Colorectal Surgery Training Research Articles

Effect of surgeon specialization on long‐term survival following colon cancer resection at an NCI‐designated cancer center

Recent studies have documented improved outcomes for patients undergoing colorectal cancer resection at NCI cancer centers compared to hospitals without this designation. Proposed contributory factors include a higher proportion of surgeons with specialty training in colorectal surgery and surgical oncology. The purpose of this study was to assess whether surgeon specialization is associated with differences in overall survival following colon cancer resection at an NCI cancer center. We conducted a retrospective review of patients undergoing colectomy for colon cancer from 1994 to 2009 at Duke University Medical Center. Patients were divided into two groups based on specialization status of the attending surgeon, and several clinicopathologic variables were compared. A multivariate analysis was then performed examining variables influencing overall survival. Total of 395 patients were included in the study, with 335 patients operated on by specialty-trained surgeons and 60 patients operated on by non-specialists. Overall, the two groups were similar with respect to demographic and pathologic variables. On multivariate analysis, surgeon specialization was found to be an independent predictor of improved overall survival [HR 0.43 (CI: 0.25-0.75), P = 0.003]. Surgeon specialization appears to be associated with improved overall survival in the setting of an NCI-designated cancer center.

Quality training in laparoscopic colorectal surgery: does it improve clinical outcome?

Laparoscopic colorectal surgery (LCRS) is a safe, effective and cost-efficient option for the treatment of various benign and malignant conditions. However, its implementation to surgical practice is still limited. That is mainly due to its association with a steep learning curve. We performed a review of the literature to determine whether quality training in LCRS can reduce that learning curve and lead to better clinical outcomes. We concluded that a structured training program with pre-clinical phase focused on basic skill acquisition and a clinical phase focused on mentoring from experts can shorten the learning curve and improve clinical outcomes.

4th meeting of the Greek society of colon and rectal surgery, 19–22 May 2011

The fourth Pan-Hellenic meeting of the Greek Society of Colon and Rectal Surgery found place in Thessaloniki, Northern Greece, between the 19th and the 22nd of May 2011. During these four sunny and warm days, Thessaloniki welcomed well-known surgeons from all over Greece but also from Europe for a very interesting congress under the presidency of Prof. G. Basdanis. The Congress Venue, a hotel next to the White Tower of Thessaloniki and the statue of Alexander the Great, enriched the surgical meeting with a cultural element of this mesmerizing Greek city. Besides, its position next to the sea and the newly refurbished city waterfront, which is already bustling with people throughout the day but especially during the sunset, was enough to enrich these 4 days with the flair and romance of summer, which has almost already begun. The round tables and lectures of the meeting included subjects from the whole spectrum of colorectal surgery, from open to laparoscopic surgery and from older techniques to the newest innovations in surgery. The meeting started on the afternoon of the 19th of May, with round tables on Crohn’s disease, management of diverticulosis, molecular carcinogenesis, and a very interesting round table on complications following colon cancer surgery. The opening ceremony found place on that evening, with a brilliant speech on medicolegal issues and a captivating choir performance. The next day started early, with two interactive round tables on hemorrhoidal disease and perianal fistulas, where participants were asked to vote on questions according to their experience and knowledge. The answer percentages were shown to the audience and some very interesting results arose, which lead to discussions. Further round tables included ulcerative colitis, new progress in colorectal cancer management, and modern surgical technology. Two well-known surgeons from Europe gave lectures on that day as well. Prof. Mario Pescatori from Italy gave a lecture on perineal-transanal procedures for rectal prolapse, in his own unique, humorous way. Furthermore, Mr. Paris Tekkis from the Imperial College of London and the Royal Marsden Hospital shared with the audience his experience on abdominosacral resections for advanced pelvic malignancy with some unique intraoperative pictures but also on the surgical management of FAP syndrome. The third day included very interesting round tables and the congress halls were crowded, even though the weather outside was warm and the sea very inviting. Subjects included laparoscopic and robotic colorectal surgery, anal surgery, management of hepatic metastases of colorectal origin, and thromboprophylaxis. The Sunday morning, last day of the meeting, included only two round tables before the closing remarks and ceremony, but the thematology on colorectal laparoscopic surgery training and the state of laparoscopic surgery in Greece were enough to gather surgeons of various ages in the lecture halls, even if only for a few hours. During the congress, a second hall was used for the presentations of free lectures and video lectures from hospitals around Greece. The presentations were held mostly by younger surgeons and residents, a fact that made them even more appealing to the audience. Also, a seminar for nurses was held during the first three mornings of the congress with very good attendance. A formal dinner found place on Saturday evening in the ‘‘Yacht Club’’ of the Congress Venue with brilliant food and wine, giving M. G. Pramateftakis (&) 4th Surgical Department, Aristotle University of Thessaloniki, Antheon 1, Panorama, 55236 Thessaloniki, Greece e-mail: mpramateftakis@hotmail.com

