Faculty Bibliography

BACKGROUND:Robotic surgery for colorectal cancer offers many potential benefits, but as with any new technology, there is a learning curve. OBJECTIVE:We sought to identify trends in the uptake of robotic resection and associated complication rates. DESIGN:This was a case sequence analysis of robotic surgery for colorectal cancer. SETTINGS:The study was conducted using the New York Statewide Planning and Research Cooperation System database. PATIENTS:Adults undergoing colorectal resection for cancer from 2008 through 2016 were identified in the New York Statewide Planning and Research Cooperative database. Case sequence analysis was used to describe surgeon experience, with cases grouped into quartiles based on the chronological order in which each surgeon performed them. MAIN OUTCOME MEASURES:Outcomes included in-hospital major events (myocardial infarction, pulmonary embolism, shock, and death) and iatrogenic complications. Generalized linear mixed models were used to estimate the relationship between case sequence and operative outcomes. RESULTS:A total of 2763 robotic procedures were included, with volume increasing from 76 cases in 2010 to 702 cases in 2015. The proportion of cases performed by surgeons earliest in their learning curve has increased to 18.2% in 2015. This quartile was composed of more black patients (11.4% earliest quartile vs 7.0% latest quartile; p < 0.001) and rectal resections (50.1% earliest quartile vs 38.9% latest quartile; p < 0.001). In adjusted analysis, major complications did not improve with increasing case sequence. However, with increasing cumulative surgeon case sequence iatrogenic complications were reduced, particularly in the highest volume quartile (OR = 0.29 (95% CI, 0.09-0.88); p = 0.03). Odds of prolonged length of stay (>75 percentile) were also decreased (OR = 0.50 (95% CI, 0.37-0.69); p < 0.001). LIMITATIONS:Data were derived from an administrative database. CONCLUSIONS:Robotic colorectal resection has been rapidly adopted. Surgeons earliest in their experience have increased iatrogenic complications and continue to make up a large proportion of cases performed. See Video Abstract at http://links.lww.com/DCR/A974. ANÁLISIS DE SECUENCIA DE CASOS DE LA CURVA DE APRENDIZAJE DE RESECCIÓN ROBÓTICA COLORRECTAL: La cirugía robótica para el cáncer colorrectal ofrece muchos beneficios potenciales, pero como con cualquier nueva tecnología, presenta una importante curva de aprendizaje. OBJETIVO:Se buscó identificar tendencias en la aceptación de la resección robótica y las tasas de complicaciones asociadas. DISEÑO:: Análisis de secuencia de casos de cirugía robótica para cáncer colorrectal AJUSTES:: Base de datos del Sistema de Cooperación para la Investigación y la Planificación del Estado de Nueva York. PACIENTES:Los adultos que se sometieron a una resección colorrectal en caso de cáncer desde 2008 hasta 2016 se identificaron en la base de datos de la Cooperativa de Investigación y Planificación del Estado de Nueva York. Se utilizó un análisis de secuencia de casos para describir la experiencia del cirujano, y los casos se agruparon en cuartiles según el orden cronológico en el que cada cirujano los operó. RESULTADOS PRINCIPALES:Los resultados incluyeron los eventos intrahospitalarios mayores (infarto de miocardio, embolia pulmonar, shock y muerte) y las complicaciones iatrogénicas. Se utilizaron modelos lineales generalizados mixtos para estimar la relación entre la secuencia de casos y los resultados operativos. RESULTADOS:Se incluyeron un total de 2.763 procedimientos robóticos, con un aumento del volumen de 76 casos en 2010 a 702 casos en 2015. La proporción de casos realizados por cirujanos en su primera curva de aprendizaje aumentó a 18.2% en 2015. Este cuartil estaba compuesto por una mayoría de pacientes de color (11.4% en el cuartil más temprano versus 7.0% en el último cuartil, p < 0.001) y de resecciones rectales (50.1% en el primer cuartil vs 38.9% en el último cuartil, p < 0.001). En el ajuste del análisis, las complicaciones mayores no mejoraron al aumentar la secuencia de casos. Sin embargo, al aumentar la secuencia acumulada de casos de cirujanos, se redujeron las complicaciones iatrogénicas, particularmente en el cuartil de mayor volumen (OR = 0,29; IC del 95%: 0,09 a 0,88; p = 0,03). Las probabilidades de una estadía hospitalaria prolongada (> percentil 75) también disminuyeron (OR 0,50; IC del 95%: 0,37 a 0,69; p < 0,001). LIMITACIONES:Los valores fueron derivados desde una base de datos administrativa. CONCLUSIONES:La resección colorrectal robótica ha sido adoptada rápidamente. Los cirujanos durante su experiencia inicial han presentado un elevado número de complicaciones iatrogénicas y éstas representan todavía, una gran proporción de casos realizados. Vea el Resumen del Video en http://links.lww.com/DCR/A974.

