Key Issues in Surgical Residency Education: Recommendations of the Blue Ribbon II Committee Residency Education Subcommittee.

In September 2022, a summit was convened by the American Board of Surgery (ABS) to discuss competency-based reform in surgical education. A key output of that summit was the recommendation that the prior work of the Blue Ribbon I Committee convened 20 years earlier be revived. With leadership from the American College of Surgeons (ACS) and the American Surgical Association (ASA) , the Blue Ribbon Committee (BRC) II was subsequently convened. This paper describes the output of the Residency Education Subcommittee of the BRC II Committee. The Subcommittee organized its work around prioritized themes including curriculum, assessment, and transition to practice. Top recommendations, time-based action steps, potential barriers, and required resources were detailed and vetted through group discussion, broader Committee review and critique, and subsequent refinement. Primary concluding emphases included transitioning to a competency-based training model, facilitating dynamically capable curricular reform emphasizing the digital transformation of surgical care, using predictive analytic assessment strategies to optimize training effectiveness and efficiency, and creating mentorship strategies to govern the transition from training to independent practice in an outcomes-accountable fashion. It was recognized that coordinated efforts across existing organizational structures will be required, informed by dataset integration strategies that meaningfully measure educational and related patient outcomes.

Implementation of Entrustable Professional Activities in General Surgery: Results of a National Pilot Study.

OBJECTIVE: The ongoing complexity of general surgery training has led to an increased focus on ensuring the competence of graduating residents. Entrustable professional activities (EPAs) are units of professional practice that provide an assessment framework to drive competency-based education. The American Board of Surgery convened a group from the American College of Surgeons, Accreditation Council for Graduate Medical Education (ACGME) Surgery Review Committee, and Association of Program Directors in Surgery to develop and implement EPAs in a pilot group of residency programs across the country. The objective of this pilot study was to determine the feasibility and utility of EPAs in general surgery resident training. METHODS: 5 EPAs were chosen based on the most common procedures reported in ACGME case logs and by practicing general surgeons (right lower quadrant pain, biliary disease, inguinal hernia), along with common activities covering additional ACGME milestones (performing a consult, care of a trauma patient). Levels of entrustment assigned (1 to 5) were observation only, direct supervision, indirect supervision, unsupervised, and teaching others. Participating in site recruitment and faculty development occurred from 2017 to 2018. EPA implementation at individual residency programs began on July 1, 2018, and was completed on June 30, 2020. Each site was assigned 2 EPAs to implement and collected EPA microassessments on residents for those EPAs. The site clinical competency committees (CCC) used these microassessments to make summative entrustment decisions. Data submitted to the independent deidentified data repository every 6 months included the number of microassessments collected per resident per EPA and CCC summative entrustment decisions. RESULTS: Twenty-eight sites were selected to participate in the program and represented geographic and size variability, community, and university-based programs. Over the course of the 2-year pilot programs reported on 14 to 180 residents. Overall, 6,272 formative microassessments were collected (range, 0 to 1144 per site). Each resident had between 0 and 184 microassessments. The mean number of microassessments per resident was 5.6 (SD = 13.4) with a median of 1 [interquartile range (IQR) = 6]. There were 1,763 summative entrustment ratings assigned to 497 unique residents. The average number of observations for entrustment was 3.24 (SD 3.61) with a median of 2 (IQR 3). In general, PGY1 residents were entrusted at the level of direct supervision and PGY5 residents were entrusted at unsupervised practice or teaching others. For each EPA other than the consult EPA, the degree of entrustment reported by the CCC increased by resident level. CONCLUSIONS: These data provide evidence that widespread implementation of EPAs across general surgery programs is possible, but variable. They provide meaningful data that graduating chief residents are entrusted by their faculty to perform without supervision for several common general surgical procedures and highlight areas to target for the successful widespread implementation of EPAs.

Surgical Education.

