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To develop and evaluate an objective method of technical skills assessment for graduating subspecialists in colorectal (CR) surgery-the Colorectal Objective Structured Assessment of Technical Skill (COSATS).It may be reasonable for the public to assume that surgeons certified as competent have had their technical skills assessed. However, technical skill, despite being the hallmark of a surgeon, is not directly assessed at the time of certification by surgical boards.A procedure-based, multistation technical skills examination was developed to reflect a sample of the range of skills necessary for CR surgical practice. These consisted of bench, virtual reality, and cadaveric models. Reliability and construct validity were evaluated by comparing 10 graduating CR residents with 10 graduating general surgery (GS) residents from across North America. Expert CR surgeons, blinded to level of training, evaluated performance using a task-specific checklist and a global rating scale. The mean global rating score was used as the overall examination score and a passing score was set at "borderline competent for CR practice."The global rating scale demonstrated acceptable interstation reliability (0.69) for a homogeneous group of examinees. Both the overall checklist and global rating scores effectively discriminated between CR and GS residents (P0.01), with 27% of the variance attributed to level of training. Nine CR residents but only 3 GS residents were deemed competent.The Colorectal Objective Structured Assessment of Technical Skill effectively discriminated between CR and GS residents. With further validation, the Colorectal Objective Structured Assessment of Technical Skill could be incorporated into the colorectal board examination where it would be the first attempt of a surgical specialty to formally assess technical skill at the time of certification.

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

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

Background Multimodal analgesia programs have been shown to decrease hospital stay, but it not clear which functions are restored after surgery. The objective of this study is to evaluate the impact of epidural anesthesia and analgesia on functional exercise capacity and health-related quality of life. Methods Sixty-four patients undergoing elective colonic resection were randomized to either patient-controlled analgesia with morphine or thoracic epidural analgesia with bupivacaine and fentanyl (epidural group). All patients in both groups received similar perioperative care and were offered the same amount of postoperative oral nutrition and assistance with mobilization. Primary outcome was functional exercise capacity as measured by the 6-min walking test, and secondary outcome was health-related quality of life, as measured by the SF-36 health survey. These were assessed before surgery and at 3 and 6 weeks after hospital discharge. Other variables measured in hospital included pain and fatigue visual analogue scale, bowel function, time out of bed, nutritional intake, complication rate, readiness for discharge, and length of hospital stay. Results Although the 6-min walking test and the SF-36 physical health component decreased in both groups at 3 and 6 weeks after surgery, the patient-controlled analgesia group experienced a significantly greater decrease at both times (P < 0.01). Patients in the epidural group had lower postoperative pain and fatigue scores, which allowed them to mobilize to a greater extent (P < 0.05) and eat more (P < 0.05). Length of hospital stay and incidence of complications were similar in both groups, although patients in the epidural group were ready to be discharged earlier. Conclusions The superior quality of pain relief provided by epidural analgesia had a positive impact on out-of-bed mobilization, bowel function, and intake of food, with long-lasting effects on exercise capacity and health-related quality of life.

PURPOSE: Colorectal surgery is associated with postoperative ileus, which contributes to delayed discharge. This study was designed to investigate the effect of thoracic epidural anesthesia and analgesia on gastrointestinal function after colorectal surgery under standardized controlled postoperative care. METHODS: Forty-two patients diagnosed with either colonic cancer, diverticulitis, polyps, or adenoma, and scheduled for elective colorectal surgery, were randomly assigned to either postoperative patient-controlled analgesia (PCA) with intravenous morphine (n=21) or epidural analgesia with a mixture of bupivacaine and fentanyl (n=21). Postoperative early oral feeding and assistance to mobilization were offered to all patients. Pain visual analog scale (1–100 mm), passage of flatus and bowel movements, length of hospital stay, and readiness for discharge were recorded. RESULTS: Pain visual analog scale (visual analog scale, 1–100 mm) at rest, on coughing, and daily on mobilization was significantly lower in the epidural group compared with the patient-controlled analgesia group. Median values for the visual analog scale group were 7 (95 percent confidence interval, 2–18) mm, 19 (95 percent confidence interval, 4–38) mm, and 10 (95 percent confidence interval, 5–33) mm, respectively, and, for the patient-controlled analgesia group, were 24 (95 percent confidence interval, 18–51) mm, 59 (95 percent confidence interval, 33–74) mm, and 40 (95 percent confidence interval, 29–79) mm, respectively (P

PURPOSE: Toxic megacolon is a rare complication of pseudomembranous enterocolitis. We reviewed our recent experience with this complication. METHODS: The first five patients of the series were studied retrospectively, and six others were followed prospectively. RESULTS: Between June 1992 and May 1994, 11 patients (8 male, 3 female) developed toxic megacolon secondary to pseudomembranous enterocolitis. Mean age was 60.7 ±11.8 (range, 40–79) years. Presenting symptoms and signs included diarrhea, 100 percent; malaise, 91 percent; abdominal pain, 82 percent; abdominal distention, 82 percent; white blood cell count greater than 10.5, 82 percent; abdominal tenderness, 72 percent; anemia less than 12 gm, 72 percent; albumin less than 3 gm, 64 percent; tachycardia greater than 100, 55 percent; fever greater than 38.5‡ Celsius, 45 percent; shock or hypotension, 45 percent. Predisposing factors included antibiotics, 64 percent; immunosuppressants or chemotherapy, 36 percent; antidiarrheals, 27 percent; and barium enema in one patient. Five patients (45 percent) had more than one predisposing factor. X-rays showed transverse colon dilation and loss of haustrations in eight patients (72 percent), with a mean diameter of 99 ±3.4 cm. Flexible proctosigmoidoscopy showed pseudomembranes in all scoped patients, and toxin assay forClostridium difficile was positive in all patients. One patient had emergency surgery. Ten patients were initially treated medically with nasogastric suction and intravenous resuscitation (90 percent) and antibiotics (100 percent), usually in the intensive care unit (80 percent). Four patients did not respond and underwent surgery; two others improved, then deteriorated, and also underwent surgery. Altogether, 7 of 11 patients (64 percent) underwent surgery. Three patients (27 percent) responded well to medical treatment. One patient was deemed too ill to undergo surgery and died. Mean delay to surgery was 3.0 ±1.3 days. No sealed or overt perforation was found at laparotomy. All patients who underwent surgery had a subtotal colectomy, with either a Hartmann's stump (71 percent) or a mucous fistula (29 percent). Eventually, five of seven patients who were operated on and two of four medically treated patients died (overall mortality, 64 percent). Only one patient underwent closure of ileostomy and anastomosis. CONCLUSION: Toxic megacolon complicating pseudomembranous enterocolitis is a serious problem that carries a high morbidity and mortality rate, regardless of treatment.

To evaluate the outcome of surgery for ulcerative colitis in pediatric and adolescent patients, the experience at the Cleveland Clinic Foundation was reviewed retrospectively. Fifty-nine percent of the patients presented with acute toxic colitis and sepsis; 94 percent underwent staged procedures with creation of a temporary or permanent ileostomy. Sepsis was the most frequent postoperative complication (38 percent), and accounted for all three deaths (5 percent). Long-term disability was minimal, and 90 percent of the patients were fully active at the time of follow-up.