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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. [ABSTRACT FROM AUTHOR]

Background Educating residents in the operating room requires balancing patient safety, operating room efficiency demands, and resident learning needs. This study explores 4 factors that influence the amount of autonomy supervising surgeons afford to residents. Methods We evaluated 7,297 operations performed by 487 general surgery residents and evaluated by 424 supervising surgeons from 14 training programs. The primary outcome measure was supervising surgeon autonomy granted to the resident during the operative procedure. Predictor variables included resident performance on that case, supervising surgeon history with granting autonomy, resident training level, and case difficulty. Results Resident performance was the strongest predictor of autonomy granted. Typical autonomy by supervising surgeon was the second most important predictor. Each additional factor led to a smaller but still significant improvement in ability to predict the supervising surgeon's autonomy decision. The 4 factors together accounted for 54% of decision variance (r = 0.74). Conclusion Residents' operative performance in each case was the strongest predictor of how much autonomy was allowed in that case. Typical autonomy granted by the supervising surgeon, the second most important predictor, is unrelated to resident proficiency and warrants efforts to ensure that residents perform each procedure with many different supervisors. [ABSTRACT FROM AUTHOR]

Background: Reversal of Hartmann's is a common surgical procedure. Routine preoperative evaluation of the distal colonic/rectal remnant (DCRR) with contrast and/or endoscopic studies is frequently performed despite lack of evidence to support this practice. We hypothesize that asymptomatic patients can safely undergo Hartmann's reversal without preoperative DCRR evaluation.Methods: Adult patients undergoing reversal of Hartmann's at a single institution were retrospectively identified. Operative characteristics and outcomes in patients with and without preoperative DCRR evaluation were compared.Results: Between 1993 and 2008, 203 patients underwent reversal of Hartmann's at a tertiary referral center. Sixty-eight patients (33%) did not undergo preoperative DCRR evaluation and had comparable demographic characteristics, comorbidities, DCRR length, and perioperative outcomes to 135 patients who underwent preoperative contrast and/or endoscopic studies. After evaluation, 125 (93%) patients had normal findings, seven (5%) patients had abnormal studies that did not impact their management, and three (2%) patients underwent additional procedures.Conclusion: Hartmann's reversal without previous DCRR evaluation is acceptable in selected asymptomatic patients, without increased risk of complications. [ABSTRACT FROM AUTHOR]

Background: Management of biliary leaks includes ERCP and stent placement. The ability to temporarily place a partially covered self-expandable metallic stent (CSEMS) might offer an advantage in the treatment of biliary leaks. Objective: We analyzed our 2 years'' experience when using this innovative technique. Design: Patients in whom a previous ERCP had failed to resolve a bile leak or patients with severe comorbidities were offered CSEMS and were followed prospectively for clinical and radiologic responses. Setting: Tertiary-care center with long-standing experience of using CSEMS. Patients: A total of 16 patients were included. Of these, 7 had previously undergone unsuccessful plastic stent placement, 3 had previously failed ERCP, and 7 had severe comorbidities that prevented multiple interventions. Intervention: ERCP with placement of a CSEMS covering the cystic duct take-off in the case of a cystic-stump leak. CSEMS were removed after resolution of the leak. Main Outcome Measurements: Efficacy and safety of the CSEMS in bile leaks; complications were also evaluated. Results: Of the patients studied, 15 responded to CSEMS placement with complete resolution of the leak on imaging. One patient with partial cholecystectomy relapsed and underwent drainage; another patient responded to the treatment but required revision because of migration. CSEMS were left in place for a median time of 3 months (range, 1-17 months). Complications included 1 proximal and 1 distal migration. Limitations: Pilot study from a single center. Conclusions: CSEMS is an excellent option in this subgroup of patients not responding to plastic stent placement or with severe comorbidities. [Copyright &y& Elsevier]