This paper summarizes the proceedings of the joint European Surgical Association ESA/American Surgical Association symposium on Surgical Education that took place in Bordeaux, France, as part of the celebrations for 30 years of ESA scientific meetings. Three presentations on the use of quantitative metrics to understand technical decisions, coaching during training and beyond, and entrustable professional activities were presented by American Surgical Association members and discussed by ESA members in a symposium attended by members of both associations.

The Quality of Operative Performance Narrative Feedback: A Retrospective Data Comparison Between End of Rotation Evaluations and Workplace-based Assessments.

OBJECTIVE: To describe the quality of operative performance feedback using evaluation tools commonly used by general surgery residency training programs. SUMMARY OF BACKGROUND DATA: The majority of surgical training programs administer an evaluation through which faculty members may rate and comment on trainee operative performance at the end of the rotation (EOR). Many programs have also implemented the system for improving and measuring procedural learning (SIMPL), a workplace-based assessment tool with which faculty can rate and comment on a trainee's operative performance immediately after a case. It is unknown how the quality of narrative operative performance feedback delivered with these tools compares. METHODS: The authors collected EOR evaluations and SIMPL narrative comments on trainees' operative performance from 3 university-based surgery training programs during the 2016-2017 academic year. Two surgeon raters categorized comments relating to operative skills as being specific or general and as encouraging and/or corrective. Comments were then classified as effective, mediocre, ineffective, or irrelevant. The frequencies with which comments were rated as effective were compared using Chi-square analysis. RESULTS: The authors analyzed a total of 600 comments. 10.7% of EOR and 58.3% of SIMPL operative performance evaluation comments were deemed effective (P < 0.0001). CONCLUSIONS: Evaluators give significantly higher quality operative performance feedback when using workplace-based assessment tools rather than EOR evaluations.

Association of socioeconomic status with 30- and 90-day readmission following open and laparoscopic hernia repair: a nationwide readmissions database analysis.

BACKGROUND: Socioeconomic disparities have been associated with outcomes in many medical conditions. The association of socioeconomic status (SES) with readmissions after ventral and inguinal hernia repair has not been well studied on a national level. This study aims to evaluate the association of SES with readmission as a significant outcome in patients undergoing ventral and inguinal hernia repair. METHODS: A retrospective cohort study was performed evaluating patients undergoing ventral hernia and inguinal hernia repair with 1:1 propensity score matching using the Nationwide Readmissions Database (2016-2017). Both 30- and 90-day readmissions were examined. After matching, a multivariate logistic regression analysis was performed using confounding variables including hospital setting, comorbidities, urgency of repair, sociodemographic status, and payer. Likelihood of readmission was reported in odds ratio form. RESULTS: Readmission rates were 11.56% (24,323 out of 210,381) and 17.94% (30,893 out of 172,210) for 30- and 90-day readmissions, respectively. Patients with Medicaid and in the lower income quartile were more likely to present in an emergent fashion for hernia repair. After matching, a multivariate logistic regression analysis showed socioeconomic status (OR 1.250 and 1.229) was a statistically significant independent predictor of readmission at 30 and 90 days, respectively. Inversely, factors associated with the least likely chance of readmission were a laparoscopic approach (OR 0.646 and 0.641), elective admission (OR 0.824 and 0.779), and care in a teaching hospital (OR 0.784 and 0.798). CONCLUSION: SES is an independent predictor of readmission at 30 and 90 days following open and laparoscopic ventral and inguinal hernia repair. Patients with a lower socioeconomic status were more likely to undergo hernia repair in the emergent setting. Efforts toward mitigating SES disparities by potentially promoting MIS techniques, enhancing access to elective cases, and systematic approaches to perioperative care for this disadvantaged population can potentially enhance overall hernia outcomes.

A Proposed Blueprint for Operative Performance Training, Assessment, and Certification.