Resultados a medio plazo en la implementación de la cirugía laparoscópica colorrectal en la práctica clínica tras la realización de un curso intensivo

Introduction Endoscopic surgery has characteristics that increase the difficulties of learning. Five years ago, an intensive colorectal laparoscopic surgery course was designed to offer training in the technical bases of this type of surgery. The aim of this article is to determine the impact of the colorectal surgery course on clinical practice, and to investigate the factors that limit its applicability and the training preferences of the surgeons. Material and methods Twenty-two courses of four days duration, with 36 hours of lessons (4 in seminar form and 32 in the surgery), and with 7 trainees, were held between June 2005 and December 2010. A survey was sent out in December 2010 to assess the impact of the course on the colorectal laparoscopic surgery activity of the trainee, to find out the difficulties encountered in its application, and to evaluate the training expectations in endoscopic surgery in this group of surgeons. Results The questionnaire was sent to 148 surgeons, with 74 (50%) responses received. The mean period after the course was 26.5 (2-60) months. A monthly increase of more than 5 cases was observed in 70% of the centres. The course enabled them to consolidate the activity in local hospitals, while in university and general hospitals it served to re-launch an initial experience. Among the obstacles that made it difficult to introduce were care load and the availability of a surgeon, particularly in general and university hospitals ( P=.001), and in local hospitals it was the availability of patients. The majority of surgeons (70%) believed that specific training was required, preferring a short period in a hospital with experience. Conclusions An intensive course on colorectal laparoscopic surgery enabled the activity to be consolidated or increased in this area. Training in colorectal laparoscopic surgery requires additional teaching efforts, which are currently unstructured.

Lernkurve in der laparoskopischen Rektumchirurgie

Laparoscopic colorectal surgery has become increasingly more common since first being described in a publication in 1990. Despite a multitude of studies about the learning curve in laparoscopic colon surgery, there are almost no such studies with regard to laparoscopic rectum surgery. This paper aims to describe a surgeon's learning curve with regard to laparoscopic rectum surgery. Based on data collected in a prospective observational study of 180 patients, it can be established that a surgeon experienced in open colorectal surgery, with basic experience in laparoscopic surgery, after suitable preparation and having a personal interest in minimally invasive surgery, needs to perform about 35 laparoscopic rectum resections within 200 laparoscopic colon resections until selection rate, operating time and rates of general and surgical complications reach a plateau. A selection of cases suited to a surgeon's personal level of operating experience, is a prerequisite for a low rate of conversions and complications and for oncological long-term results comparable to those achieved through open surgery. However, the learning curve is dependent on a multitude of factors that are partly unknown at this point. Its duration most certainly varies between individual surgeons. Every surgeon is required to critically evaluate his or her own laparoscopic experience and select cases accordingly. Supervision by surgeons more experienced in laparoscopic colorectal surgery prevents disadvantages for patients in the early phases of the surgeon's learning curve. Training in laparoscopic colorectal surgery should take place only in institutions with a sufficient number of cases treated and a continuity in experienced teachers. CAMIC's efforts in establishing centres of competence and reference are therefore to be commended and supported.

