados Unidos , Adulto Jovem
16.
J Gastrointest Surg ; 21(2): 398-411, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27966058

RESUMO

Surgery remains a cornerstone of the management of Crohn's disease (CD). Despite the rise of biologic therapy, most CD patients require surgery for penetrating, obstructing, or malignant complications. Optimal surgical therapy requires sophisticated operative judgment and medical optimization. Intraoperatively, surgeons must balance treatment of CD complications against bowel preservation and functional outcome. This demands mastery of multiple techniques for anastomosis and strictureplasty, accurate assessment of bowel integrity for margin minimization, and a comprehensive skillset for navigating adhesions and altered anatomy, controlling thickened mesentery, and safely managing the hostile abdomen. Outside of the operating room, a multi-disciplinary team is critical for pre-operative optimization, patient support, and medical management. Postoperatively, prevention and surveillance of recurrence remain a matter of research and debate, and medical options include older drugs with limited efficacy and tolerability versus biologic agents with greater effect sizes and shorter track records. The evidence base for current management is limited by the inherent challenges of studying a chronic disease marked by heterogeneity and recurrence, but also by a lack of prospective trials incorporating both medical and surgical therapies.


Assuntos
Doença de Crohn/cirurgia , Intestino Delgado , Doença de Crohn/complicações , Doença de Crohn/patologia , Humanos , Seleção de Pacientes
17.
J Surg Educ ; 73(6): e118-e130, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27886971

RESUMO

PURPOSE: Intraoperative performance assessment of residents is of growing interest to trainees, faculty, and accreditors. Current approaches to collect such assessments are limited by low participation rates and long delays between procedure and evaluation. We deployed an innovative, smartphone-based tool, SIMPL (System for Improving and Measuring Procedural Learning), to make real-time intraoperative performance assessment feasible for every case in which surgical trainees participate, and hypothesized that SIMPL could be feasibly integrated into surgical training programs. METHODS: Between September 1, 2015 and February 29, 2016, 15 U.S. general surgery residency programs were enrolled in an institutional review board-approved trial. SIMPL was made available after 70% of faculty and residents completed a 1-hour training session. Descriptive and univariate statistics analyzed multiple dimensions of feasibility, including training rates, volume of assessments, response rates/times, and dictation rates. The 20 most active residents and attendings were evaluated in greater detail. RESULTS: A total of 90% of eligible users (1267/1412) completed training. Further, 13/15 programs began using SIMPL. Totally, 6024 assessments were completed by 254 categorical general surgery residents (n = 3555 assessments) and 259 attendings (n = 2469 assessments), and 3762 unique operations were assessed. There was significant heterogeneity in participation within and between programs. Mean percentage (range) of users who completed ≥1, 5, and 20 assessments were 62% (21%-96%), 34% (5%-75%), and 10% (0%-32%) across all programs, and 96%, 75%, and 32% in the most active program. Overall, response rate was 70%, dictation rate was 24%, and mean response time was 12 hours. Assessments increased from 357 (September 2015) to 1146 (February 2016). The 20 most active residents each received mean 46 assessments by 10 attendings for 20 different procedures. CONCLUSIONS: SIMPL can be feasibly integrated into surgical training programs to enhance the frequency and timeliness of intraoperative performance assessment. We believe SIMPL could help facilitate a national competency-based surgical training system, although local and systemic challenges still need to be addressed.


Assuntos
Competência Clínica , Educação Baseada em Competências/métodos , Educação de Pós-Graduação em Medicina/métodos , Cirurgia Geral/educação , Cuidados Intraoperatórios/educação , Adulto , Estudos de Viabilidade , Feminino , Humanos , Internato e Residência/métodos , Cuidados Intraoperatórios/métodos , Masculino , Sensibilidade e Especificidade , Análise e Desempenho de Tarefas , Fatores de Tempo
18.
J Surg Res ; 204(1): 123-9, 2016 07.
Artigo em Inglês | MEDLINE | ID: mdl-27451878

RESUMO

BACKGROUND: The surgical management of colitis-associated rectal cancer (CARC) is not well defined. This study determines outcomes after surgery for CARC compared with sporadic rectal cancer. MATERIALS AND METHODS: This is a retrospective cohort study comparing 27 patients with CARC with 54 matched patients with sporadic cancer. Matching criteria included age, gender, neoadjuvant chemoradiation, and American Joint Committee on Cancer stage. Outcome measures were disease-free and overall survival, tumor characteristics, and postoperative morbidity. RESULTS: Compared to those with sporadic rectal cancer, patients with CARC underwent proctocolectomy more frequently (21 [78%] versus 6 [22%] P < 0.001) and were more likely to have mucinous tumors (11 [40.7%] versus 12 [22.3%] P = 0.03). Overall 3-y survival was significantly reduced in CARC patients compared with patients with sporadic rectal cancer. Those with CARC undergoing segmental proctectomy only demonstrated reduced overall and disease-free survival compared to patients with sporadic rectal cancer and to colitis patients undergoing proctocolectomy (P = 0.002). CONCLUSIONS: Patients with CARC undergoing proctectomy demonstrate reduced disease-free survival versus those undergoing proctocolectomy, and versus patients with sporadic rectal cancer undergoing proctectomy. These findings warrant further study and suggest that proctocolectomy should be considered the preferred surgical approach for CARC.


