Operative Experience of Esophageal Surgery among General Surgery Residents in the United States: An Analysis of ACGME Operative Case Logs

INTRODUCTION

Esophageal surgery is an essential component of general surgery training and encompasses several types of cases that are logged by general surgery residents. There is a scarcity of data on the quality and volume of esophageal surgery experience during surgical residency in the United States. We analyzed trends for 9 different esophageal procedure categories logged by residents in the United States, with the aim to identify areas for improvement in training.

METHODS

We conducted a retrospective analysis of operative case logs of all general surgery residents graduating from programs accredited by the ACGME over a fourteen-year period from 2009 to 2023. Data on mean esophageal cases reported by graduates, including mean in each procedure subcategory were retrieved. Cases were categorized as either surgeon chief or surgeon junior for each procedure category. Mann-Kendall trend test was used to obtain tau statistics and p-value for trends in mean operative surgical volume for the total number of cases in each operative category over the study period. Trends in surgeon chief and surgeon junior cases were also investigated for each operative category.

RESULTS

The mean number of all esophageal procedures performed per resident during their training increased significantly from 10.5 in 2009 to 16 in 2022 (τ = 0.833, p < 0.001). This trend observed among all esophageal procedures during this 14-year study can be largely attributed to the steady increase in the number and proportion of laparoscopic esophageal antireflux procedures performed (τ = 0.950, p < 0.001). Additionally, esophagectomy procedures had a statistically significant, but modest, increase during the study period (τ = 0.505, p = 0.023), from a mean of 1 case during training in 2009 to a peak of 1.3 in 2020. Although the general trend of esophagus procedures increased during the study period, most categories (7 out of 9) either decreased or did not significantly change. Esophagogastrectomy volume decreased significantly by 30%, from 1 per resident during their training in 2009 to 0.7 in 2022 (τ = -0.510, p = 0.018), esophageal diverticulectomy procedures decreased by 50% from 0.2 to 0.1 (τ = -0.609, p = 0.009), and operations for esophageal stenosis decreased by 75% from 0.4 to 0.1 (τ = -0.734, p = 0.001). Mean number of esophageal bypasses (τ = -0.128, p = 0.584), repair of perforated esophageal disease (τ = -0.333, p = 0.156), and other major esophagus procedures (τ = 0.416, p = 0.063) did not significantly change.

CONCLUSION

The operative volume of esophageal surgery that general surgery residents in the United States are exposed to has significantly risen over the past 14 years, largely driven by the increase in laparoscopic antireflux procedures. However, given the recent advances and the resultant heterogeneity in both esophageal surgery, the increase in resident operative volume is still inadequate to ensure the training of safe and adept esophageal surgeons, necessitating postresidency specialized training for trainees interested in esophageal surgery.

Can my surgeon scope? Trends in endoscopy training volume and experience among general surgery residents in the United States: a nationwide analysis

INTRODUCTION

Endoscopy is a major part of surgical training. Accreditation Council for Graduate Medical Education (ACGME) has set standards regarding the minimum volume of endoscopy cases required for graduation. However, there is paucity of high-quality data on the number of cases that most surgical graduates perform.

METHODS

We conducted a retrospective analysis of operative case logs of all general surgery residents graduating from ACGME-accredited programs from 2010 to 2023. Data on mean number of endoscopy cases, including mean in each subcategory, were retrieved. Mann-Kendall trend test was used to investigate trends in endoscopy experience.

RESULTS

Between 2010 and 2023, the mean overall endoscopy procedures per resident remained stable, with 129.5 in 2010 and 132.1 in 2023 (t = 0.429; p-value = 0.037). The majority of these cases were performed as surgeon junior (76.6% in 2010; 80.9% in 2023), while the remaining cases were logged as surgeon chief. The most substantial contribution to the overall volume was from flexible colonoscopy (mean: 64.1 in 2010 and 67.2 in 2023). The volume for colonoscopy remained fairly stable (t = 0.429; p-value = 0.036). This was followed by esophagogastroduodenoscopy (mean: 35.3 in 2010 and 35.5 in 2023), which saw a significant increase in volume (t = 0.890; p-value ≤ 0.001). There was a significant increase in the number of overall upper endoscopic procedures (t = 0.791; p-value ≤ 0.001), while lower endoscopic procedures did not change significantly (t = 0.319; p-value = 0.125). The procedural volume for endoscopic retrograde cholangiography, sigmoidoscopy, cystoscopy/ureteroscopy, laryngoscopy, and bronchoscopy decreased significantly (p-value < 0.05 for all).

CONCLUSION

The overall endoscopy volume for general surgery residents has largely remained stable, with a minor increase in esophagogastroduodenoscopy and no change in colonoscopy. Future research should investigate whether simulation-based exercises can bridge the gap between procedural volume and learning curve requirements for endoscopy.