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.

Transanal total mesorectal excision achieves equivalent oncologic resection compared to laparoscopic approach, but with functional consequences

BACKGROUND

This study compared transanal total mesorectal excision (taTME) to laparoscopic total mesorectal excision (laTME) for the treatment of low rectal cancer. Adequacy of oncologic resection as well as postoperative outcomes were analyzed.

METHODS

We retrospectively reviewed all proctectomy for low rectal cancer by a single surgeon at our institution from January 2014 to September 2019.

RESULTS

There were 20 taTME and 30 laTME patients. TaTME patients had more distal tumors with no difference in pathologic resection margins or frequency of positive distal margin. Operative times were longer for taTME, but there were no differences in short-term outcomes or complications. TaTME patients had a higher rate of postoperative fecal incontinence.

CONCLUSION

TaTME may be a good option for the most distal tumors, when distal margins may be compromised. TaTME provides equivalent oncologic resection, but there is a higher incidence of postoperative fecal incontinence.

Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes: The ACOSOG Z6051 Randomized Clinical Trial

IMPORTANCE

Evidence about the efficacy of laparoscopic resection of rectal cancer is incomplete, particularly for patients with more advanced-stage disease.

OBJECTIVE

To determine whether laparoscopic resection is noninferior to open resection, as determined by gross pathologic and histologic evaluation of the resected proctectomy specimen.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter, balanced, noninferiority, randomized trial enrolled patients between October 2008 and September 2013. The trial was conducted by credentialed surgeons from 35 institutions in the United States and Canada. A total of 486 patients with clinical stage II or III rectal cancer within 12 cm of the anal verge were randomized after completion of neoadjuvant therapy to laparoscopic or open resection.

INTERVENTIONS

Standard laparoscopic and open approaches were performed by the credentialed surgeons.

MAIN OUTCOMES AND MEASURES

The primary outcome assessing efficacy was a composite of circumferential radial margin greater than 1 mm, distal margin without tumor, and completeness of total mesorectal excision. A 6% noninferiority margin was chosen according to clinical relevance estimation.

RESULTS

Two hundred forty patients with laparoscopic resection and 222 with open resection were evaluable for analysis of the 486 enrolled. Successful resection occurred in 81.7% of laparoscopic resection cases (95% CI, 76.8%-86.6%) and 86.9% of open resection cases (95% CI, 82.5%-91.4%) and did not support noninferiority (difference, -5.3%; 1-sided 95% CI, -10.8% to ∞; P for noninferiority = .41). Patients underwent low anterior resection (76.7%) or abdominoperineal resection (23.3%). Conversion to open resection occurred in 11.3% of patients. Operative time was significantly longer for laparoscopic resection (mean, 266.2 vs 220.6 minutes; mean difference, 45.5 minutes; 95% CI, 27.7-63.4; P < .001). Length of stay (7.3 vs 7.0 days; mean difference, 0.3 days; 95% CI, -0.6 to 1.1), readmission within 30 days (3.3% vs 4.1%; difference, -0.7%; 95% CI, -4.2% to 2.7%), and severe complications (22.5% vs 22.1%; difference, 0.4%; 95% CI, -4.2% to 2.7%) did not differ significantly. Quality of the total mesorectal excision specimen in 462 operated and analyzed surgeries was complete (77%) and nearly complete (16.5%) in 93.5% of the cases. Negative circumferential radial margin was observed in 90% of the overall group (87.9% laparoscopic resection and 92.3% open resection; P = .11). Distal margin result was negative in more than 98% of patients irrespective of type of surgery (P = .91).

CONCLUSIONS AND RELEVANCE

Among patients with stage II or III rectal cancer, the use of laparoscopic resection compared with open resection failed to meet the criterion for noninferiority for pathologic outcomes. Pending clinical oncologic outcomes, the findings do not support the use of laparoscopic resection in these patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00726622.

Acute ischemic proctitis: report of four cases

Acute ischemic proctitis is an extremely rare clinical entity. It is mainly described in patients with significant atherosclerotic and cardiac risk factors who present with lower gastrointestinal symptoms in the setting of hemodynamic instability. Previous reports of ischemic proctitis suggest that rectal resection is not necessary in the treatment of this disease. We present four cases of acute ischemic proctitis that required complete proctectomy. All patients had large vessel atherosclerosis with rectal bleeding and sepsis as the presenting signs and symptoms. Three of four patients underwent complete proctectomy as the initial procedure. The fourth patient underwent complete proctectomy five days after the initial intervention. Two of four patients survived and were ultimately discharged from the hospital. A third patient recovered from surgery but ultimately died of respiratory complications. Only the patient who was initially treated by subtotal proctectomy died as the result of the disease. Although ischemic necrosis of the rectum is rare, complete proctectomy may be necessary to save the patient's life.

Removal of a large spherical foreign object from the rectum using an obstetric vacuum device: a case report

Reports of retained rectal foreign bodies are increasingly common worldwide. It is likely that any surgeon practicing at a major medical center will encounter this type of case, and thus, should be familiar with both surgical and nonsurgical management options. The diagnosis is usually easy to confirm with a thorough history and physical exam and plain abdominal films. Low-lying objects can usually be extracted in the emergency room transanally, whereas high-lying foreign bodies may require anesthesia and laparotomy. We report an experience using an obstetric vacuum device to extract a high-lying foreign body from the rectum.

Removal of a Large Spherical Foreign Object from the Rectum Using an Obstetric Vacuum Device: A Case Report

Reports of retained rectal foreign bodies are increasingly common worldwide. It is likely that any surgeon practicing at a major medical center will encounter this type of case, and thus, should be familiar with both surgical and nonsurgical management options. The diagnosis is usually easy to confirm with a thorough history and physical exam and plain abdominal films. Low-lying objects can usually be extracted in the emergency room transanally, whereas high-lying foreign bodies may require anesthesia and laparotomy. We report an experience using an obstetric vacuum device to extract a high-lying foreign body from the rectum.

Ileosalpingeal fistula: an unusual complication of Crohn's disease

Enterosalpingeal fistula is a rare complication of Crohn's disease that is rarely diagnosed pre-operatively. We describe two cases of enterosalpingeal fistula. Both cases were diagnosed during exploration and required en bloc resection of the small bowel and fallopian tube. Literature review yielded only one specific case report of ileosalpingeal fistula and two other cases described in a larger series. Management of ileosalpingeal fistula should include resection of the diseased bowel as well as removal of the affected fallopian tube. Crohn's disease has an extremely wide spectrum of clinical manifestations. The hallmark of Crohn's disease is bowel inflammation with fistula or stricture formation. Organs commonly involved in fistula formation include the skin, small bowel, colon, and bladder. Rare fistula sites include the duodenum, stomach and gynecological structures such as the ovaries, fallopian tubes and vagina. We present two cases of Crohn's disease of the terminal ileum fistulizing to the fallopian tube. There is only one specific report of an ileosalpingeal fistula, although another author has described two additional cases in a large series of Crohn's fistulas.