Medium term results on introducing colorrectal laparoscopic surgery into clinical practice after having an intensive training course

IntroductionEndoscopic surgery has characteristics that increase the difficulties of learning. Five years ago, an intensive colorectal laparoscopic surgery course was designed to offer training in the technical bases of this type of surgery. The aim of this article is to determine the impact of the colorectal surgery course on clinical practice, and to investigate the factors that limit its applicability and the training preferences of the surgeons. Material and methodsTwenty-two courses of four days duration, with 36hours of lessons (4 in seminar form and 32 in the surgery), and with 7 trainees, were held between June 2005 and December 2010. A survey was sent out in December 2010 to assess the impact of the course on the colorectal laparoscopic surgery activity of the trainee, to find out the difficulties encountered in its application, and to evaluate the training expectations in endoscopic surgery in this group of surgeons. ResultsThe questionnaire was sent to 148 surgeons, with 74 (50%) responses received. The mean period after the course was 26.5 (2–60) months. A monthly increase of more than 5 cases was observed in 70% of the centres. The course enabled them to consolidate the activity in local hospitals, while in university and general hospitals it served to re-launch an initial experience.Among the obstacles that made it difficult to introduce were care load and the availability of a surgeon, particularly in general and university hospitals (P=.001), and in local hospitals it was the availability of patients. The majority of surgeons (70%) believed that specific training was required, preferring a short period in a hospital with experience. ConclusionsAn intensive course on colorectal laparoscopic surgery enabled the activity to be consolidated or increased in this area. Training in colorectal laparoscopic surgery requires additional teaching efforts, which are currently unstructured.

Systematic Review on Mentoring and Simulation in Laparoscopic Colorectal Surgery

To identify and evaluate the influence of mentoring and simulated training in laparoscopic colorectal surgery (LCS) and define the key components for learning advanced technical skills. Laparoscopic colorectal surgery is a complex procedure, often being self-taught by senior surgeons. Educational issues such as inadequate training facilities or a shortfall of training fellowships may result in a slow uptake of LCS. The effectiveness of mentored and simulated training, however, remains unclear. We conducted a systematic search, using Ovid databases. Four study categories were identified: mentored versus nonmentored cases, training case selection, simulation, and assessment. We performed a meta-analysis and a mixed model regression on the difference of the main outcome measures (conversion rates, morbidity, and mortality) for mentored trainees and expert surgeons. We also compared conversion rates of mentored and nonmentored. Meta-analysis of risk factors for conversion was performed using published and unpublished data sets requested from various investigators. For studies on simulation, we compared scores of surveys on the perception of different training courses. Thirty-seven studies were included. Pooled weighted outcomes of mentored cases (n = 751) showed a lower conversion rate (13.3% vs 20.5%, P = 0.0332) compared with nonmentored cases (n = 695). Compared to expert case series (n = 5313), there was no difference in conversion (P = 0.2835), anastomotic leak (P = 0.8342), or mortality (P = 0.5680). A meta-analysis of training case selection data (n = 4444) revealed male sex (P < 0.0001), previous abdominal surgery (P = 0.0200), a BMI greater than 30 (P = 0.0050), an ASA of less than 2 (P < 0.0001), colorectal cancer (P < 0.0001) and intra-abdominal fistula (P < 0.0001), but not older than 64 years (P = 0.4800), to significantly increase conversion risk. Participants on cadaveric courses were highly satisfied with the teaching value yet trainees on an animal course gave less positive feedback. Structured assessment for LCS has been partially implemented. This review and meta-analysis supports evidence that trainees can obtain similar clinical results like expert surgeons in laparoscopic colorectal surgery if supervised by an experienced trainer. Cadaveric models currently provide the best value for training in a simulated environment. There remains a need for further research into technical skills assessment and the educational value of simulated training.

Modular Training in Laparoscopic Colorectal Surgery Maximizes Training Opportunities without Clinical Compromise

