Colorectal Residency Research Articles

Predictive factors of first-time failure on the American Board of Colorectal Surgery certifying and qualifying examinations

Objective To discover if first-attempt failure of the American Board of Colon and Rectal Surgery (ABCRS) board examination is associated with surgical training or personal demographic characteristics. Methods Current colon and rectal surgery program directors in the United States were contacted via email. Deidentified records of trainees from 2011 to 2019 were requested. Analysis was performed to identify associations between individual risk factors and failure on the ABCRS board examination on the first attempt. Results Seven programs contributed data, totaling 67 trainees. The overall first-time pass rate was 88% (n = 59). Several variables demonstrated potential for association, including Colon and Rectal Surgery In-Training Examination (CARSITE) percentile (74.5 vs 68.0, P = 0.09), number of major cases in colorectal residency (245.0 vs 219.2, P = 0.16), >5 publications during colorectal residency (75.0% vs 25.0%, P = 0.19), and first-time passage of the American Board of Surgery certifying examination (92.5% vs 7.5%, P = 0.18). Conclusion The ABCRS board examination is a high-stakes test, and training program factors may be predictive of failure. Although several factors showed potential for association, none reached statistical significance. Our hope is that by increasing our data set, we will identify statistically significant associations that can potentially benefit future trainees in colon and rectal surgery.

Applicants' Perspectives on Virtual vs In-person Colorectal Residency Interviews.

Abelson, Jonathan S. M.D., M.S.1; Al Jabri, Ali M.D.1; Kelley, Scott R. M.D.2; D’Angelo, Jonathan D. Ph.D.2; D’Angelo, Anne-Lise D. M.D., M.S.Ed.2; Husain, Syed M.B.B.S.3 Author Information

Current status of robotic surgery in colorectal residency training programs.

Robotic surgery (RS) has been increasingly incorporated into colorectal surgery (CRS) training. The degree to which RS has been integrated into CRS residency training is not well described. A web-based survey was sent to all 2019 accredited CRS residency programs within the United States and Canada. Program directors (PDs) were queried on how robotic surgery had been integrated into their program, specifics on RS curriculum and opinions on RS training during general surgery residency. We compared survey responses by program type (university-based, university-affiliated programs, or independent programs) and by geographic region. In addition, a chi-square test was used to evaluate differences in survey responses with respect to robotic curriculum components. Of 66 programs, 42 (64%) responded to the survey. Of the responding programs, 35 (83%) were university-based or university-affiliated, while 7 (17%) were independent. Most programs were in the Midwest (33%). Forty-one (98%) reported having a surgical robot in use at their institution, with 95% reporting active participation of CRS residents in RS. While 74% of programs have a formal RS training curriculum for CRS residents, there was considerable variability in the curriculum elements employed by each institution, and the differences in proportions of these elements were significant (χ2 99.8, p < 0.001). The median operative approach to abdominopelvic cases was estimated to be 33% robotic, 40% laparoscopic and 20% open. There were no significant differences in the survey responses between university/university-affiliated and independent programs (p > 0.05) or among the different regions (p > 0.05). This study demonstrated that almost all CRS residencies have integrated RS and have trainees operating at the robotic console. Most programs have a robotics curriculum and there are expanding indications for RS within CRS. This expansion calls for discussion on implementation of training standards such as curricular requisites, baseline competency assessments, and definitions of minimum case requirements to ensure adequate training.

Initiation of a Transanal Total Mesorectal Excision Program at an Academic Training Program: Evaluating Patient Safety and Quality Outcomes.