OBJECTIVE:To describe public willingness to participate in regionalized surgical care for cancer. SUMMARY OF BACKGROUND DATA:Improved outcomes at high-volume centers following complex surgery have driven a push to regionalize surgical care. Patient attitudes toward regionalization are not well described. METHODS:As part of the Cornell National Social Survey, a cross-sectional telephone survey was performed. Participants were asked about their willingness to seek regionalized care in a hypothetical scenario requiring surgery. Their responses were compared with demographic characteristics. A geospatial analysis of hospital proximity was performed, as well as a qualitative analysis of barriers to regionalization. RESULTS:Cooperation rate was 48.1% with 1000 total respondents. They were an average of 50 years old (range 18 to 100 years) and 48.9% female. About 49.6% were unwilling to travel 5 hours or more to seek regionalized care for improved survival. Age >70 years [odds ratio (OR) 0.34, 95% confidence interval (95% CI) 0.19-0.60] and perceived distance to a center >30 minutes (OR 0.60, 95% CI 0.41-0.86) were associated with decreased willingness to seek regionalized care, while high income (OR 2.09, 95% CI 1.39-3.16) was associated with increased willingness. Proximity to a major center was not associated with willingness to travel (OR 0.92, 95% CI 0.67-1.22). Major perceived barriers to regionalization were transportation, life disruption, social support, socioeconomic resources, poor health, and remoteness. CONCLUSION:Americans are divided on whether the potential for improved survival with regionalization is worth the additional travel effort. Older age and lower income are associated with reduced willingness to seek regionalized care. Multiple barriers to regionalization exist, including a lack of knowledge of the location major centers.

BACKGROUND:Medical school experience informs the decision to pursue graduate surgical education. However, it is possible that inadequate preparation in medical school is responsible for the high rate of attrition seen in general surgery residency. MATERIALS AND METHODS:We performed a national prospective cohort study of all categorical general surgery interns who entered training in the 2007-2008 academic year. Interns answered questions about their medical school experience and reasons for pursuing general surgery residency. Responses were linked with American Board of Surgery residency completion data. Multivariable logistic regression was used to evaluate the association between medical school experiences and residency attrition. RESULTS:Seven hundred and ninety-two surgery interns participated, and the overall attrition rate was 19.3%. Most interns had performed ≤8 wk of third year surgery clerkships (53.2% of those who completed versus 49.7% of those who dropped out, P = 0.08). After multivariable adjustment, shorter duration of third year rotations was protective from attrition (OR: 0.53, 95% CI: 0.29-0.99; P = 0.05). There was no difference in attrition based on whether a surgical subinternship was performed (OR: 0.67, 95% CI: 0.38-1.19; P = 0.18). Residents who perceived that their medical school surgical faculty were happy with their careers were less likely to experience attrition (OR: 0.57, 95% CI: 0.34-0.96; P = 0.03), but those who had gotten along well with attending surgeons had higher odds of attrition (OR: 2.93, 95% CI: 1.34-6.39, P < 0.01). CONCLUSIONS:Increased quality, rather than quantity, of clerkships is associated with improved rates of residency completion. Learner relationships with positive yet demanding role models were associated with a reduced risk of attrition.