Laparoscopic surgery is increasingly proposed as the gold standard technique for colorectal resections and is offered to greater numbers of patients. To meet the rising service demands, more trainees and established consultants need to learn the technique. We sought to establish whether it is feasible and safe to train on a large proportion of patients without adversely affecting clinical outcome or smooth running of clinical service. Between September 2006 and July 2008, four senior trainees of the Wessex Specialist Registrar training rotation were involved in training in laparoscopic colorectal surgery. Major colorectal resections were separated into clearly defined modules for training purposes. Right and left hemicolectomies each comprised two modules, and low anterior resection comprised three modules. Prospective data on consecutive patients undergoing laparoscopic colorectal surgery were collected. Data included type of surgery, module of procedure performed by trainee or trainer, body mass index (BMI), conversion rates, median operative time, complications, length of hospital stay, and mortality. During the study period 227 colorectal resections were attempted laparoscopically. Of these, 216 (96%) proved suitable for training and 97% were completed laparoscopically. Some 23% of patients were American Society of Anesthesiologists score (ASA)≥3; 35% had a BMI≥28; 38% had a history of previous laparotomy. Trainees performed 96% (142/148) of right hemicolectomy modules, 99% (154/156) of left hemicolectomy modules, and 67% (128/192) of rectal resection modules. Each trainee was competent to do right and left hemicolectomy at the end of the training period. Four patients (2%) required further surgery for postoperative complications. Of the procedures completed by the trainees, 155/171 (91%) cancer resections were potentially surgically curative, and R0 resections were achieved in 99%. The readmission rate was 10% (22/216) and median length of hospital stay was 4 days. Postoperative mortality was zero. Using a modular approach it is possible to provide effective training during almost all laparoscopic colorectal resections while achieving good clinical outcomes for the patients.

Development, validation and implementation of a monitoring tool for training in laparoscopic colorectal surgery in the English National Training Program

The National Training Program for laparoscopic colorectal surgery (LCS) provides supervised training to colorectal surgeons in England. The purpose of this study was to create, validate, and implement a method for monitoring training progression in laparoscopic colorectal surgery that met the requirements of a good assessment tool. A generic scale for different tasks in LCS was created under the guidance of a national expert group. The scores were defined by the extent to which the trainees were dependent on support (1 = unable to perform, 5 = unaided (benchmark), 6 = proficient). Trainers were asked to rate their trainees after each supervised case; trainees completed a similar self-assessment form. Construct validity was evaluated comparing scores of trainees at different experience levels (1-5, 6-10, 11-15, 16+) using the Wilcoxon signed-rank test and ANOVA. Internal consistency was determined by Crohnbach's alpha, interrater reliability by comparing peer- and self-assessment (interclass correlation coefficient, ICC). Proficiency gain curves were plotted using CUSUM charts. Analysis included 610 assessments (333 by trainers and 277 by trainees). There was high interrater reliability (ICC = 0.867), internal consistency (α = 0.920), and construct validity [F(3,40) = 6.128, p < 0.001]. Detailed analysis of proficiency gain curves demonstrates that theater setup, exposure, and anastomosis were performed independently after 5 to 15 sessions, and the dissection of the vascular pedicle took 24 cases. Mobilization of the colon and of the splenic/hepatic flexure took more than 25 procedures. Median assessment time was 3.3 (interquartile range (IQR) 1-5) minutes and the tool was accepted as useful [median score 5 of 6 (IQR 4-5)]. A valid and reliable monitoring tool for surgical training has been implemented successfully into the National Training Program. It provides a description of an individualized proficiency gain curve in terms of both the level of support required and the competency level achieved.

Training in laparoscopic colorectal surgery – experience of training in a specialist unit

Laparoscopic colorectal surgery, although technically demanding, is an increasingly desirable skill for coloproctologists. We believe that trainees with adequate supervision from an experienced trainer may perform these procedures safely with good outcome. Surgical logbooks of two senior trainees were reviewed over a 2-year period. A case note analysis was then undertaken. Patient data were recorded with regards to age, sex, operation type, American Society of Anesthesia (ASA) grade, conversion, length of hospital stay and complications. Lymph node yield, resection margins and grade of total mesorectal excision were recorded in oncological procedures. Over the 2-year period, trainees were involved in 140 resections (age range, 23-88 years; ASA grades I-III). Seventy patients were male. Trainees were first assistant in at least 20 cases prior to undertaking the procedures themselves. Trainees performed a total of 71 operations. Median hospital stay was 7 days (range, 2-48 days). There were three conversions. Anastomotic leaks developed in two patients, one requiring a laparotomy. One patient developed small bowel obstruction secondary to a port site hernia, which was repaired laparoscopically. There was one postoperative death. All oncological resection margins were clear with adequate lymphadenectomies. All total mesorectal excisions were Quirke grade III. Adequately trained and supervised trainees may perform major colorectal resections without compromising outcome.

