Characteristics of pathologic complete response for locally advanced rectal cancer

BACKGROUND

Neoadjuvant chemoradiation (NACRT) is the standard of care for locally advanced rectal cancers. The purpose of this study was to determine patient and tumor factors associated with a pathologic complete response (pCR).

METHODS

The National Surgical Quality Improvement Program proctectomy-targeted database was utilized to identify all patients from 2016 to 2020 who underwent NACRT followed by proctectomy with curative intent for T3-4N0-2 rectal cancers.

RESULTS

A total of 1891 patients were included, of which 253 (13.4%) demonstrated a pCR. Pretreatment N0 staging was associated with a higher rate of pCR (18.9%) when compared to N1 (6.7%) and N2 (6.7%) (p < 0.0001). Patients clinically staged at T3N0 had the highest rate of pCR (19.5%). Gender, age, race, weight, smoking status, and tumor height were not associated with pCR.

CONCLUSIONS

Patients with cN0 disease were more likely to experience a pCR compared to cN1-2 patients. Tumor height relative to anal verge or patient demographics were not associated with pCR.

Virtual interviews for resident and fellow recruitment

Since 2020, all general surgery residency interviews have been mandatorily virtual, elevating the importance of social media and online reputation management for applicants and residency programs. This article highlights how virtual interviews changed the way programs and applicants engage each other online, including some pros and cons of these new interactions.

Evaluation and Medical Management of Uncomplicated Diverticulitis

Uncomplicated diverticulitis is common, and its evaluation and treatment have evolved over time. Most patients present in a nontoxic manner with localized pain, leukocytosis, and reliable findings on computed tomography (CT). Healthy and stable patients are typically treated in the outpatient setting with very high rates of success. Recently, the necessity of antibiotic therapy has come into question, and several alternative agents have emerged, with the jury still out on their relative roles in diverticular disease. Currently, colonoscopy is still recommended after the resolution of an index episode of uncomplicated diverticulitis, and recurrence rates remain low. Several diet and lifestyle modifications have been shown to impact the rates of diverticulitis recurrence.

Less is more: creation and validation of a novel, affordable suturing simulator for anorectal surgery

BACKGROUND

Duty hour restrictions have increased the role of simulation in surgical education. A simulation that recreates the unique visual, anatomic, and ergonomic challenges of anorectal surgery has yet to be described. The aim of this study was to develop a low-cost, low-fidelity anorectal surgery simulator and provide validity evidence for the model.

METHODS

A novel, low-fidelity simulator was constructed, and anorectal surgery workshops were implemented for general surgery interns at a single institution. Face and content validity were assessed with separate questionnaires using a 5-point Likert scale. Participants performed a simulated hemorrhoid excision with longitudinal wound closure, and transverse wound closure. Time-to-task completion and quality of suturing/knot tying were evaluated by a blinded observer to assess construct validity.

RESULTS

Material cost was US $11 per simulator. We recruited 20 first-year surgery residents (novices) and 4 practicing colorectal surgeons (experts), and conducted 3 workshops in 2014-2016. All face and content validity measures achieved a median score greater than 4 (range 4.0-5.0). Time-to-task completion was significantly lower in the expert cohort (hemorrhoid excision with longitudinal wound closure: 195 vs. 477 s and transverse closure: 79 vs. 192 s, p < 0.001 for both). Suturing and knot-tying scores were significantly higher in the expert cohort for both tasks (p < 0.05 for all comparisons).

CONCLUSIONS

Our low-fidelity, low-cost anorectal surgery model demonstrated evidence of face, content, and construct validity. We believe that this simulator could be a useful instrument in the education of junior surgical trainees and will allow residents to obtain proficiency in anorectal suturing tasks in conjunction with traditional surgical training.

Multidisciplinary Approach to the Management and Treatment of Anal Dysplasia

The incidence of anal intraepithelial neoplasia (AIN) has been increasing over the years. AIN acts as a precursor lesion for anal squamous cell cancer. Factors leading to progression of AIN into malignancy are complex and involve grade of the lesion, human papillomavirus and HIV coinfection, as well as patient-related risk factors such as immunocompromised state and men who have sex with men. The multifaced aspects of this disease make its management challenging, as it involves several disciplines including pathology, primary care, infectious disease, and colorectal specialties. Each of these fields brings its own expertize to the management of AIN, and their collaborative, coordinated work culminates into best practice and optimized outcomes in the care of the AIN patient.

Predictors of adequate lymph node harvest during colectomy for colon cancer

BACKGROUND

Consensus guidelines recommend a yield of 12 lymph nodes in resections for colon cancer. Factors affecting this yield are not well defined.

METHODS

Retrospective study using the colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program for years 2014-2016. Primary outcome was resection of at least 12 nodes. Univariate and multivariate analyses determined factors associated with ≥12 LN yield.

