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Aim The study was performed to evaluate factors influencing postoperative adverse events after Hartmann’s reversal (HR). Method This was a retrospective study of unselected patients who underwent HR after the Hartmann’s procedure (HP) for left colonic perforation with peritonitis at a single institution. Data were retrieved from an Institutional Review Board-approved database. The study end-point was postoperative adverse events, which included mortality, complications, reoperations and 30-day readmission. Lag time was defined as the time from HP to HR. The results are expressed as mean ± SD. Results From 1997 to 2007, 204 (39.1%) of all patients who underwent the HP [60 ± 16 years of age; 58% men; body mass index (BMI) = 27.6 ± 5.7; 2% were American Society of Anesthesiology (ASA) 1, 50.2% were ASA 2, 39.9% were ASA 3 and 7.9% were ASA 4) underwent HR at an interval of 158 ± 107 days. There were 24 laparoscopic and 180 open HRs, with no deaths. The operating time was 167 ± 64 min, estimated blood loss was 245 ± 283 ml and the 30-day readmission rate was 4.9%. Eleven (5.4%) patients developed 14 (6.8%) complications and five (2.4%) of these patients required a new stoma at the time of HR or later. On multivariate analysis controlling for confounders, chronic renal failure requiring dialysis (OR = 21.0; 95% CI: 1.5–284; P = 0.02) was significantly associated with increased adverse events. Conclusion The study showed that chronic renal failure requiring dialysis was the only independent predictor of postoperative adverse event rates following HR.

Surgical resection remains the standard of care for operable early-stage non-small-cell lung cancer (NSCLC). However, some patients are not fit for surgery because of comorbidites such as chronic obstructive pulmonary disease (COPD) and other medical conditions. We aimed to evaluate pulmonary function and tumor volume before and after stereotactic body radiotherapy (SBRT) for patients with and without COPD in early-stage lung cancer.A review of prospectively collected data of Stage I and II lung cancers, all treated with SBRT, was performed. The total SBRT treatment was 60 Gy administered in three 20 Gy fractions. The patients were analyzed based on their COPD status, using their pretreatment pulmonary function test cutoffs as established by the American Thoracic Society guidelines (forced expiratory volume [FEV]% ≤ 50% predicted, FEV%/forced vital capacity [FVC]% ≤ 70%). Changes in tumor volume were also assessed by computed tomography.Of a total of 30 patients with Stage I and II lung cancer, there were 7 patients in the COPD group (4 men, 3 women), and 23 in t he No-COPD group (9 men, 14 women). At a mean follow-up time of 4 months, for the COPD and No-COPD patients, pretreatment and posttreatment FEV% was similar: 39 ± 5 vs. 40 ± 9 (p = 0.4) and 77 ± 0.5 vs. 73 ± 24 (p = 0.9), respectively. The diffusing capacity of the lungs for carbon monoxide (DL(CO)) did significantly increase for the No-COPD group after SBRT treatment: 60 ± 24 vs. 69 ± 22 (p = 0.022); however, DL(CO) was unchanged for the COPD group: 49 ± 13 vs. 50 ± 14 (p = 0.8). Although pretreatment tumor volume was comparable for both groups, tumor volume significantly shrank in the No-COPD group from 19 ± 24 to 9 ± 16 (p0.001), and there was a trend in the COPD patients from 12 ± 9 to 6 ± 5 (p = 0.06).SBRT did not seem to have an effect on FEV(1) and FVC, but it shrank tumor volume and improved DL(CO) for patients without COPD.

TAVR continues to be associated with variability in hospital outcomes. While some complications may not be preventable, the ability to rapidly diagnose and “rescue” (Failure to Rescue, FTR) a patient from a complication relates to the quality of care of the health care system Patients

Post-operative atrial fibrillation (POAF) is common after cardiac surgery. However, few studies examine the effect on early and late outcomes following thoracic aortic surgery. Patients (n=993) who underwent proximal aortic surgery, without pre-operative atrial fibrillation (n=135), at a single

Aim The study was designed to address the unanswered question of the influence of the extent of rectal mobilization, the type of rectal fixation and the surgical access (open vs laparoscopic) on recurrence rates following abdominal surgery for full-thickness rectal prolapse (FTRP). Method Individual patient data were pooled and data merging was performed following comparison of variable definitions to ensure similarity in definitions. Recurrence after rectopexy was defined as the presence of FTRP on physical examination. The impact of categorical factors on recurrence was assessed using Fisher's exact and the chi-squared tests. Recurrence-free survival curves were generated for patients and differences in time to recurrence were compared using the log rank test. Factors passing univariate screening with a P value

Background There are no evidence based guidelines for the surveillance of patients with moderate-sized (