OBJECTIVE: The aim of this study was to propose an evidence-based blueprint for training, assessment, and certification of operative performance for surgical trainees. SUMMARY BACKGROUND DATA: Operative skill is a critical aspect of surgical performance. High-quality assessment of operative skill therefore has profound implications for training, accreditation, certification, and the public trust of the profession. Current methods of operative skill assessment for surgeons rely heavily on global assessment strategies across a very broad domain of procedures. There is no mechanism to assure technical competence for individual procedures. The science and scalability of operative skill assessment has progressed significantly in recent decades, and can inform a much more meaningful strategy for competency-based assessment of operative skill than has been previously achieved. METHODS: The present article reviews the current status and science of operative skill assessment and proposes a template for competency-based assessment which could be used to update training, accreditation, and certification processes. The proposal is made in reference to general surgery but is more generally applicable to other procedural specialties. RESULTS: Streamlined, routine assessment of every procedure performed by surgical trainees is feasible and would enable a more competency-based educational paradigm. In light of the constraints imposed by both clinical volume and assessment bias, trainees should be expected to become proficient and be measured against a mastery learning standard only for the most important and highest-frequency procedures. For less frequently observed procedures, performance can be compared to a norm-referenced standard and, to provide an overall trajectory of performance, analyzed in aggregate. Key factors in implementing this approach are the number of evaluations, the number of raters, the timeliness of evaluation, and evaluation items. CONCLUSIONS: A competency-based operative skill assessment can be incorporated into surgical training, assessment, and certification. The time has come to develop a systematic approach to this issue as a means of demonstrating professional standards worthy of the public trust.

International Delphi Expert Consensus on Safe Return to Surgical and Endoscopic Practice: From the Coronavirus Global Surgical Collaborative.

OBJECTIVE: The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities. BACKGROUND: The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers. METHODS: Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting. RESULTS: One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements. CONCLUSIONS: The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic.

Establishment of an endoscopic retrograde cholangiopancreatography (ERCP) program in rural Kenya: a review of patient and trainee outcomes.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a leading modality for treatment of biliary and pancreatic disease but is not widely available in sub-Saharan Africa. We aimed to assess the development and outcomes of an ERCP service in southwestern Kenya, including case volumes, success rates, infrastructure, and training. METHODS: We conducted a retrospective review of all ERCPs performed at Tenwek Hospital in Bomet, Kenya between January 1, 2011 and March 31, 2020. RESULTS: In total 277 ERCP procedures were attempted during the study period. The commonest indication was obstructive jaundice: 91 patients (32.9%) had malignancy and 85 (30.7%) had choledocholithiasis. Overall clinical success rate was 76.1% and was the highest in patients with biliary stones (81.2%) and lowest in those with tumors (73.5%) (p = 0.094). Procedure-related adverse events occurred in 11.9%, including post-ERCP pancreatitis in 3.6%, with a procedure-related mortality rate of 1.4%. Annual case volumes increased, and mean procedure duration decreased from 162 to 115 min (p = 0.0007) over time. A previously- rained endoscopist initially performed all cases; two staff endoscopists were trained in ERCP during the study period, performing 130 and 89 ERCPs during training, with clinical success rates of 84% and 74% during their subsequent independent practice. CONCLUSION: An ERCP service can be successfully developed at a rural African hospital, with acceptable success and adverse event rates. Biliary obstruction due to stones or tumors are the most common findings. While a previously trained endoscopist should initiate and champion the service, staff endoscopists can be successfully trained despite limited case volumes.

Determinants of 90-day readmission following ventral hernia repair with and without myocutaneous flap reconstruction: a National Readmissions Database analysis.