BACKGROUND:Racial/ethnic diversity remains poor in academic surgery. However, no study has quantified differences in the rates of retention and promotion of underrepresented minority (URM) academic surgeons. METHODS:The American Association of Medical Colleges Faculty Roster was used to track all first-time assistant and associate professors appointed between 1/1/2003 and 12/31/2006. Primary endpoints were percent promotion and retention at ten-year follow-up. RESULTS:Initially, the majority of assistant and associate professors of surgery were White (62%; 75%). Black assistant professors had lower 10-year promotion rates across all specialties (p < 0.01). There were no race/ethnicity-based differences in promotion for associate professors. Retention rates were higher for White assistant professors than Asian or Black/Hispanic/Other minority faculty (61.3% vs 52.8% vs. 50.8% respectively; p < 0.01). There was no difference in 10-year retention rates among associate professors based on race/ethnicity. CONCLUSIONS:Underrepresented minority surgeons are less likely to remain in academia and Black assistant professors have the lowest rates of promotion. These findings highlight the need to develop institutional programs to better support and develop minority faculty members in academic medicine.

BACKGROUND:There is no consensus on the ideal management of complicated appendicitis. METHODS:The New York State Planning and Research Cooperative database was used to identify all patients admitted with complicated appendicitis and undergoing appendectomy within 1-year. Primary outcome was any complication. Secondary outcomes included length of stay (LOS), hospital charges, and laparoscopy use. Outcomes were compared in appendectomy before or after 48h from admission. RESULTS:31,167 patients ≥18yo were identified for analysis, 28,015(89.9%) underwent early appendectomy. Early appendectomy patients were more likely to be White (69.8% vs. 64.2% p < 0.01), and commercially insured (53.1% vs. 45.4%, p < 0.01). Of the 3152 undergoing delayed surgery, 1610(51.1%) had surgery later during the index admission, 715(22.7%) were readmitted urgently and underwent appendectomy, and 827(26.2%) had elective appendectomy. Patients undergoing delayed surgery had more complications (OR 1.34 95%CI 1.23-1.45), readmissions (OR 1.55 95%CI 1.42-1.70), high hospital charges (OR 4.79 95%CI 4.35-5.27), and prolonged LOS (OR 6.12 95%CI 5.61-6.68). CONCLUSIONS:In this population-level study of complicated appendicitis we found more complications, longer LOS, and higher charges in patients undergoing delayed surgery.

Importance:Attrition from general surgery training is highest during internship. Whether the expectations and attitudes of new trainees affect their subsequent risk of attrition is unknown. Objective:To identify the expectations of general surgery residency associated with attrition from training. Design, Setting, and Participants:This prospective observational cohort study included categorical general surgery interns entering training in the 2007-2008 academic year. Residents were surveyed regarding their expectations of training and of life as an attending at the start of their intern year (June 1 to August 31, 2007). Expectations were grouped into factors by principal component analysis, and a multivariable model was created using these factors in addition to known demographic and program characteristics associated with attrition. Follow-up was completed on December 31, 2016. Main Outcomes and Measures:Attrition from training was determined by linkage to American Board of Surgery resident files through 2016, allowing 8 additional years of follow-up. Results:Of 1048 categorical surgery interns in the study period, 870 took the survey (83.0% response rate), and 828 had complete information available for analysis (524 men [63.3%], 303 women [36.6%], and 1 missing information [0.1%]). Most were white (569 [69.1%]) and at academic programs (500 [60.4%]). Six hundred sixty-six residents (80.4%) completed training. Principal component analysis generated 6 factors. On adjusted analysis, 2 factors were associated with attrition. Interns who choose their residency based on program reputation (factor 2) were more likely to drop out (odds ratio, 1.08; 95% CI, 1.01-1.15). Interns who expected as an attending to work more than 80 hours per week, to have a stressful life, and to be the subject of malpractice litigation (career life expectation [factor 6]) were less likely to drop out (odds ratio, 0.90; 95% CI, 0.82-0.98). Conclusions and Relevance:Interns with realistic expectations of the demands of residency and life as an attending may be more likely to complete training. Medical students and residents entering training should be given clear guidance in what to expect as a surgery resident.