Training periods with experts improve results in colorectal laparoscopic surgery

ObjectiveTo analyse the effects of training in elective colorectal laparoscopic surgery with a minimum 6 months follow up to assess early and delayed complications, and comparing the first 40 cases in the 1st Period (P-1: 1996–2002) with the 100 cases in the 2nd Period (P-2: 2003–2008). One of the surgeons had 2 training courses between P-1 and P-2. Material and methodsA total of 66 colorectal resections due to cancer were performed and 74 operations for benign disease. The cases of malignant diseases increased between P-1 and P-2 (P<.001). (odds ratio=0.16). ResultsThere number of complex cases increased between P-1 and P-2 (anterior resectionamputation, left hemicolectomy, total colectomy, rectopexy) versus others (sigmoidectomy, right resections) (P<.05), but the mean duration of the operations was reduced by 29 minutes P<01). There were 24% conversions, with no change in P-2 (P=.85). Surgical mortality at 3 months (1.4%) showed no differences (P=.49). The total complications rate (31%) was significantly lower in P-2 (P=.001), because medical complications (P=.05), the more serious surgical complications (with reintervention) (P=.05) and wound infections (P=.0001) were lower. There was no change in the other surgical complications (P=.61). The overall mean stay was 7.8 days (3-36) (median = 6 days), with no differences between P-1 and P-2 (P=.165). Conversion significantly lengthened the mean hospital stay (P=.015) (from 7.2 [5] days to 10.1 [7] days), but there was no increase in complications (P=.31). ConclusionTraining in colorectal laparoscopy and training periods with experts improve results (duration, complications, more complex surgery). Conversions did not decrease with experience and the hospital stays lengthened, but they were not associated with more complications.

Las estancias de formación con expertos mejoran los resultados en cirugía laparoscópica colorrectal

Objective To analyse the effects of training in elective colorectal laparoscopic surgery with a minimum 6 months follow up to assess early and delayed complications, and comparing the first 40 cases in the 1st Period (P-1: 1996–2002) with the 100 cases in the 2nd Period (P-2: 2003–2008). One of the surgeons had two training courses between P-1 and P-2. Material and methods A total of 66 colorectal resections due to cancer were performed and 74 operations for benign disease. The cases of malignant diseases increased between P-1 and P-2 ( P<0.001). (Odds-Ratio=0.16). Results There number of complex cases increased between P-1 and P-2 (Anterior resection-amputation, left hemicolectomy, total colectomy, rectopexy) vs. Others (Sigmoidectomy, right resections) ( P<0.05), but the mean duration of the operations was reduced by 29 minutes P<0.01). There were 24% conversions, with no change in P-2 ( P=0.85). Surgical mortality at 3 months (1.4%) showed no differences ( P=0.49). The total complications rate (31%) was significantly lower in P-2 ( P=0.001), because medical complications ( P=0.05), the more serious surgical complications (with reintervention) ( P=0.05) and wound infections ( P=0.0001) were lower. There was no change in the other surgical complications ( P=0.61). The overall mean stay was 7.8 days (3-36) (median=6 days), with no differences between P-1 and P-2 ( P=0.165). Conversion significantly lengthened the mean hospital stay ( P=0.015) (from 7.2±5 days to 10.1±7 days), but there was no increase in complications ( P=0.31). Conclusion Training in colorectal laparoscopy and training periods with experts improve results (duration, complications, more complex surgery). Conversions did not decrease with experience and the hospital stays lengthened, but they were not associated with more complications.

Expert benchmark for the GI Mentor IITM

There is increasing interest in the use of virtual-reality simulators in general surgery residency training. Many simulators lack a benchmark against which trainees can measure competence and skill. Surgeons who had performed over 1,000 colonoscopies were evaluated on module 1, case 5 of the GI Mentor I or II virtual-reality endoscopy simulator (Simbionix, Cleveland). Participants were given 5 min to familiarize themselves with the simulator, and then performed the study case with standardized instructions. Metrics were recorded by using the previously calibrated simulator. Twenty-three surgeons (21 male, 2 female) participated. Mean height was 69.6 +/- 2.6 inches, mean age 51 +/- 9 years, median surgical glove size 7.5, and surgeons had 18.8 +/- 10.1 years of practice, and did 8 +/- 6 colonoscopies weekly. Ten participants had advanced training in endoscopy, laparoscopy or colorectal surgery; eight had used the simulator before, of whom six had used it once. Mean time to complete the study case was 13.6 +/- 5.3 min and time to reach the cecum was 6.5 +/- 4.3 min. Participants examined 92.3 +/- 3.6% of the simulated colonic mucosa with a clear view of the lumen 89.5 +/- 4.2% of the time. Total time the colon was looped was 22 +/- 35 s (range 0-133 s). The overall efficiency of screening was 70.33 +/- 23.45% (range 20-94%). Participants tended to mistake normal simulated colonic structures as pathology. Performance on a virtual-reality endoscopic simulator has a wide amount of variability even among a group of experienced endoscopists. Expert benchmark tests should be performed on simulators that will be used for resident assessment prior to any attempts at certification of competence.