BACKGROUND: Readmission status is an important clinical component of healthcare outcomes. 90-day readmission following complex open ventral hernia repair has not been well studied with national level data. This study aims to compare readmission rates for patients undergoing standard vs. complex (myocutaneous flap-based) ventral hernia repair. We hypothesize that complexity of reconstruction will be an independent predictor of readmission after ventral hernia repair. METHODS: A retrospective cohort study was performed with 1:1 matching of hernia repair type using the National Readmissions Database. Patients were selected using ICD-9 codes corresponding to ventral hernia repair with or without myocutaneous flap. 90-day readmissions were determined on patients within the first through third quarters of each year. After matching, a multivariable logistic regression analysis was performed using confounding variables including hospital setting, comorbidities, type of repair, urgency of repair, sociodemographic status, and payer. Likelihood of 90-day readmission was calculated from odds ratios. RESULTS: Readmission rates were 19.1% (38,313 out of 200,266) and 22.5% (692 out of 3075) at 90-day for standard ventral hernia repair and complex ventral hernia repair, respectively. 3116 standard ventral hernia repair patients were matched with 3074 complex ventral hernia repair patients. After matching there was a significantly increased readmission rate for repairs involving myocutaneous flaps, with odds ratio (OR) 1.30 (95% CI 1.22-1.60). Payer status (OR 1.82; 95% CI 1.21-2.74), teaching hospital status (OR 1.42; 95% CI 1.23-1.64) and income quartile (OR 1.35; CI 1.10-1.65) were independent predictors of readmission. CONCLUSIONS: Patients undergoing myocutaneous flap-based reconstruction have higher readmission rates than those undergoing less complex ventral hernia repair. Socioeconomic disparity as reflected in payer status is a particularly strong predictor of readmission. The data support the concept that focused efforts are needed to optimize patient outcomes for patients requiring more complex repair, including socioeconomically disadvantaged patient populations.

Informed consent: a shared decision-making process that creates a new professional obligation for care.

This statement on informed consent, developed by the SAGES Ethics Committee, has been reviewed and approved by the Board of Governors of SAGES. This statement is provided to offer guidance about the purpose and process of obtaining informed consent, and it is intended for practicing surgeons as well as patients seeking surgical intervention. It is an expression of well-established principles and extensive literature. Excluded from this document are discussions of informed consent for research and informed consent for introduction of new technology, as that has been addressed in previous publications (Strong in Surg Endosc 28:2272, 2014; Stefanidis in Surg Endosc 28:2257, 2014; as reported by Sillin (in: Stain (ed) The SAGES Manual Ethics of Surgical Innovation, Springer, Switzerland, 2016)).

The COVID-19 reset: lessons from the pandemic on Burnout and the Practice of Surgery.

BACKGROUND: Burnout among physicians is an increasing concern, and surgeons are not immune to this threat. The ongoing COVID-19 pandemic has caused dramatic changes to surgeon workflow, often leading to redeployment to other clinical areas, slowdown and shutdown of elective surgery practices, and an uncertain future of surgical practice in the post-pandemic setting. Paradoxically, for many surgeons who had to prepare for but not immediately care for a major surge, the crisis did allow for reflective opportunities and a resetting of priorities that could serve to mitigate chronic patterns contributory to Burnout. METHODS: SAGES Reimagining the Practice of Surgery task force convened a webinar to discuss lessons learned from the COVID pandemic that may address burnout. RESULTS: Burnout is multifactorial and may vary in cause among different generation/experience groups. Those that report burnout symptoms often complain of lacking purpose or meaning in their work. Although many mechanisms to address Burnout are from a defensive standpoint-including coping mechanisms, problem solving, and identification of a physician having wellness difficulties-offensive mechanisms such as pursuing purpose and meaning and finding joy in one's work can serve as reset points that promote thriving and fulfillment. Understanding what motivates physicians will help physician leaders to develop and sustain effective teams. Reinvigorating the surgical workforce around themes of meaning and joy in the service rendered via our surgical skills may diminish Burnout through generative and aspirational strategies, as opposed to merely reactive ones. Fostering an educational environment free of discriminatory or demeaning behavior may produce a new workforce conducive to enhanced and resilient wellbeing at the start of careers. CONCLUSION: Surgeon wellness and self-care must be considered an important factor in the future of all healthcare delivery systems, a need reaffirmed by the COVID-19 pandemic.