Assuntos
Adenocarcinoma/cirurgia , Colite Ulcerativa/complicações , Neoplasias Retais/cirurgia , Reto/cirurgia , Adenocarcinoma/etiologia , Adulto , Idoso , Estudos de Casos e Controles , Doença de Crohn/complicações , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Proctocolectomia Restauradora , Neoplasias Retais/etiologia , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento
19.
J Surg Oncol ; 113(3): 323-32, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27094456

RESUMO

Distal resection margin (DRM) and circumferential resection margin (CRM) are two important considerations in rectal cancer management. Although guidelines recommend a 2 cm DRM, studies have shown that a shorter DRM is adequate, especially in patients receiving neoadjuvant chemoradiation. Standardization of total mesorectal excision has greatly improved quality of CRM. Although more patients are undergoing sphincter-saving procedures, abdominoperineal resection is indicated for very distal tumors, and pelvic exenteration is often necessary for tumors involving pelvic organs.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Procedimentos Cirúrgicos do Sistema Digestório/normas , Laparoscopia , Recidiva Local de Neoplasia/prevenção & controle , Tratamentos com Preservação do Órgão , Neoplasias Retais/prevenção & controle , Neoplasias Retais/cirurgia , Canal Anal/cirurgia , Anastomose Cirúrgica , Colo/cirurgia , Secções Congeladas , Humanos , Período Intraoperatório , Laparoscopia/métodos , Terapia Neoadjuvante , Estadiamento de Neoplasias , Neoplasia Residual/prevenção & controle , Tratamentos com Preservação do Órgão/métodos , Tratamentos com Preservação do Órgão/normas , Equipe de Assistência ao Paciente , Neoplasias Retais/patologia , Resultado do Tratamento
20.
Gastrointest Endosc ; 84(1): 115-125.e4, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26769407

RESUMO

BACKGROUND AND AIMS: It is not possible to accurately count adenomas in many patients with familial adenomatous polyposis (FAP). Nevertheless, polyp counts are critical in evaluating each patient's response to interventions. However, the U.S. Food and Drug Administration no longer recognizes the decrease in polyp burden as a sufficient chemoprevention trial treatment endpoint requiring a measure of "clinical benefit." To develop endpoints for future industry-sponsored chemopreventive trials, the International Society for Gastrointestinal Hereditary Tumors (InSIGHT) developed an FAP staging and intervention classification scheme for lower-GI tract polyposis. METHODS: Twenty-four colonoscopy or sigmoidoscopy videos were reviewed by 26 clinicians familiar with diagnosis and treatment of FAP. The reviewers independently assigned a stage to a case by using the proposed system and chose a stage-specific intervention for each case. Our endpoint was the degree of concordance among reviewers staging and intervention assessments. RESULTS: The staging and intervention ratings of the 26 reviewers were highly concordant (ρ = 0.710; 95% credible interval, 0.651-0.759). Sixty-two percent of reviewers agreed on the FAP stage, and 90% of scores were within ±1 stage of the mode. Sixty percent of reviewers agreed on the intervention, and 86% chose an intervention within ±1 level of the mode. CONCLUSIONS: The proposed FAP colon polyposis staging system and stage-specific intervention are based on a high degree of agreement on the part of experts in the review of individual cases of polyposis. Therefore, reliable and clinically relevant means for measuring trial outcomes can be developed. Outlier cases showing wide scatter in stage assignment call for individualized attention and may be inappropriate for enrollment in clinical trials for this reason.


Assuntos
Polipose Adenomatosa do Colo/patologia , Cirurgia Colorretal , Gastroenterologistas , Neoplasias Primárias Múltiplas/patologia , Índice de Gravidade de Doença , Polipose Adenomatosa do Colo/terapia , Colectomia , Colonoscopia , Consenso , Ressecção Endoscópica de Mucosa , Feminino , Humanos , Masculino , Estadiamento de Neoplasias , Sigmoidoscopia , Sulfassalazina , Gravação em Vídeo
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