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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.

Clostridium difficile enterocolitis is endemic in most modern hospitals. The spectrum of clinical presentation varies from the asymptomatic carrier state to fulminant colitis with toxic megacolon and perforation. Highly toxigenic and lethal strains of C. difficile have emerged worldwide. Medical treatment consists of discontinuing the precipitating antibiotic, supportive measures and bowel rest, and antibiotic treatment with metronidazole or vancomycin. Surgical treatment may be necessary in cases of fulminant disease. Subtotal colectomy with end ileostomy is the operation of choice.

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

Background: There have been no attempts to objectively compare resident teaching ability with resident knowledge level. Methods: Resident teaching ability, as rated by medical students and junior surgical residents, was compared with resident knowledge level, estimated by in-training examination results, for 18 PGY5 and PGY4 surgical residents at McGill University (September 1996 to July 1997). Results: There was a trend to suggest that greater teaching ability is associated with higher in-training examination scores; this did not achieve statistical significance. PGY4 residents were rated as better teachers than PGY5 residents. Resident self-evaluation revealed a high degree of interest in teaching; inadequate time was the principal deterrent to resident teaching; enjoyment and learning during teaching were found to be the most common incentives. Conclusions: Our results suggest an association between resident level of knowledge and teaching ability. The principal deterrent to teaching—inadequate time—must be addressed to effectively assist surgical resident teaching.

The stage of disease at presentation is the most important predictor of outcome for colon cancer patients. Stage I (T1-2N0M0) disease carries an excellent prognosis of up to 95% 5-year survival rate after resection, and surgical treatment alone is considered sufficient; adjuvant treatment is not indicated.1 Patients with stage II disease (T3-4N0M0) also have excellent 5-year survival, averaging 70–80%, but a subset of high-risk patients have poorer prognosis.1 As such, it has been suggested that some stage II patients may benefit from adjuvant therapy, but the role of treatment in this patient population remains controversial. In contrast, adjuvant treatment repeatedly has been shown to improve survival for stage III (TanyN1-2M0) disease.

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.

Since its inception in 1899, the American Society of Colon and Rectal Surgeons (ASCRS) has been actively providing support for the education of its members specializing in colon and rectal surgery, general surgeons, surgical residents, and medical students. With new developments in surgical education, the ASCRS continues to offer educational tools and activities tailored to meet acquisition of medical knowledge and technical skills in an ongoing fashion throughout surgeons' careers, foster high-quality patient care, and promote the integration of the core competencies of communication skills, professionalism, system-based practice and practice-based learning, and improvement in daily practice. These tools and activities are presented in this article.

We measured the effect of MC-26 mouse colon cancers (of different sizes) on the circadian rhythm of hepatic ornithine decarboxylase (ODC) activity and hepatic ODC activity during the 24 hr after 60% hepatectomy. Tumor-free control mice showed a normal circadian rhythm of ODC activity with the highest levels at 1100 hr and the lowest levels at 2300 hr. The amplitude of the rhythm was diminished significantly in mice with a large tumor burden (3% of their body weight), and hepatic ODC activity was significantly less than in the tumor-free mice at every point during the 24 hr of the study. In mice with "early" tumors (0.3% of body weight), basal activity of ODC was normal and there was no reactive increase in activity following hepatectomy. In contrast, mice with "late" (3% of body weight) tumors had significantly lower basal ODC activities and the increase in ODC activity following hepatectomy was prolonged and exaggerated. We concluded that tumor burden is associated with abnormal ODC activity and that these differences are exaggerated after hepatectomy. Furthermore, although average ODC concentrations in tumor-bearing mice fell precipitously, the circadian rhythm in hepatic ODC persisted. This finding indicates early recognition by the host of tumor presence, which has a profound negative regulatory effect on hepatic ODC. Apparently, this effect does not impinge on circadian control mechanisms, indicating that these signals act independently.

The past 25 years have seen a revolution in the way surgery is learned, taught, and practiced. This revolution has increased the need for surgical educators to adapt surgical educational strategies to the modern practice environment. The purposes of this article are (1) to describe the impact of recent and upcoming changes in surgical education, (2) to explore the benefits of participating in surgical education activities both for academic surgeons and for surgeons in private practice, and (3) to review some of the avenues available to surgeons wishing to become involved or build a career in surgical education.