Gastric pouch necrosis and intraabdominal sepsis is an uncommon complication following laparoscopic gastric bypass. The intraoperative management of this complication centers on resection of the necrotic pouch, esophageal diversion, drainage, and enteral access for nutrition. Reestablishing gastrointestinal continuity at a later surgery following this complication can be challenging. We present a case in which the colon was found to be unacceptable for use in reconstruction; the remaining stomach was used as the conduit for a transhiatal reconstruction of gastrointestinal continuity instead. [Copyright &y& Elsevier]

Background & Aims: Observational studies and small randomized controlled trials have shown that the use of laparoscopy in colon resection for diverticular disease is feasible and results in fewer complications. We analyzed data from a large, prospectively maintained, multicenter database (National Surgical Quality Initiative Program) to determine whether the use of laparoscopy in the elective treatment of diverticular disease decreases rates of complications compared with open surgery, independent of preoperative comorbid factors. Methods: The analysis included data from 6970 patients who underwent elective surgeries for diverticular disease from 2005 to 2008. Patients with diverticular disease were identified by International Classification of Diseases, 9th revision codes and then categorized into open or laparoscopic groups based on Current Procedural Terminology codes. Preoperative, intraoperative, and postoperative data were analyzed to determine factors associated with increased risk for postoperative complications. Results: Data were analyzed from 3468 patients who underwent open surgery and 3502 patients who underwent laparoscopic procedures. After correcting for probability of morbidity, American Society of Anesthesiology class, and ostomy creation, overall complications (including superficial surgical site infections, deep incisional surgical site infections, sepsis, and septic shock) occurred with significantly lower incidence among patients who underwent laparoscopic procedures compared with those who received open operations. Conclusions: The use of laparoscopy for treating diverticular disease, in the absence of absolute contraindications, results in fewer postoperative complications compared with open surgery. [Copyright &y& Elsevier]

Background: Program directors in surgery are now facing the challenge of incorporating the ACGME''s practice-based learning and improvement (PBLI) competency into residency curriculum. We introduced a comprehensive PBLI experience for postgraduate year 2 (PGY2) residents designed to integrate specific competency goals (ie, quality improvement, clinical thinking, and self-directed learning) within the context of residents'' clinical practice. Study Design: Fourteen PGY2 residents participated in a 3-week PBLI curriculum consisting of 3 components: complex clinical decision making, individual learning plan, and quality improvement (QI). To assess how effectively the curriculum addressed these 3 competencies, residents rated their understanding of PBLI by answering a 12-question written survey given pre- and post-rotation. Resident satisfaction was assessed through standard post-rotation evaluations. Results: Analysis of the pre- and post-rotation surveys from the 14 participants showed an increase in all measured elements, including knowledge of PBLI (p < 0.001), ability to assess learning needs (p < 0.001), set learning goals (p < 0.001), understanding of QI concepts (p = 0.001), and experience with QI projects (p < 0.001). Fourteen QI projects were developed. Although many residents found the creation of measurable learning goals to be challenging, the process of identifying strengths and weaknesses enhanced the resident''s self-understanding and contributed to overall satisfaction with the rotation. Conclusions: The initial implementation of our PBLI curriculum demonstrated that residents report personal progress in their clinical decision making, self-directed learning, and familiarity with QI. This comprehensive PBLI curriculum was accepted by surgical residents as a valuable part of their training. We are encouraged to continue a clinically grounded PBLI experience for PGY2 residents. [Copyright &y& Elsevier]