Introduction: Reported infection rates in breast reconstruction with acellular dermal matrix (ADM) can exceed 31%. Prophylactic antibiotics remain controversial due to the absence of evidence-based literature. The purpose of this study was to examine published antibiotic regimens and their associated infection rates in this population. Methods: Systematic electronic searches were performed in PubMed, OVID, and the Cochrane databases for studies that reported on prophylactic antibiotic use and infection in patients undergoing ADM breast reconstruction. Two independent authors reviewed studies between 1970 and 2012 for inclusion and data extraction. Results: A total of 863 studies were identified and abstracts reviewed. A total of 24 articles were included, with 2148 patients and 3189 ADM reconstructions. Mean infection rates varied between 0% and 31.25%, with a combined average of 11.59%. When comparing antibiotic protocols of less than 24 hours and more than 24 hours, the average infection rate was 2.48% and 13.21%, respectively. Conclusion: The current literature lacks consensus on the necessary duration for postoperative antibiotic prophylaxis following breast reconstruction. The potential increased risk of infection associated with ADM remains controversial. Because of the lack of supportive evidence, we do not recommend prolonged postoperative antibiotics in ADM breast reconstruction. Level of Evidence: Therapeutic level III evidence.

Transit time flow (TTF) probes may be useful for predicting long-term graft patency and assessing grafts intraoperatively in patients undergoing coronary artery bypass grafting (CABG); however, studies of TTF probe use are limited.To examine 1-year graft patency and intraoperative revision rates in patients undergoing CABG based on intraoperative TTF assessment.Retrospective analysis of a multicenter randomized clinical trial conducted at 18 Veterans Affairs hospitals using the Randomized On/Off Bypass (ROOBY) Trial data set. Of the original 2203 patients undergoing CABG surgery with or without cardiopulmonary bypass from February 1, 2002, through May 31, 2008, we studied a subset of 1607 who underwent TTF probe analysis of 1 or more grafts during surgery.Use of TTF probes to assess graft flow and pulsatility index (PI) values. The decision to revise a graft was based on the judgment of the attending surgeon.Rates of 1-year FitzGibbon grade A patency and intraoperative revision were compared based on TTF measurements (20 [low flow] vs ≥20 mL/min [normal flow]) and PI values (3, 3-5, and5).We measured TTF and/or PI in 2738 grafts, and 1-year patency was determined in 1710 (62.5%) of these grafts. FitzGibbon grade A patency occurred significantly less often in grafts with a TTF with low flow (259 of 363 [71.3%]) than in those with normal flow (1174 of 1347 [87.2%]; P .01). FitzGibbon grade A patency was also inversely correlated with increasing PI values, as found in 936 of 1093 grafts (85.6%) with a PI less than 3, 136 of 182 grafts (74.7%) with a PI of 3 to 5, and 91 of 134 grafts (67.9%) with a PI greater than 5 (P ≤ .01). Intraoperative graft revision was more frequent in grafts with low flow (44 of 568 [7.7%]) than in those with normal flow (8 of 2170 [0.4%]; P .01). Graft revision was also more frequent as PI increased (12 of 1827 [0.7%] with a PI3, 9 of 307 [2.9%] with a PI 3-5, and 9 of 155 [5.8%] with a PI5; P .01).Intraoperative TTF probe data may be helpful in predicting long-term patency and in the decision of whether to revise a questionable graft for patients undergoing CABG surgery.