RESULTS

17,612 colectomies for colon cancer were extracted from the NSQIP database. 7.26% of cases did not reach a 12 LN harvest. Harvesting ≥12 LN was 74% more likely (p = 0.001) if the resection was laparoscopic and 72% more likely (p < 0.0001) if hand-assisted. Advanced T and N stage had a higher likelihood of reaching 12 LN harvest. Older age, female gender and smoking history decreased the likelihood of ≥12 LN harvest.

CONCLUSIONS

Laparoscopic and robotic colectomies were 1.5-2.5 times more likely to achieve adequate LN harvest compared to open surgery. Several non-modifiable patient and disease related factors may render adequate LN yield challenging.

How Can Social Media Get Us in Trouble?

When utilized properly, social media offers several personal and professional benefits for the practicing surgeon, including peer networking, education, e-mentorship, marketing, recruitment, and patient outreach. However, unprofessional online behavior is common among surgeons, and this improper use of social media can be quite dangerous. This article reviews the dangers of social media and illustrates this with examples of unprofessional behavior and the associated consequences. It also provides recommendations for maintaining a professional and productive online persona. Surgeons must understand the various social media platforms and their target audience while upholding online professionalism at all times.

Imaging for Colorectal Cancer

A comprehensive approach to colorectal cancer includes thorough radiologic imaging, which allows appropriate initial staging of the disease, as well as subsequent surveillance for disease recurrence. Several imaging modalities are used with different associated advantages and disadvantages, which are outlined in this article with specific attention paid to the local staging of rectal cancer.

Balancing Privacy and Professionalism: A Survey of General Surgery Program Directors on Social Media and Surgical Education

PURPOSE

Unprofessional behavior is common among surgical residents and faculty surgeons on Facebook. Usage of social media outlets such as Facebook and Twitter is growing at exponential rates, so it is imperative that surgery program directors (PDs) focus on professionalism within social media, and develop guidelines for their trainees and surgical colleagues. Our study focuses on the surgery PDs current approach to online professionalism within surgical education.

METHODS

An online survey of general surgery PDs was conducted in October 2015 through the Association for Program Directors in Surgery listserv. Baseline PD demographics, usage and approach to popular social media outlets, existing institutional policies, and formal curricula were assessed.

RESULTS

A total of 110 PDs responded to the survey (110/259, 42.5% response rate). Social media usage was high among PDs (Facebook 68% and Twitter 40%). PDs frequently viewed the social media profiles of students, residents, and faculty. Overall, 11% of PDs reported lowering the rank or completely removing a residency applicant from the rank order list because of online behavior, and 10% reported formal disciplinary action against a surgical resident because of online behavior. Overall, 68% of respondents agreed that online professionalism is important, and that residents should receive instruction on the safe use of social media. However, most programs did not have formal didactics or known institutional policies in place.

CONCLUSIONS

Use of social media is high among PDs, and they often view the online behavior of residency applicants, surgical residents, and faculty surgeons. Within surgical education, there needs to be an increased focus on institutional policies and standardized curricula to help educate physicians on social media and online professionalism.

Transanal endoscopic microsurgery and transanal minimally invasive surgery: is one technique superior?

BACKGROUND

Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) have been shown to improve the quality of transanal resections, allowing for improved visibility and access to the proximal rectum. This study compares the short-term outcomes between TEM and TAMIS among experienced colorectal surgeons.

METHOD

A retrospective review was conducted for TEM and TAMIS performed from 2012 to 2015 by local colorectal surgeons. Baseline patient demographics, operative variables, pathology results, and short-term outcomes were assessed.

RESULTS

Sixty-nine patients were identified (40 TEM and 29 TAMIS). Patient demographics, tumor characteristics, operative variables, margin status, and postoperative complications were similar for both. Volume of resection was higher for TAMIS (P < .001). Lymph node retrieval was achieved in 17.2% of TAMIS cases compared with 0% of TEM (P = .01).

CONCLUSIONS

TAMIS appears to have equivalent indications and outcomes compared with TEM. TAMIS is associated with larger specimens and more frequent presence of mesorectal lymph nodes.

The Glass Houses of Attending Surgeons: An Assessment of Unprofessional Behavior on Facebook Among Practicing Surgeons

PURPOSE

Our recent publication demonstrated that unprofessional behavior on Facebook is common among surgical residents. In the formulation of standards and curricula to address this issue, it is important that surgical faculty lead by example. Our current study refocuses on the Facebook profiles of faculty surgeons involved in the education of general surgery residents.

METHODS

The American College of Surgeons (ACS) web site was used to identify general surgery residencies located in the Midwest. Departmental web sites were then searched to identify teaching faculty for the general surgery residency. Facebook was then searched to determine which faculty had profiles available for viewing by the general public. Profiles were then placed in 1 of the 3 following categories: professional, potentially unprofessional, or clearly unprofessional.