Short-term results have shown that transanal total mesorectal excision is safe and effective for patients with mid to low rectal cancers. Transanal total mesorectal excision is considered technically challenging; thus, adoption has been limited to a few academic centers in the United States. The aim of this study is to describe outcomes after the initiation of a transanal total mesorectal excision program in the setting of an academic colorectal training program. This is a single-center retrospective review of consecutive patients who underwent transanal total mesorectal excision from December 2014 to August 2016. This study was conducted at an academic center with a colorectal residency program. Patients with benign and malignant diseases were selected. All transanal total mesorectal excisions were performed with abdominal and perineal teams working simultaneously. The primary outcomes measured were pathologic quality, length of hospital stay, 30-day morbidity, and 30-day mortality. There were 40 patients (24 male). The median age was 55 years (interquartile range, 46.7-63.4) with a median BMI of 29 kg/m (interquartile range, 24.6-32.4). The primary indication was cancer (n = 30), and tumor height from the anal verge ranged from 0.5 to 15 cm. Eighty percent (n = 24) of the patients who had rectal cancer received preoperative chemoradiation. The most common procedures were low anterior resection (67.5%), total proctocolectomy (15%), and abdominoperineal resection (12.5%). Median operative time was 380 minutes (interquartile range, 306-454.4), with no change over time. For patients with malignancy, the mesorectum was complete or nearly complete in 100% of the specimens. A median of 14 lymph nodes (interquartile range, 12-17) were harvested, and 100% of the rectal cancer specimens achieved R0 status. Median length of stay was 4.5 days (interquartile range, 4-7), and there were 6 readmissions (15%). There were no deaths or intraoperative complications. This study's limitations derive from its retrospective nature and single-center location. A transanal total mesorectal excision program can be safely implemented in a major academic medical center. Quality outcomes and patient safety depend on a comprehensive training program and a coordinated team approach. See Video Abstract at http://links.lww.com/DCR/A448.

Current State of Colorectal Surgery Training: A Survey of Program Directors, Current and Recently Matched Colorectal Residents, and Recent Colorectal Graduates.

Colorectal residency has become one of the more competitive postgraduate training opportunities; however, little information is available to guide potential applicants in gauging their competitiveness. The aim of this study was to identify the current trends colorectal residency training and to identify what factors are considered most important in ranking a candidate highly. We hypothesized that there was a difference in what program directors, current and recently matched colorectal residents, and recent graduates consider most important in making a candidate competitive for a colorectal residency position. Three 10-question anonymous surveys were sent to 59 program directors, 87 current and recently matched colorectal residents, and 119 recent graduates in March 2015. The study was conducted as an anonymous internet survey. Current trends in applying for a colorectal residency, competitiveness of recent colorectal residents, factors considered most important in ranking a candidate highly, and what future colorectal surgeons can expect after finishing their training were measured. The study had an overall response rate of 43%, with 28 (47%) of 59 program directors, 46 (53%) of 87 current and recently matched colorectal residents, and 39 (33%) of 119 recent graduates responding. The majority of program directors felt that a candidate's performance during the interview process was the most important factor in making a candidate competitive, followed by contact from a colleague, letters of recommendation, American Board of Surgery In-Training Exam scores, and number of publications/presentations. The majority of current and recently matched colorectal residents felt that a recommendation/telephone call from a colleague was the most important factor, whereas the majority of recent graduates favored letters of recommendation as the most important factor in ranking a candidate highly. Limitations to the study include its small sample size, selection bias, responder bias, and misclassification bias. There are differences in what program directors and current/recent residents consider most important in making an applicant competitive for colorectal residency.

Dr. James w. Fleshman and dr. Warren e. Lichliter.