SAGES primer for taking care of yourself during and after the COVID-19 crisis.

COVID-19 is a pandemic which has affected almost every aspect of our life since starting globally in November 2019. Given the rapidity of spread and inadequate time to prepare for record numbers of sick patients, our surgical community faces an unforeseen challenge. SAGES is committed to the protection and care of patients, their surgeons and staff, and all who are served by the medical community at large. This includes physical health, mental health, and well-being of all involved. The fear of the unknown ahead can be paralyzing. International news media have chronicled the unthinkable situations that physicians and other health care providers have been thrust into as a result of the COVID-19 pandemic. These situations include making life or death decisions for patients and their families regarding use of limited health care resources. It includes caring for patients with quickly deteriorating conditions and limited treatments available. Until recently, these situations seemed far from home, and now they are in our own hospitals. As the pandemic broadened its reach, the reality that we as surgeons may be joining the front line is real. It may be happening to you now; it may be on the horizon in the coming weeks. In this context, SAGES put together this document addressing concerns on clinician stressors in these times of uncertainty. We chose to focus on the emotional toll of the situation on the clinician, protecting vulnerable persons, reckoning with social isolation, and promoting wellness during this crisis. At the same time, the last part of this document deals with the "light at the end of the tunnel," discussing potential opportunities, lessons learned, and the positives that can come out of this crisis.

Survival Implications of Increased Utilization of Local Excision for cT1N0 Esophageal Cancer.

OBJECTIVE: We hypothesized that patients with cT1N0 esophageal cancer undergoing local excision would have lower survival compared with esophagectomy due to potential discordant staging. BACKGROUND: Local excision has become an attractive alternative for management of early esophageal cancer, avoiding the morbidity of esophagectomy. It is uncertain if occult nodal metastasis impacts survival. METHODS: An observational study was conducted using the National Cancer Database (1998-2012) for patients with clinical T1N0 esophageal cancer who underwent local excision (n = 1625) or esophagectomy (n = 3255). RESULTS: The proportion of patients undergoing local excision increased from 12% in 1998 to 50% in 2012 (P < 0.001). After esophagectomy, 61% of cT1N0 cancers had concordant clinical and pathological staging, with 5.2% having positive nodal disease; 37% were staged concordant after local excision, with excess missing data (60%). Ninety-day mortality was 7.4% after esophagectomy compared with 2.8% after local excision (P < 0.001). While no significant difference was seen in unadjusted survival, adjusted Cox regression analysis indicated worse survival after esophagectomy compared with local excision for all cases [hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.27-1.95] and for patients with concordant staging (HR 1.68, 95% CI 1.23-2.28). CONCLUSIONS: Local excision for cT1N0 esophageal cancer has increased over time. Contrary to our hypothesis, despite incomplete nodal staging, patients undergoing local excision have favorable survival, particularly in the adenocarcinoma subgroup. This may reflect early differences in mortality due to differences in procedure-related complications and/or selection bias. As this study has limited power to compare outcomes between T1a and T1b cancers, further analysis is warranted.

Multi-institutional Surgical Education Interventions: A Scoping Review.

OBJECTIVE: The aim of the study was to identify and evaluate scholarship in multi-institutional interventional surgical education trials. SUMMARY BACKGROUND DATA: Most research on interventions in surgical education occurs at individual institutions. These studies typically involve a small number of learners in a unique environment, thereby limiting their generalizability. The status of multi-institutional studies in surgical education remains unknown. METHODS: We searched the Pubmed, ERIC, PsycINFO, SCOPUS, and CINAHL databases for all English language articles published from January 1, 2000 to December 31, 2015 using the keywords "medical education," "surgical education," "multi-institutional," "multi-center," and related terms. Articles published in an English language peer-reviewed journal that described an educational intervention conducted at more than one institution and involving surgeons were included. RESULTS: Of 3511 identified articles, 53 met criteria for full-text review and inclusion in this review. The median number of institutional sites was 4, with a range of 2 to 54. The 2 most common areas of focus were technical skills (43% of studies) and clinical knowledge (32% of studies). These were also the 2 most commonly measured outcomes (technical skills 32% of studies, clinical knowledge 21% of studies). Thirteen percentage of studies measured only learner attitudes and perceptions rather than learning outcomes. CONCLUSIONS: Multi-institutional surgical education studies do not uniformly incorporate characteristics of high quality research, particularly related to study design, measurable outcomes, and assessment tools used. Coordinated support, including grant funding, that addresses the challenging nature of multi-institutional surgical education research may improve the quality of these studies.