While it has been commonly thought that the surgeon’s technical ‘‘talent’’ in the operating room is somehow linked with better patient outcomes, it was not until recently that this association has been reported in a large-scale study [1]. Birkmeyer et al. collected representative surgical videos from 20 bariatric surgeons in Michigan performing laparoscopic gastric bypass. The videos were blinded, peer evaluated, and scored based on technical aptitude. The surgical aptitude scores were strongly related to risk adjusted outcomes including a complication composite, operating times, re-admission, and overall mortality [1]. Interestingly, there was no association between the number of years in practice and the assigned technical aptitude score. This is a very important finding, given that it sheds light on a generally accepted belief among surgeons; some surgical talent cannot be taught or transferred, trainees either have it, or they do not. While this inherent ability is not necessary for all surgical procedures, findings from this study suggest that this ability may lead to a difference in outcome for technically demanding operations. This begs the question, should we be selecting applicants for surgical training that are more likely to possess this inherent ability? Currently, the selection process of residents for surgical residency training, for the most part, comes down to five important components, (a) USMLE board examination scores (and/or in-service exam scores for fellows), (b) medical school performance, in particular, performance on surgical rotations, (c) strength and prestige of letters or recommendations, (d) research and other academic pursuits, and finally, (e) performance on the interview day [2, 3]. The emphasis on one of these over another, despite some institutional variation, is for the most part standardized. For instance, in a large-scale recent study looking at selection criteria for general surgery applicants, the strongest emphasis was placed on the USMLE step 1 and the interview day [2]. The USMLE score, however, is often used for screening for interview selection, and those not meeting a minimum cut-off were most likely overlooked. In the study, which was a survey of program directors and departmental chairs, there was no mention of any testing for technical aptitude of any sort during the interview and/ or overall selection process. This is not to say that all interview days are the same. Some programs have instituted some unique components to their interview days including Mass General Hospital question and answer session, and some integrated surgical programs adding clinical scenario questions, and basic suturing and knot tying sessions. However, these efforts remain very sporadic, and not well studied. The present attitude toward technical aptitude testing for candidate selection stems largely from the belief that differences in baseline abilities will no longer matter during the constant repetition of residency training. However, recent data suggest that while repetition leads to improvement over time (for some), the learning curve varies greatly based on baseline aptitude [3]. In a study by Buckley et al. [3], medical students that had higher baseline aptitude (visual spatial ability, depth perception, and psychomotor ability) were able to achieve proficiency with a laparoscopic suture simulator after a mean of 7 attempts, compared to only 30 % of the lower aptitude students achieving similar proficiency after a mean of 14 attempts! M. Bishawi (&) Department of Surgery, Stony Brook School of Medicine, Stony Brook, NY, USA e-mail: muath.bishawi@stonybrookmedicine.edu

New-onset postoperative atrial fibrillation (POAF) after coronary artery bypass graft surgery (CABG) is associated with worse in-hospital morbidity and mortality, extended hospital stays, and higher costs. Beyond the initial hospital discharge, the cost and outcomes of POAF have not been well studied.For CABG patients with and without new-onset POAF, a retrospective propensity-matched, multivariable regression analysis was performed to compare 1-year outcomes (including health-related quality of life [HRQoL] scores and mortality rates) and costs (standardized to 2010 dollars). Regression models controlled for site and patient factors, with propensity matching used to adjust for differences in POAF versus no-POAF patients' risk profiles.Using the existing CABG trial database, 2,096 patient records were analyzed, including POAF patients (n = 549) versus no-POAF patients (n = 1,547). For the index CABG hospitalization, POAF patients had longer postoperative length of stay (+3.9 days) and higher discharge costs (+$13,993) than no-POAF patients. At 1 year, POAF patients had more than twice the adjusted odds of dying (p0.01), with higher 1-year total cumulative costs. This 1-year cost difference (+$15,593) was largely attributable to hospital-based costs during the index surgery hospitalization. There was no difference in 1-year HRQoL scores (or HRQoL score changes) between POAF patients and no-POAF patients.Compared with no-POAF patients, POAF patients had higher discharge and 1-year costs along with higher 1-year mortality rates, but no differences were observed in 1-year HRQoL scores. Additional research appears warranted to improve the longer-term survival rates for POAF CABG patients, targeting future POAF-specific postdischarge interventions.

Background There is no evidence demonstrating the feasibility of colorectal natural orifice transluminal endoscopic surgery (NOTES) resection with currently available endoscopic instrumentation. Objective This study aimed to evaluate the responsiveness of surgical endoscopists to simulated transanal NOTES sigmoidectomy training. Design Participants were trained in simulated NOTES sigmoidectomy by using disposable abdominal trays with tattooed sigmoid cancer in a hybrid simulator. Setting Endoscopy simulation laboratory in a university hospital. Interventions NOTES sigmoidectomy included 8 steps performed transanally with 2 colonoscopes, endoscopic scissors, and clip applier: (1) colonoscopic viscerotomy with a balloon; (2) retroperitoneal dissection; (3) left ureter identification, inferior mesenteric vessels division; (4) colonoscopy; (5) splenic flexure mobilization; (6) left side of the colon/rectal mobilization; (7) transanal specimen transection; (8) extracorporeal colorectal anastomosis. Main Outcome Measurements Responsiveness was defined as a change in performance over time and assessed comparing baseline testing with unmentored final testing. Content-valid measures included the length of the specimen, the distance of the anastomosis from the anal verge, and the proximal and distal resection margins and operating time (minutes). Results Four participants performed 21 resections. Tumor distance from the anal verge was 29.2 cm (range 26-2.5 cm). Operating time overall (127.5 vs 74 minutes, P = .068), viscerotomy (17.5 vs 9 minutes, P = .197), colonoscopy (4.5 vs 3.5 minutes, P = .655), flexure mobilization (19.5 vs 10 minutes, P = .144), colon mobilization (20 vs 14.5 minutes, P = .461), specimen extraction (9.5 vs 8.5 minutes, P = .465), and anastomosis (14 vs 11 minutes, P = .715) times improved. Limitations Ceiling effects because of fixed anatomy. Conclusions Simulated NOTES sigmoidectomy training affected responsiveness of surgical endoscopists with a 42% reduction in operating time.