Dr. James W. Fleshman is the Helen Buchanan and Stanley Joseph Seeger Endowed Professor and Chairman—Department of Surgery, Baylor University Medical Center, and Chief of Surgery at Baylor University Medical Center, Dallas, Texas. James was born in New Orleans, Louisiana, and received an MD degree from Washington University School of Medicine, St. Louis, MO. His general surgery training, which included a year of research, was conducted at The Jewish Hospital of St. Louis, Washington University School of Medicine, St. Louis, MO. He then performed a fellowship in Colon and Rectal Surgery at the University of Toronto, Toronto, Canada. In 1987, he joined the colorectal staff at Washington University School of Medicine, St. Louis, MO, and eventually became professor and section head of the division of colon and rectal surgery. In 2012, he moved to Dallas, TX, to assume his current position. Dr. Fleshman is a major force in colorectal research. In addition to being honored with the American Society of Colon and Rectal Surgeon's Young Researcher's Award in 1992, he served as the President of the American Society of Colon and Rectal Surgeons Research Foundation. He has been involved in most of the major multicenter colorectal trials including the COST (Clinical Outcomes of Surgical Therapy) trial and remains an active researcher. Dr. Fleshman is a member of and held leadership positions in multiple national surgical and colorectal societies. He has served as the president of the ASCRS (American Society of Colon and Rectal Surgeons) and the American Board of Colorectal Surgery, and is a senior member of the American Board of Surgery. Dr. Fleshman has served on the Editorial Board of Diseases of the Colon and Rectum and Annals of Surgery as well as eight other journals. He has had a long interest in cancer and has published over 161 peer-reviewed articles, 34 non–peer-reviewed articles, and 60 book chapters on this and other colorectal subjects. He has edited four textbooks, including the first edition of the ASCRS Textbook of Colon and Rectal Surgery. Dr. Fleshman maintains a very busy clinical practice in which the management of rectal cancer plays a major role. He educates medical students and surgical and colorectal residents on a daily basis. James and his wife, Linda, live in Dallas, Texas. When not working, Jim enjoys golf, reading, and spending time with his family, especially his four grandchildren. In summary, Dr. Fleshman is one of the major leaders and academic surgeons in colorectal surgery. It is an honor to know him and consider him a friend. Dr. Warren E. Lichliter is the Chief of the Department of Colon and Rectal Surgery and Colorectal Surgery Residency Director at Baylor University Medical Center, Dallas, Texas. Warren was born in Murphysbort, Illinois and did his undergraduate training at the University of Tennessee. He attended medical school at the University of Texas Medical Branch at Galveston. His general surgery residency and colorectal surgery training was performed at Baylor University Medical Center, Dallas, Texas. Following his colorectal surgery training, Dr. Lichliter joined the staff at the Baylor University and progressed to the positions listed above. Dr. Lichliter educates medical students and general surgery and colorectal residents on a daily basis and mentors trainees and junior faculty as well as conducting research. His publications include nine peer reviewed articles and he has made multiple presentations at regional and national forums. Dr. Lichliter is a fellow of the American College of Surgeons and the American Society of Colon and Rectal Surgeons (ASCRS). He has served on several important committees and as President of the North Texas Chapter of the American College of Surgeons. He is also Board Certified in General Surgery and Colon and Rectal Surgery and is listed in Best Doctors in America Warren has four children and lives with his wife in Dallas, Texas. On behalf of the readers and staff of Clinics of Colon and Rectal Surgery, I thank Dr. Fleshman and Lichliter for serving as Guest Editors and for providing us with a comprehensive update and state-of-the-art review of rectal cancer management.

A Novel Approach to Assessing Technical Competence of Colorectal Surgery Residents

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 (P < 0.01), 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.

Steven D. Mills, MD

Dr. Steven D. Mills is an Associate Clinical Professor and Chief of the Division of Colon and Rectal Surgery and Colorectal Surgery Residency Director at the University of California, Irvine School of Medicine, and was recently appointed as the Director of the General Surgery Medical Student Clerkship. He also serves as a staff colorectal surgeon at the Long Beach VA Medical Center. Born in Ridgecrest, California, Steven did his undergraduate training at the University of California, San Diego, but then traveled to New York to attend medical school at the New York Medical College in Valhalla. He did his general surgery residency at Oregon Health Sciences University in Portland; he completed his colorectal surgery training at the University of Southern California in Los Angeles, California. Following his colorectal surgery training, Dr. Mills joined the staff at the University of California, Irvine, where he has developed a busy clinical colorectal practice that focuses on improving outcomes with minimally invasive techniques. He has also worked tirelessly to improve surgical education at UCI Irvine and to advance the field of colorectal surgery through research. Dr. Mills is recognized as a national leader in surgical education. He educates medical students and general surgery and colorectal residents daily and mentors trainees and junior faculty—all while actively pursuing his research interests. He has received several awards recognizing his contributions including the University of California, Irvine Golden Apple Award for the “Best Clinical Teaching Professor” at the medical school. His publications include four book chapters and more than 35 peer-reviewed articles. He also has served as a reviewer for numerous prestigious journals. He is a frequent presenter at regional, national, and international forums. Dr. Mills is a fellow of the American College of Surgeons and the American Society of Colon and Rectal Surgeons (ASCRS)and has served on the ASCRS Standard's Committee. He is Board Certified in General Surgery and Colon and Rectal Surgery and is listed in Best Doctors in America. Steven and his wife, Kelly Young, PhD, live in Long Beach, California. They have two daughters (Alexa and Elyse). When not working, he enjoys camping, hiking (he recently completed the Grand Canyon Rim-to-Rim-to-Rim [R2R2R] in one day!), standup paddle-boarding, and cooking with things grown in his garden. However, his favorite pastime is exploring the world with his family. On behalf of the readers of Clinics in Colon and Rectal Surgery, the Editorial Board thanks Dr. Mills for serving as Guest Editor and for providing an important issue on trauma, bowel obstruction, and colorectal emergencies.