National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training.

BACKGROUND: Concerns persist regarding the effect of current surgical resident duty-hour policies on patient outcomes, resident education, and resident well-being. METHODS: We conducted a national, cluster-randomized, pragmatic, noninferiority trial involving 117 general surgery residency programs in the United States (2014-2015 academic year). Programs were randomly assigned to current Accreditation Council for Graduate Medical Education (ACGME) duty-hour policies (standard-policy group) or more flexible policies that waived rules on maximum shift lengths and time off between shifts (flexible-policy group). Outcomes included the 30-day rate of postoperative death or serious complications (primary outcome), other postoperative complications, and resident perceptions and satisfaction regarding their well-being, education, and patient care. RESULTS: In an analysis of data from 138,691 patients, flexible, less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications (9.1% in the flexible-policy group and 9.0% in the standard-policy group, P=0.92; unadjusted odds ratio for the flexible-policy group, 0.96; 92% confidence interval, 0.87 to 1.06; P=0.44; noninferiority criteria satisfied) or of any secondary postoperative outcomes studied. Among 4330 residents, those in programs assigned to flexible policies did not report significantly greater dissatisfaction with overall education quality (11.0% in the flexible-policy group and 10.7% in the standard-policy group, P=0.86) or well-being (14.9% and 12.0%, respectively; P=0.10). Residents under flexible policies were less likely than those under standard policies to perceive negative effects of duty-hour policies on multiple aspects of patient safety, continuity of care, professionalism, and resident education but were more likely to perceive negative effects on personal activities. There were no significant differences between study groups in resident-reported perception of the effect of fatigue on personal or patient safety. Residents in the flexible-policy group were less likely than those in the standard-policy group to report leaving during an operation (7.0% vs. 13.2%, P<0.001) or handing off active patient issues (32.0% vs. 46.3%, P<0.001). CONCLUSIONS: As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality. (FIRST ClinicalTrials.gov number, NCT02050789.).

Surgeon-performed endoscopic retrograde cholangiopancreatography. Outcomes of 2392 procedures at two tertiary care centers.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure that, in the United States, is traditionally performed by gastroenterologists. We hypothesized that when performed by well-trained surgeons, ERCP can be performed safely and effectively. The objectives of the study were to assess the rate of successful cannulation of the duct of interest and to assess the 30-day complication and mortality rates. METHODS: We retrospectively reviewed the charts of 1858 patients who underwent 2392 ERCP procedures performed by five surgeons between August 2003 and June 2016 in two centers. Demographic and historical data, indications, procedure-related data and 30-day complication and mortality data were collected and analyzed. RESULTS: The mean age was 53.4 (range 7-102) years and 1046 (56.3%) were female. 1430 (59.8%) of ERCP procedures involved a surgical endoscopy fellow. The most common indication was suspected or established uncomplicated common bile duct stones (n = 1470, 61.5%), followed by management of an existing biliary or pancreatic stent (n = 370, 15.5%) and acute biliary pancreatitis (n = 173, 7.2%). A therapeutic intervention was performed in 1564 (65.4%), a standard sphincterotomy in 1244 (52.0%), stent placement in 705 (29.5%) and stone removal in 638 (26.7%). When cannulation was attempted, the rate of successful cannulation was 94.1%. When cannulation was attempted during the patient's first ERCP the cannulation rate was 92.4%. 94 complications occurred (5.4%); the most common complication was post-ERCP pancreatitis in 75 (4.2%), significant gastrointestinal bleeding in 7 (0.4%), ascending cholangitis in 11 (0.6%) and perforation in 1 (0.05%). 11 mortalities occurred (0.5%) but none of which were ERCP-related. CONCLUSION: When performed by well-trained surgical endoscopists, ERCP is associated with high success rate and acceptable complication rates consistent with previously published reports and in line with societal guidelines.