Current colonoscopy guidelines do not address the issue of when to stop performing screening and surveillance colonoscopy in the elderly. We reviewed our experience and results of colonoscopy in patients aged 80 years and older to assess the risks and diagnostic yield in this population. We reviewed retrospectively the endoscopic and pathologic reports from consecutive colonoscopies performed on patients aged 80 years and older at a single, high-volume endoscopy center between August 1999 and May 2003. Patient characteristics, indications for examination, findings at colonoscopy, and complications were recorded and analyzed. A total of1,199 colonoscopic examinations were performed on 1,112 patients. Average age was 83.1 (range, 80–100) years. Male:female distribution was 1:1.7. Leading exclusive indications for colonoscopy included: polyp surveillance, 227 (19 percent); altered bowel habits, 168 (14 percent); iron-deficiency anemia, 132 (11 percent); and cancer follow-up, 108 (9 percent). Eighty-six examinations (7 percent) were performed solely for an indication of colorectal cancer screening. Twenty-two percent of patients had more than one indication for colonoscopy. Forty-five malignancies were found (3.7 percent). No cancers were found in the screening group, and two malignancies (0.7 percent) were detected in patients undergoing colonoscopy for polyp surveillance. There were eight (0.6 percent) reported major complications. Colonoscopy can be performed safely in patients aged 80 years and older. However, the diagnostic yield is low, particularly in patients undergoing routine screening or surveillance examinations. Colonoscopy should for the most part be limited to elderly patients with symptoms or specific clinical findings.

This study was designed to determine the results of patients with rectal adenocarcinoma treated with local excision. A retrospective, chart review was conducted for all patients treated with local excision for rectal adenocarcinoma from 1984 to 1998. Sixty-four patients were retained for analysis. The median follow-up was 37 (range, 9–125) months. There were 15 local failures with a median time to local failure of 12 months. Seven patients were salvaged with further operation (4 by repeat local excision, 4 by abdominoperineal resection, and 1 by low anterior resection). The incidence of local recurrence increased with advancing stage of the carcinoma (T1, 13 percent; T2, 24 percent; T3, 71 percent), histologic grade of differentiation, (well, 12 percent; moderately, 24 percent; poorly, 44 percent), and margin status (negative, 16 percent; close (within 2 mm), 33 percent; positive, 50 percent). Sixteen percent of carcinomas ≤ 3 cm failed compared with 47 percent for carcinomas > 3 cm. Nine percent (1/11) of T2 patients treated with adjuvant radiation therapy recurred locally compared with 36 percent (5/14) without radiation therapy. Three of four T3 patients who received radiation therapy failed locally compared with two of three who did not. Using the Kaplan-Meier method, the overall survival at five years was 71 percent, and disease-free survival was 83 percent. Actuarial local failure was 27 percent and freedom from distant metastasis was 86 percent. The sphincter preservation rate was 90 percent at five years. Local excision alone is an acceptable option for well-differentiated, T1 carcinomas, ≤ 3 cm. Adjuvant radiation is recommended for T2 lesions. The high local recurrence rate in patients after local excision of T3 lesions with or without adjuvant radiotherapy would mandate a radical resection.

BACKGROUND AND STUDY AIMS:A novel brachytherapy (BT) protocol evaluated at McGill University has shown promise in terms of downstaging and achieving high tumour sterilization rates in rectal cancer. Endoscopic ultrasound (EUS) has emerged as the imaging modality of choice for local staging of rectal cancer. However, external beam radiotherapy appears to decrease the accuracy of EUS from 85% to 40%. The aim of the present study was to prospectively evaluate the accuracy of EUS in assessing the response of rectal cancer to BT.PATIENTS AND METHODS:Thirty-three patients with locally advanced (stage T2 or T3) operable rectal carcinomas were included in an experimental protocol involving a novel conformal technique, using three-dimensional planning, to administer high-dose rate preoperative BT. The 18 patients who were able to have a post-BT EUS exam arranged within two weeks before surgery (eg, four to eight weeks post-BT) were included in this study. Tumour (T)- and lymph node (N)-staging on radial EUS, as well as interpretation of the residual tumour, were assessed prospectively. Pathologists were blinded to the post-BT EUS results.RESULTS:The mean age was 70 years (SD ±11; range, 52 to 93 years) and 78% of the patients were male. Pre-BT EUS indicated that 16 patients (89%) were stage T3, and two were stage T2. Five patients (28%) had positive nodes (N1) by ultrasound. With BT, the mean maximal wall thickness on EUS decreased from 14 mm to 9.4 mm (PÃ0.001). At the time of surgery, seven of the 18 patients (39%) had no detectable tumour in the resected specimen; one had carcinoma in situ, one was stage T1, one was stage T2, and eight were stage T3. Eleven patients (61%) underwent an abdominoperineal resection, including four of the 11 (36%) with no ultimate evidence of residual carcinoma. Eight patients (44%) were node-positive. The sensitivity, specificity, and positive and negative predictive values of post-BT EUS in predicting residual tumour were 82%, 29%, 64% and 50%, respectively. The post-BT EUS accurately predicted the T-stage in eight (44%) patients; most errors were due to overstaging.CONCLUSIONS:Rectal cancer T-staging by EUS post-BT is inaccurate, and although it appears sensitive in predicting the presence or absence of residual tumor in rectal adenocarcinoma after preoperative BT, the low predictive values in this setting limit its utility at this time.