Teaching and Assessing Colorectal Surgery Residents in the Age of ACGME Competencies: Pieces of the Whole

Educators have struggled with teaching and evaluation of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies since their introduction in 1999. In addition, many authors have questioned the construct validity of the competencies. Concern has also arisen regarding the educational effects of the competencies and the subsequent limitation of resident duty hours, the combination of which have forced unprecedented changes in American graduate medical education. This article attempts to present an understanding of how these events have had direct and indirect effects on the education of residents in colon and rectal surgery, and to provide a framework for educators in colon and rectal surgery to adapt in their curricula.

Judith L. Trudel, M.D.

Dr. Judith L. Trudel is a clinical professor in the Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, where she is the program director for the colon and rectal surgery residency program. She practices colon and rectal surgery in St. Paul, Minnesota. Judith was born in Montreal, Canada and received her undergraduate and medical school training at Laval University in Quebec, Canada. Her general surgery residency was completed at McGill University in Montreal; her colorectal surgery training at the Cleveland Clinic in Cleveland, Ohio. In addition, her academic formation includes several years of basic and clinical research, a Master of Science degree in experimental surgery from McGill University and a Masters degree in health professions education from the University of Illinois in Chicago. Following her colorectal surgery training, Dr. Trudel joined the faculty at McGill University and had a busy educational and clinical colorectal practice. She moved to Minnesota in 2002 and maintains citizenship in both Canada and the United States. Dr. Trudel is recognized as a national leader in surgical education. She has been involved in educating medical students and general surgery or colorectal residents for her entire professional career. As program director, she mentors trainees and junior faculty on a daily basis, and is involved in curriculum development and educational research. Her publications include eight book chapters and 42 peer-reviewed articles, and she is a reviewer for numerous prestigious journals. She actively participates in forums and committees on a national level to improve our knowledge and ability to educate trainees. In addition to these activities, Dr. Trudel maintains a busy colorectal surgery practice. Dr. Trudel is a fellow of the Royal College of Physicians and Surgeons of Canada, of the American College of Surgeons, of the American Society of Colon and Rectal Surgeons (ASCRS), and the Society of Surgical Oncology. She is board certified in general surgery and colon and rectal surgery and is also listed in Best Doctors in America. She is the immediate past vice-president of the ASCRS, serves actively on national society committees, and is a member of several Canadian and American specialty societies. She is a board member of the American Board of Colon and Rectal Surgery. Judith and her husband, Francois Bedard, Ph.D., live in Woodbury, Minnesota. She has two children: Vincent, a freshman studying hospitality management at the University of Central Florida, Orlando; and Nicolas, a junior in high school. When not working, she enjoys keeping fit, spending time with friends and family, dragon boat racing, and cooking; she and Francois climbed Mount Kilimanjaro in July 2011. On behalf of the readers of Clinics in Colon and Rectal Surgery, the Editorial Board thanks Dr. Trudel for serving as Guest Editor and for providing an important issue on surgical education.

The impact of practice environment on laparoscopic colectomy utilization following colorectal residency: a survey of the ASCRS Young Surgeons

It is often thought that practice patterns are different in private (PP) vs university hospital (UH) settings. We aimed to describe the impact of practice environment on the type of laparoscopic colectomy procedures performed by graduating colorectal surgeons. A review was carried out of prospectively gathered self-reported questionnaire data. Graduates of American Society of Colon and Rectal Surgeons' (ASCRS)-approved colorectal residencies from 2004 to 2008 underwent an on-line survey, developed by the ASCRS Young Surgeons' Committee. About 177 (52%) of 342 graduates surveyed responded. Practice setting data were available for 157 (89%) surgeons. Gender, geographical location and age were similar in both cohorts. PP surgeons utilized a laparoscopic approach more often for rectal cancer (37% vs 19%; P=0.003). There was no significant difference in the rate of laparoscopic surgery in colon cancer, diverticular disease, inflammatory bowel disease, Clostridium difficile or emergency surgery. PP surgeons operated more often with a partner (43% vs 8%) or surgical assistant (13% vs 4%; both P<0.001), while UH surgeons had a colorectal resident (10% vs 21%) or general surgery resident (15% vs 55%; both P<0.001). Impediments to performing laparoscopic surgery for PP surgeons included a perceived lack of hospital equipment (33% vs 20%) and support (29% vs 17%; both P<0.05). Perception of personal experience, access to trained assistants, financial reimbursement, length of surgery and patient availability were equivalent in both groups. While differences such as type of assistant and impediments to laparoscopic utilization exist between PP- and UH-based practices, early laparoscopic practice patterns remain similar. PP surgeons more frequently perform laparoscopic resection for rectal cancer and with hand-assistance. Despite differences, newly trained colorectal surgeons in both settings utilize and require laparoscopic skills.