Colorectal cancer screening perceptions and practices: Results from a national survey of gastroenterology, surgery and radiology trainees

Colorectal cancer (CRC) screening in the United States is suboptimal. We conducted a national survey to learn about CRC screening perceptions and practices among trainees who perform CRC screening tests including those enrolled in Gastroenterology and Hepatology (GIH), General and Colorectal Surgery, and Diagnostic and Abdominal Radiology training programs. Program directors/administrators (PDs/PAs) from 642 programs were contacted by e-mail with an invitation to forward our survey to trainees in their programs. Participating trainees then completed an anonymous, Web-based questionnaire. A total of 130/642 (20%) PDs/PAs forwarded our survey to their trainees, with responses received from 476 trainees (80 GIH, 261 surgery, 135 radiology). Colonoscopy was felt to be the best CRC screening test at reducing CRC mortality, with patient-related factors perceived as greater barriers than system-related factors. No single guideline was deemed very influential on CRC screening practices by most trainees. A total of 2 of 5 above-average risk patient profiles were not recognized by most trainees. Colonoscopy was selected as the preferred follow-up test for a positive CRC screening test by most trainees. However, 34% of respondents chose an option other than colonoscopy alone for follow-up of a positive fecal occult blood test. Based on data from this national survey of gastroenterology, surgery, and radiology trainees, opportunities exist for curricular changes that may help enhance current perceptions and practices of trainees who perform CRC screening tests.

Pursuing Fellowship Training in Colorectal Surgery: A Candidate's Perspective

Colorectal surgery is a fulfilling profession that has become more difficult to match into. There are many factors that go into choosing a career in colorectal surgery. Having a mentor as a colorectal surgeon, performing research in colorectal surgery, and being involved with the American Society of Colon and Rectal Surgeons are all important aspects in providing exposure to young surgeons in training and guiding them toward the field of colorectal surgery. Once the decision has been made, the application and interview process can be daunting. This article reviews salient points about the process I took in choosing colorectal surgery and the steps I took in applying and interviewing for my fellowship.

The duration of postoperative ileus after elective colectomy is correlated to surgical specialization

Postoperative ileus is an important factor of complications following gastrointestinal procedures. Its pathophysiology and the parameters, which may impact on its duration, remain unclear. The aim of this study was to measure the role of various clinical determinants on restoration of intestinal function after elective colorectal surgery. From July 2002 to September 2003, all patients who underwent laparotomy for colectomy (laparoscopic resections excluded) with either an ileotransverse, colocolic, or high colorectal anastomosis were entered in this prospective study. The intervals in hours between the end of the surgical procedure and passing of flatus (PG) and passing of stool (PS) were recorded by an independent investigator. PG and PS were eventually correlated with the following parameters: type of colectomy, early removal of nasogastric tube (NGT), mechanical bowel preparation (MBP), type of underlying disease, systemic administration of opiates, and surgical training (colorectal fellowship or other). One hundred twenty-four patients were entered in this study. Four patients (3.2%) developed septic complications (3 anastomotic leaks and 1 intraabdominal abscess) and were excluded from the analysis. Median age in this population was 68 (range 30-95) years. Mean duration of postoperative ileus was 70+/-28 h (PG) and 99+/-34 h (PS). The type of colectomy, underlying disease, MBP, and early NGT removal failed, in univariate analysis, to correlate with the duration of postoperative ileus. By contrast, time intervals PG and PS were statistically shorter in the group of patients treated by a colorectal surgeon [56+/-23 vs 74+/-28 h (PG); 82+/-26 vs 103+/-35 h (PS), p=0.004], as well as in patients who received systemic opiates for less than 2 days [64+/-27 vs 75+/-28 h (PG), p=0.04; 88+/-32 vs 108+/-33 h (PS), p=001]. Restoration of normal intestinal function after elective open colectomy takes 3 (PG) to 4 (PS) days. In our series, specialized training in colorectal surgery has a positive impact on the duration of postoperative ileus. Surgical specialization should be considered an important parameter in future clinical trials aiming to minimize postoperative ileus.