STATISTICAL ANALYSIS

A chi-square test was used to determine significance.

RESULTS

In all, 57 residency programs were identified on the ACS web site, 100% of which provided an institutional web site listing the surgical faculty. A total of 758 general surgery faculty were identified (133 women and 625 men), of which 195 (25.7%) had identifiable Facebook accounts. In all, 165 faculty (84.6%) had no unprofessional content, 20 (10.3%) had potentially unprofessional content, and 10 (5.1%) had clearly unprofessional content. Inter-rater reliability was good (88.9% agreement, κ = 0.784). Clearly unprofessional behavior was found only in male surgeons. For male surgeons, clearly unprofessional behavior was more common among those in practice for less than 5 years (p = 0.031). Alcohol and politics were the most commonly found variables in the potentially unprofessional group. Inappropriate language and sexually suggestive material were the most commonly found variables in the clearly unprofessional group.

CONCLUSIONS

Unprofessional behavior on Facebook is less common among surgical faculty compared with surgical residents. However, the rates remain unacceptably high, especially among men and those in practice for less than 5 years. Education on the dangers of social media should not be limited to residents but should instead be extended to attending surgeons as well.

An assessment of unprofessional behavior among surgical residents on Facebook: a warning of the dangers of social media

PURPOSE

Dismissal from residency is most commonly because of unprofessional conduct rather than cognitive failure. Disciplinary action by medical boards has also been associated with prior unprofessional behavior during medical school. Facebook is a social media network that has become ubiquitous in recent years and has the potential to offer an unvarnished view into the lives of residents using a public forum that is open to the public and program directors alike. The aim of this study was to evaluate the publically available Facebook profiles of surgical residents to determine the incidence and degree of unprofessional conduct.

METHODS

The American College of Surgeons Web site was used to identify general surgery residencies located in the Midwest. Resident rosters were then obtained using departmental Web sites. Facebook was then searched to determine which residents had profiles available for viewing by the public. The Accreditation Council for Graduate Medical Education's components of professionalism and the American Medical Association's report on professionalism in the use of social media were used to develop the following 3 categories: professional, potentially unprofessional, or clearly unprofessional.

STATISTICAL ANALYSIS

The chi-square test was used to determine significance.

RESULTS

A total of 57 residency programs were identified on the American College of Surgeons Web site, of which 40 (70.2%) provided an institutional Web site with a current resident roster. A total of 996 surgical residents were identified, of which 319 (32%) had identifiable Facebook profiles. Overall, 235 residents (73.7%) had no unprofessional content, 45 (14.1%) had potentially unprofessional content, and 39 (12.2%) had clearly unprofessional content. Binge drinking, sexually suggestive photos, and Health Insurance Portability and Accountability Act violations were the most commonly found variables in the clearly unprofessional group. There were no statistical differences in professionalism based on sex (p = 0.93) or postgraduate year status (p = 0.88).

CONCLUSIONS

Unprofessional behavior is prevalent among surgical residents who use Facebook, and this behavior does not appear to decrease as residents progress through training. This represents a risk to the reputations of hospitals and residency programs, and residents should be educated on the dangers of social media. Although it may be perceived as an invasion of privacy, this information is publically available, and program directors may benefit from monitoring these sites to identify gaps in professionalism that require correction.

Do strong resident teachers help medical students on objective examinations of knowledge?

BACKGROUND

Despite a lack of formal training, surgical residents at our institution have an integral role instructing medical students on their general surgery clerkship. It is unknown how the instruction provided by surgical residents affects the students' testable knowledge base and performance on standardized surgical examinations. The purpose of this survey study was to evaluate the impact of surgical resident teachers on medical student performance on the National Board of Medical Examiners surgery shelf examination.

STUDY DESIGN

Surveys were provided to all third-year medical students completing an 8-week clerkship in general surgery. Students were asked to rate the quality and quantity of instruction received from surgical residents. Resident instruction was evaluated in several categories using a 5-point Likert scale. Analyses were conducted to evaluate the impact of survey responses on student percentile scores on the surgery shelf examination.

RESULTS

Seventy-five of 110 (67.3%) students completed the surveys over a period of 22 months. Forty-two individual residents were evaluated in several categories, and an overall teaching evaluation was completed. The mean shelf percentile score by the medical students was 48.1 ± 31.4 (range, 1st to 98th percentile). Using univariate analyses, no individual resident factors or overall factors had a significant effect on student performance. A regression analysis revealed that overall quality of instruction had a significantly positive impact on student performance (p = 0.038). Individual residents and increasing PGY level had a significantly negative impact on the students' shelf performance (p < 0.001). The model R(2) showed our model to predict only 13.8% of the student's examination score variability.

CONCLUSIONS

A statistically significant relationship exists between student performance on the shelf examination and their perception of the overall quality of instruction that they receive from surgical residents. However, this seems to account only for a small portion of the variability in student percentile scores.