Volume, specialty background, practice pattern, and outcomes in endoscopic retrograde cholangiopancreatography: an analysis of the national inpatient sample.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a complex endoscopic procedure performed by both gastroenterologists and surgeons. There has been recent controversy regarding training paradigms for gastrointestinal endoscopy. No prior studies have evaluated comparative outcomes for ERCP in relation to specialty training background. This study utilized the National Inpatient Sample (NIS) to assess ERCP outcomes as a function of training background, practice pattern, and individual provider volume. METHODS: NIS data was queried from 2007 to 2009. Gastroenterologists and surgeons were identified by procedural profiles and unique physician identifiers. Comorbidity was assessed via Charlson Score. Outcomes including cost, length of stay (LOS), and mortality were analyzed, with and without propensity score matching (PSM). Analysis of outcomes as a function of provider procedural volume was also performed. Comparison for statistical significance was accomplished via t test. RESULTS: A total of 110,811 ERCP's were identified, of which 42,025 (37.9%) were performed by surgeons. Surgeons exhibited longer LOS (8.7 vs. 7.2 days), overall cost ($24,739 vs. $16,960), and mortality (3.9 vs. 1.2%, odds ratio 3.3), with p < 0.001 for all measures. 71.6% of surgical patients, versus 19.6% of gastroenterologic, underwent subsequent inpatient laparoscopic cholecystectomy or laparotomy. Outcome differences persisted when PSM included performance of subsequent laparoscopic cholecystectomy. Evaluation of minimum performance standards revealed up to a fivefold increased mortality for providers who performed less than 5 ERCP's/year, irrespective of specialty background. CONCLUSIONS: Gastroenterologists demonstrate favorable gross outcomes compared to surgeons performing ERCP. Differences may correlate in part with more frequent subsequent surgical management of comorbid conditions by surgical providers. Lower volume providers achieve inferior outcomes regardless of specialty background. Analyses of this type may help inform discussions on optimal training and proficiency paradigms, including maintenance of proficiency, for therapeutic endoscopic procedures.

Validity evidence for a new portable, lower-cost platform for the fundamentals of endoscopic surgery skills test.

BACKGROUND: The fundamentals of endoscopic surgery (FES) examination measures the knowledge and skills required to perform safe flexible endoscopy. A potential limitation of the FES skills test is the size and cost of the simulator on which it was developed (GI Mentor II virtual reality endoscopy simulator; Simbionix LTD, Israel). A more compact and lower-cost alternative (GI Mentor Express) was developed to address this issue. The purpose of this study was to obtain evidence for the validity of scores obtained on the Express platform, so that it can be used for testing. STUDY DESIGN: General surgery residents at various levels of training and practicing endoscopists at five institutions participated. Each completed the five FES tasks on both simulator platforms in random order, with 3-14 days between tests. Scores were calculated using the same standardized computer-generated algorithm and compared using Pearson's correlation coefficient. RESULTS: There were 58 participants (mean age 32; 76% male) with a broad range of endoscopic experience. The mean (95% confidence interval) FES scores were 72 (67:77) on the GI Mentor II and 66 (60:71) on the Express. The correlation between scores on the two platforms was 0.86 (0.77:0.91; p < 0.0001). CONCLUSION: There is a high correlation between FES manual skills scores measured on the original platform and the new Express, providing evidence to support the use of the GI Mentor Express for FES testing.