Learning laparoscopic colectomy during colorectal residency: what does it take and how are we doing?

The ability to perform a laparoscopic colectomy is an integral part of a young colorectal surgeon's practice. However, the number of resections required during colorectal residency for a surgeon to be very comfortable performing a laparoscopic colectomy independently is poorly defined. Furthermore, the percentage of trainees that achieve this goal also is unknown. An electronic survey designed by the Young Surgeon's Committee of the American Society of Colon and Rectal Surgeons (ASCRS) was sent to graduates completing Accreditation Council for Graduate Medical Education (ACGME) colorectal residencies after publication of the Clinical Outcomes Study Group (COST) trial (2004-2009). The data collected included the number of laparoscopic right (LR), laparoscopic left (LL), and laparoscopic hand-assisted left (HAL) colectomies performed during residency. Trainees were asked to assess whether at the completion of their fellowship they with each case were very comfortable (VC, would perform a laparoscopic colectomy independently), somewhat comfortable (SC, would require assistance from colleagues), or not comfortable (NC, would not perform a laparoscopic colectomy). Of the 176 (51%) former fellows responding to the survey, 42 (24%) reported performing fewer than 10 LRs, 108 (62%) reported 10 to 30 LRs, and 24 (14%) reported more than 30 LRs during their fellowship. With LR, 13 (7.5%) respondents were NC, 42 (21%) were SC, and 119 (68%) were VC. As reported, 58 fellows (33%) performed fewer than 10 LLs, 92 (53%) performed 10-30 LLs, and 22 (13%) performed more than 30 LLs. With LL, 12.2% were NC, 33.7% were SC, and 54.1% were VC. Most of the fellows (90%) who performed 30 or more LR, LL, or HAL colectomies were VC. On the average, each year's graduating fellows were more comfortable with laparoscopic colectomy than those graduating in previous years (P < 0.002). Performing more than 10 LR colectomies and more than 30 LL colectomies provided the vast majority of colorectal residents with the ability to be very comfortable with these procedures as they entered practice. A concerning number of trainees (46% of LL and 24% of LR trainees) did not reach this benchmark. The new general minimal American Board of Colon and Rectal Surgery (ABCRS) requirement of 50 laparoscopic resections seems appropriate but may require definition regarding the side of the procedure.

Jan Rakinic, M.D.

Dr. Jan Rakinic is Chief of Colorectal Surgery and an Associate Professor of Surgery at the Southern Illinois University School of Medicine, Springfield, Illinois. She earned her M.D. degree from Tulane University Medical School, New Orleans, LA and completed a General Surgery Residency at the University of Illinois-Chicago/Cook County Hospital Combined Program in General Surgery. One year during residency was spent performing research in the Trauma Surgery laboratory, and her work won the Harry M. Vars Research Award from the American Society for Enteral and Parenteral Nutrition for outstanding research by a young investigator in specialized nutrition research. Her colon and rectal surgery training was completed at the Thomas Jefferson University Hospital, Philadelphia, PA. After completing her fellowship, Jan remained on staff at Jefferson Medical College. In 2001, she moved to Illinois and assumed her current position as the Chief, Section of Colorectal Surgery. Dr. Rakinic also serves as the Program Director for a newly accredited Colorectal Surgery Residency at Southern Illinois University. Jan is board certified in both general surgery and colon and rectal surgery and is an active participant in multiple surgical societies. She is an ad hoc reviewer of several journals and her contribution to the medical literature includes 22 peer-reviewed manuscripts and seven book chapters. She has made multiple presentations at national meetings and is an active researcher. She has served on and chaired multiple committees of the ASCRS and was the program co-chairman for the ASCRS national meeting as well as the Tripartite meeting in 2002. Jan lives in Springfield with her daughter Alina, aged 12, who plays volleyball and her son Milan, aged 9, is into basketball and video games. When Jan is not raising her children and working, she enjoys gardening, sport scuba diving in locations with warm water, and is currently learning to speak Italian. On behalf of the readers and staff of Clinics in Colon and Rectal Surgery, I sincerely thank Dr. Rakinic for serving as a Guest Editor and for providing us with a superb issue on Anal Cancer and Retrorectal Tumors.