BACKGROUND:The American Board of Surgery In-Training Exam is administered annually to general surgery residents and could provide a way to predict attrition, potentially offering a point of intervention. METHODS:In 2007, a national survey of categorical general surgery interns was performed. Resident characteristics were linked to an American Board of Surgery database of American Board of Surgery In-Training Exam scores. Attrition was determined based on completion of training during eight years of follow-up. To identify residents at risk of attrition, American Board of Surgery In-Training Exam scores were analyzed based on average rank and change in American Board of Surgery In-Training Exam score. RESULTS:Of 1,048 residents, 739 (70.5%) participated and 108 (14.6%) did not complete training. Average American Board of Surgery In-Training Exam rank was higher for participants who completed training than those who did not (51.8 vs. 42.7 percentile respectively, P < .001). Ranking below the 25th percentile was less common among those who dropped out (41.7% ranked below 25th percentile and dropped out versus 51.5% ranked below 25th percentile and completed, P = .06), but those whose rank dropped >16.5 percentile points were more likely to leave training (attrition rate 13.0% with a drop versus 6.0% without a drop, P = .003). In adjusted analysis, a one percentile increase in American Board of Surgery In-Training Exam rank was associated with decreased odds of attrition (OR 0.98, P < .01). CONCLUSION:Lower American Board of Surgery In-Training Exam scores are associated with attrition, but this difference is small, and some residents complete training with very low scores. A large drop in American Board of Surgery In-Training Exam scores from one year to the next appears to be associated with attrition. Program directors should focus their efforts on these at-risk residents.

Importance:Attrition in general surgery residency remains high, and attrition that occurs in the later years is the most worrisome. Although several studies have retrospectively investigated the timing of attrition, no study to date has prospectively evaluated a national cohort of residents to understand which residents are at risk for attrition and at what point during residency. Objective:To prospectively evaluate individual resident and programmatic factors associated with the timing of attrition during general surgery residency. Design, Setting, and Participants:This longitudinal, national cohort study administered a survey to all categorical general surgery interns from the class of 2007-2008 during their first 30 days of residency and linked the data with 9-year follow-up data assessing program completion. Data were collected from June 1, 2007, through June 30, 2016. Main Outcomes and Measures:Kaplan-Meier curves evaluating time to attrition during the 9 years after the start of residency. Results:Among our sample of 836 residents (306 women [36.6%] and 528 men [63.2%]; gender unknown in 2), cumulative survival analysis demonstrated overall attrition for the cohort of 20.8% (n = 164). Attrition was highest in the first postgraduate year (67.6% [n = 111]; absolute rate, 13.3%) but continued during the next 6 years, albeit at a lower rate. Beginning in the first year, survival analysis demonstrated higher attrition among Hispanic compared with non-Hispanic residents (21.1% vs 12.4%; P = .04) and at military programs compared with academic or community programs after year 1 (32.3% vs 11.0% or 13.5%; P = .01). Beginning in year 4 of residency, higher attrition was encountered among women compared with men (23.3% vs 17.4%; P = .05); at year 5, at large compared with small programs (26.0% vs 18.4%; P = .04). Race and program location were not associated with attrition. Conclusions and Relevance:Although attrition was highest during the internship year, late attrition persists, particularly among women and among residents in large programs. These results provide a framework for timing of interventions in graduate surgical training that target residents most at risk for late attrition.

INTRODUCTION:Hormone replacement therapy has been shown to reduce colorectal cancer incidence, but its effect on colorectal cancer mortality is controversial. The objective of this study was to determine the effect of hormone replacement therapy on survival from colorectal cancer. PATIENTS AND METHODS:We performed a secondary analysis of data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, a large multicenter randomized trial run from 1993 to 2001, with follow-up data recently becoming mature. Participants were women aged 55 to 74 years, without recent colonoscopy. Data from the trial were analyzed to evaluate colorectal cancer incidence, disease-specific mortality, and all-cause mortality based on subjects' use of hormone replacement therapy at the time of randomization: never, current, or former users. RESULTS:A total of 75,587 women with 912 (1.21%) incident colorectal cancers and 239 associated deaths were analyzed, with median follow-up of 11.9 years. Overall, 88.6% were non-Hispanic white, and < 10% had not completed high school. The never-user group was slightly older than the current or former user groups (average, 63.8 vs. 61.4 vs. 63.3 years; P < .001). Almost one-half (47.1%) of the current users had undergone hysterectomy, compared with 21.6% of never-users and 34.0% of former users (P < .001). Adjusted colorectal cancer incidence in current users compared to never-users was lower (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.69-0.94; P = .005), as was death from colorectal cancer (HR, 0.63; 95% CI, 0.47-0.85; P = .002) and all-cause mortality (HR, 0.76; 95% CI, 0.72-0.80; P < .001). CONCLUSIONS:Hormone replacement therapy is associated with a reduced risk of colorectal cancer incidence and improved colorectal cancer-specific survival, as well as all-cause mortality.