Background: Although numerous studies have demonstrated improved short-term outcomes after laparoscopic resection of colon cancer, the benefits of laparoscopic-assisted proctectomy (LAP) for rectal cancer are less clear. The current report addresses the need for a large multi-institutional study on early outcomes after proctectomy for cancer. Study Design: Patients who underwent elective LAP or open proctectomy for cancer during 2005 to 2009 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. The frequency of postoperative complications and other early outcomes was determined. Multivariate logistic regression identified predictors of 30-day morbidity. Propensity scores, stratified by quintiles, were included in all multivariable models to partially adjust for nonrandom assignment of treatment. Results: Of 5,420 patients who underwent surgery for rectal cancer, 4,380 underwent open proctectomy and 1,040 (19.2%) LAP. The LAP group had a lower frequency of blood transfusion (12.3% versus 4.3%; p < 0.0001) and a longer mean operative time (242 versus 219 minutes; p < 0.0001). Median length of stay was 5 days after LAP and 7 days after open resection (p < 0.0001). Although no difference in 30-day mortality was detected, the frequency of complications was less after LAP (20.5% versus 28.8%; p < 0.0001). Specifically, the frequencies of superficial surgical site infection, sepsis, respiratory complications, renal failure, and venous thromboembolism were each lower in the LAP group. After adjusting for potential confounders, the likelihood of 30-day morbidity was significantly greater in open versus laparoscopic proctectomy (odds ratio = 1.41; 95% CI, 1.19–1.68). Conclusions: Compared with open proctectomy, LAP is associated with decreased length of stay and 30-day morbidity. If ongoing randomized clinical trials confirm oncologic equivalency, LAP might eventually replace open resection as the standard of care for the treatment of patients with resectable rectal cancer. [Copyright &y& Elsevier]

Background: We reported previously a 26% incidence of surgical site infection (SSI) in patients undergoing elective colorectal resection. Multiple risk factors have been identified, including obesity, improper administration of prophylactic antibiotics, hypothermia, and poor glycemic control. We hypothesized that implementation of a multidisciplinary wound management protocol targeting these risk factors would reduce the incidence of SSI. Study Design: Previously reported baseline data were collected from February 2000 to January 2002. Beginning September 2004, the protocol was implemented, including appropriate administration of prophylactic antibiotics 0 to 60 minutes before incision, continued antibiotic administration for ≤ 24 hours postoperatively, maintenance of intraoperative normothermia (> 36°C), improved glycemic control (goal <200 mg/dL 48 hours postoperatively) in diabetic patients, and placement of penrose drains in the subcutaneous space of patients with a body mass index ≥ 25. Data were collected on patients undergoing elective colorectal resection from January 2005 to August 2005 and compared with baseline. Results: One hundred seventy-five and 132 patients during the baseline and study periods, respectively, met criteria for inclusion. Compliance with administration of prophylactic antibiotics increased from 68% to 91% (p ≤ 0.0001), and compliance with cessation within 24 hours increased from 71% to 93% (p ≤ 0.0001). Compliance with normothermia increased from 64% to 71% (p = 0.25). Incidence of SSI fell from 25.6% to 15.9% (p ≤ 0.05). Conclusions: After implementation of a multidisciplinary wound-management protocol, incidence of SSI improved 39%. These results demonstrate that compliance with a prospectively designed protocol for perioperative care can effectively reduce operative morbidity in patients undergoing colorectal operations. [Copyright &y& Elsevier]

Background: While the costs of medical training continue to increase, surgeon income and personal financial decisions may be challenged to manage this expanding debt burden. We sought to characterize the financial liability, assets, income, and debt of surgical residents, and evaluate the necessity for additional financial training.Study Design: All surgical trainees at a single academic center completed a detailed survey. Questions focused on issues related to debt, equity, cash flow, financial education, and fiscal parameters. Responses were used to calculate debt-to-asset and debt-to-income ratios. Predictors of moderate risk debt-to-asset ratio (0.5 to 0.9), high risk debt-to-asset ratio (≥0.9), and high risk debt-to-income ratio (>0.4) were evaluated. All analyses were performed in SPSS v.21.Results: One hundred five trainees completed the survey (80% response rate), with 38% of respondents reporting greater than $200,000 in educational debt. Overall, 82% of respondents had a moderate or high risk debt-to-asset ratio. Residency program, year, sex, and perception of financial knowledge did not correlate with high risk debt-to-asset ratio. Residents with high debt-to-asset ratios were more likely to have a high level of concern about debt (52% vs 0%, p < 0.001) when compared with residents who had low debt-to-asset ratios. The majority (79%) of respondents felt strongly that inclusion of additional financial training in residency education is a critical need.Conclusions: In a climate of increasingly delayed financial gratification, surgical trainees are on critically unstable financial footing. There is a major gap in current surgical education that requires reassessment for the long-term financial health of residents. [ABSTRACT FROM AUTHOR]