The Gap in Laparoscopic Colorectal Experience Between Colon and Rectal and General Surgery Residency Training Programs

In this article, we review the laparoscopic experience of general surgery and colorectal residency training programs in the United States during the past 5 and 12 years, respectively. The purpose of this study was to determine whether an adequate experience was being provided, and at what level of training, to safely and effectively perform advanced laparoscopy. General Surgery Operative Reports from the training years 2000 to 2004 were obtained from the Accreditation Council for Graduate Medical Education. Similarly, colorectal operative performance logs from the training years 1994 to 2005 were obtained from the American Board of Colon and Rectal Surgery. From 2000 to 2004, basic and advanced laparoscopic cases (as designated by the Accreditation Council for Graduate Medical Education) have increased from 10.1 to 12.2 percent and 2.1 to 3.7 percent, respectively. Within this period, the number of laparoscopic colon cases/resident/career has increased from 1.8 to 4.6. The percentage of cases performed laparoscopically increased from 3.9 to 22.5 percent from 1993-1994 to 2004-2005 training years. From 1993 to 2001, the average number of laparoscopic cases/resident increased from 6.3 to 16.1. In 2004, the average number of cases/resident increased to 45.3. Of this number, 30 were colon, 9.4 were rectal, and the remaining 5.9 were miscellaneous colorectal procedures. Learning curves for laparoscopic colectomy are reported in the range of 20 to 60 cases. Based on the most recent data reviewed, colon and rectal resident experience is tending toward this threshold. Recent general surgery graduates may be lacking the appropriate volume to reach proficiency in laparoscopic colorectal surgery.

Decision-making in rectal cancer surgery: survey of North American colorectal residency programs.

Although rectal cancer is common in the United States, there is significant variation in management and outcome of this disease. The aim of this study is to measure the amount of variability that exists in the way colorectal surgeons investigate and manage patients with rectal cancer. A detailed questionnaire covering preoperative assessment, operative technique, and follow-up of primary rectal cancer was sent to all colorectal surgeons associated with colorectal residency programs throughout North America. One hundred ten responses were obtained (response rate, 71 percent). Surgeons were in broad agreement (>75 percent agree) on the routine preoperative use of endorectal ultrasound and carcinoembryonic antigen and the postoperative use of endorectal ultrasound. There was also broad agreement about the use of adjuvant therapy and radical resection for a poorly differentiated uT2,N0 cancer, the use of total mesorectal excision for a mid rectal cancer, and for the choice of loop ileostomy if diversion is necessary. Two-thirds of the surgeons used adjuvant therapy and radical resection for a uT3,N0 cancer and preferred a follow-up schedule of three monthly visits for two years with six monthly visits for the next three years. Opinion was divided (<63 percent agreement) on the use of a preoperative liver scan, the approach to a moderately differentiated uT2,N0 cancer, the use of rectal irrigation before resection, the timing of colonoscopy in a patient with stenosing rectal cancer, and the frequency of postoperative colonoscopies. There is considerable variation in the management of low rectal cancer advocated by colorectal surgeon educators. For each histologic and pathologic stage, opinion is divided about which operation is best. Careful outcomes analysis is required to clarify the situation.

Colon and rectal surgery: a true subspecialty.

The study contained herein used the database of the American Board of Colon and Rectal Surgery to demonstrate trends in colorectal practice from 1989 to 1996 and to compare the one-year technical experience of a colorectal resident with the five-year totals of a general surgery resident. Complete case lists from applicants for the American Board of Colon and Rectal Surgery's qualifying examination have been entered into a database. Similar data have been compiled from the Residency Review Committee for Surgery. From 1989 through 1996, 446,082 procedures have been listed by 417 colorectal residents, an average of 1,060 cases per resident. When contrasted with the operative experience of a general surgery resident, the colorectal resident performs substantially more anorectal operations, more endoscopic procedures, and more index abdominal operations in one year than the average general surgery resident performs in five years. When added to the required general surgery experience, one year of training in colorectal surgery trains a true subspecialist with unique expertise in the treatment of disorders of the colon, rectum, and anus.

New colorectal residency program

New colorectal residency program