PURPOSE: The value of specialization has frequently been challenged by many health care institutions and providers. This review was conducted to determine whether there were any outcome differences in the management of fistulas complicating diverticulitis. METHODS: We conducted an historical cohort study using hospital charts of all cases of fistulas complicating diverticulitis that were operated on in four university-affiliated hospitals between 1975 and 1995. There were 122 patients, with 37 under the care of fully trained colorectal surgeons and 85 under the care of general surgeons. RESULTS: There were no significant differences in patient demographics, preoperative comorbidities, or the number of preoperative diagnostic investigations between the two groups. The colorectal surgeons performed more intraoperative ureteral stenting (Colorectal Surgery 55.5 percentvs. General Surgery 24.4 percent,P=0.001). The general surgeons performed more initial diverting Hartmann's and colostomy procedures (Colorectal Surgery 5.4 percentvs. General Surgery 27 percent,P=0.013). The patients in the General Surgery group had longer preoperative lengths of stay (median Colorectal Surgery 3 (range, 1–28) daysvs. General Surgery 8 (range, 0–29) days;P

This case report describes a patient who was previously prescribed alendronate (Fosamax) and presented with postoperative hypophosphatemia and hypocalcemic tetany after bowel preparation with Fleet Phospho-Soda. This report suggests that patients taking bone metabolism regulators may not be able to respond appropriately to hypocalcemic stressors.

Patients with colorectal cancer respond poorly to in vivo immunotherapy with lymphokine-activated killer (LAK) cells generated from peripheral blood mononuclear cells (PBMC). We postulated that gut-derived immune cells could be a more relevant source of LAK cells directed against colorectal cancer. Intestinal lamina propria mononuclear cells (LPMC) and colonic adenocarcinoma cells were isolated from operative specimens by combination of mechanical and enzymatic dissociation methods. LAK cells were generated by culturing PBMC and LPMC with recombinant interleukin 2 (IL2), with and without OKT3 monoclonal antibody, in short-(4 days) and long-term (21 days) cultures. Other cultured tumor cells, normal intestinal fibroblasts, and hapten-modified autologous LPMC were used as control targets. Cytotoxicity was measured by a 4-hr 51 Cr release assay. Short-term cultured LAK cells exhibited a strong to moderate degree of killing against normal intestinal fibroblasts, hapten-modified self cells, and four different tumor cell lines. Instead, fresh colon cancer cells were resistant to cytotoxicity, regardless of their degree of histologic differentiation and the autologous or allogeneic nature of the LAK cells. Long-term culture with IL2 remarkably increased LAK cell activity against all tumor targets, but not against colonic adenocarcinoma cells. The results of this study, showing that freshly isolated colon cancer cells are intrinsically resistant in vitro to highly activated cytotoxic effector cells, may explain the poor clinical results observed in human trials with in vivo administration of IL2 or LAK cells.

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.

The authors reviewed their experience with diagnosis and treatment of lower gastrointestinal bleeding secondary to colonic arteriovenous malformations (AVM). A diagnosis was established exclusively by endoscopy in 80 percent of the patients. Twenty-eight patients were treated by endoscopic coagulation; bleeding stopped after one or more treatments in 67.9 percent of these patients. There were no complications or mortality as a consequence of endoscopic treatment. Surgery controlled the recurrent bleeding in six of seven cases of failed endoscopic coagulation, and in 13 of 17 cases where surgery only was undertaken, for an overall success rate of 79.2 percent. It is concluded that colonoscopy can accurately establish the diagnosis of colonic AVMs in chronic lower gastrointestinal bleeding. Endoscopic coagulation is a useful adjunct in the treatment of this condition, and is safe, effective, and leaves other options open.