Influence of surgical subspecialty training on in-hospital mortality for gastrectomy and colectomy patients.

This study examined the relationship of surgeon subspecialty training and interests to in-hospital mortality while controlling for both hospital and surgeon volume. The relationship between volume of surgical procedures and in-hospital mortality has been studied and shows an inverse relationship. A large Statewide Planning and Research Cooperative System was used to identify all 55,016 inpatients who underwent gastrectomy (n = 6434) or colectomy (n = 48,582) between January 1, 1998 and December 31, 2001. Surgical subspecialty training and interest was defined as surgeons who were members of the Society of Surgical Oncology (training/interest; n = 68) or the Society of Colorectal Surgery (training; n = 61) during the study period. The association of in-hospital mortality and subspecialty training/interest was examined using a logistic regression model, adjusting for demographics, comorbidities, insurance status, and hospital and surgeon volume. Overall mortality for colectomy patients was 4.6%; the adjusted mortality rate for subspecialty versus nonsubspecialty-trained surgeons was 2.4% versus 4.8%, respectively (adjusted odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.34, 0.60; P < 0.0001). Gastrectomy patients experienced an overall mortality rate of 8.4%; the adjusted mortality rate for patients treated by subspecialty trained surgeons was 6.5%, while the adjusted mortality rate for nonsubspecialty trained surgeons was 8.7% (adjusted OR = 0.70; 95% CI = 0.46, 1.08; P = 0.10). For gastrectomies and colectomies, risk-adjusted mortality is substantially lower when performed by subspecialty interested and trained surgeons, even after accounting for hospital and surgeon volume and patient characteristics. These findings may have implications for surgical training programs and for regionalization of complex surgical procedures.

Surgeon-related factors and outcome in rectal cancer.

To determine whether surgical subspecialty training in colorectal surgery or frequency of rectal cancer resection by the surgeon are independent prognostic factors for local recurrence (LR) and survival. Variation in patient outcome in rectal cancer has been shown among centers and among individual surgeons. However, the prognostic importance of surgeon-related factors is largely unknown. All patients undergoing potentially curative low anterior resection or abdominoperineal resection for primary adenocarcinoma of the rectum between 1983 and 1990 at the five Edmonton general hospitals were reviewed in a historic-prospective study design. Preoperative, intraoperative, pathologic, adjuvant therapy, and outcome variables were obtained. Outcomes of interest included LR and disease-specific survival (DSS). To determine survival rates and to control both confounding and interaction, multivariate analysis was performed using Cox proportional hazards regression. The study included 683 patients involving 52 surgeons, with > 5-year follow-up obtained on 663 (97%) patients. There were five colorectal-trained surgeons who performed 109 (16%) of the operations. Independent of surgeon training, 323 operations (47%) were done by surgeons performing < 21 rectal cancer resections over the study period. Multivariate analysis showed that the risk of LR was increased in patients of both noncolorectal trained surgeons (hazard ratio (HR) = 2.5, p = 0.001) and those of surgeons performing < 21 resections (HR = 1.8, p < 0.001). Stage (p < 0.001), use of adjuvant therapy (p = 0.002), rectal perforation or tumor spill (p < 0.001), and vascular/neural invasion (p = 0.002) also were significant prognostic factors for LR. Similarly, decreased disease-specific survival was found to be independently associated with noncolorectal-trained surgeons (HR = 1.5, p = 0.03) and surgeons performing < 21 resections (HR = 1.4, p = 0.005). Stage (p < 0.001), grade (p = 0.02), age (p = 0.02), rectal perforation or tumor spill (p < 0.001), and vascular or neural invasion (p < 0.001) were other significant prognostic factors for DSS. Outcome is improved with both colorectal surgical subspecialty training and a higher frequency of rectal cancer surgery. Therefore, the surgical treatment of rectal cancer patients should rely exclusively on surgeons with such training or surgeons with more experience.