Background Observational studies have documented an off-pump over on-pump advantage for high-risk patients, including diabetic patients. Randomized trials have not confirmed this advantage. The VA Randomization On Versus Off Bypass (ROOBY) trial randomly assigned 2,203 coronary artery bypass graft surgery (CABG) patients at 18 sites to either on-pump (n = 1,099) or off-pump (n = 1,104) procedures. An a priori ROOBY aim was to evaluate treatment impact on diabetic patients. Methods Actively treated diabetic patients (n = 835, receiving oral hypoglycemic or insulin medications) received off-pump CABG (n = 402) or on-pump CABG (n = 433). The primary ROOBY trial endpoints were a short-term composite (30-day operative death or major complications) and a 1-year composite (death, nonfatal acute myocardial infarction, or repeat revascularization). Secondary ROOBY endpoints included 1-year all-cause death, 1-year graft patency, 1-year changes from baseline in neurocognitive status and health-related quality of life, and costs. Results Diabetic patients' risk factors at baseline were balanced across treatments. For diabetic patients, the primary short-term composite outcome rate showed a worse trend for off-pump (8.0%) than on-pump (3.9%, p = 0.013), with no difference in the 1-year primary composite outcome or 1-year death rate. One-year patency was 83.1% off-pump versus 88.4% on-pump ( p = 0.004). No differences were found in neurocognitive, health-related quality of life, discharge cost, and 1-year cumulative cost. Conclusions Concordant with the ROOBY trial's overall findings, off-pump CABG yielded no advantage over on-pump CABG for actively treated diabetic patients. The 1-year graft patency was lower and the short-term composite trended higher for off-pump CABG, with no other significant outcome or cost differences.

Background There are several endovenous methods to ablate the saphenous vein, all of which require tumescent anesthesia. This report was designed to evaluate the efficacy of a tumescent-free technique using mechanochemical ablation (MOCA). Methods This was a prospective observational multicenter report on the efficacy of MOCA in selected patients with lower extremity chronic venous disease. Demographic information, clinical and procedural data were collected on a customized database. The distribution and extent of venous reflux and the closure rate of the treated veins were assessed with duplex ultrasound. Pain was evaluated during the procedure and postoperatively using an analog scale. The presence and severity of complications were recorded. Patient improvement was assessed by clinical-etiology-anatomy-pathophysiology (CEAP) class and venous clinical severity score (VCSS). Results There were 126 patients that were included at baseline, 81% females, with a mean age of 65.5 ± 14 years. The average BMI was 30.5 ± 6. The mean diameter of the great saphenous vein in the upper thigh was 7.3 mm and the mean treatment length was 38 cm. Adjunctive treatment of the varicosities was performed in 11% of patients during the procedure. Closure rates were 100% at one week, 98% at three months, and 94% at six months. Post-procedure complications included hematoma 1%, ecchymosis 9%, and thrombophlebitis 10%. There were no cases of venous thromboembolism. There was significant improvement in VCSS ( p Conclusion MOCA of the saphenous veins has the advantage of endovenous ablation without tumescent anesthesia, making it an almost pain-free procedure. High occlusion rates with significant clinical improvement can be achieved with this method at short term.

Objectives To determine the rate of superficial venous thrombosis in patients undergoing great saphenous vein (GSV) harvesting for coronary artery bypass surgery (CABG). Methods Post-CABG patients with suspected lower-extremity thrombosis underwent duplex scanning. Thrombus in the saphenofemoral junction stump was noted, and thrombus extension and associated complications collected. Results Out of 2335 patients who underwent CABG in five years, 98 patients presented with signs and symptoms of lower-extremity thrombosis. Thrombosis was present in 19 (19.4%) of these patients, 15 of which had a thrombus in the GSV. Five patients had significant signs and symptoms of pulmonary embolism (PE). On objective diagnostic imaging, three of them had a PE. Conclusion Patients undergoing great saphenous vein harvesting for CABG are at an increased risk of developing superficial vein thrombosis especially at the saphenous stump. Given the increased risk of deep vein thrombosis and PE, further studies investigating this topic are warranted.

The literature reports overall complication rates in breast reconstruction to be as high as 60 percent. Infection rates can exceed 20 percent, much higher than anticipated in clean elective surgery. There is no consensus among surgeons regarding the necessary duration of antibiotic prophylaxis, although the Centers for Disease Control and Prevention guidelines suggest only 24 hours. This systematic review examines antibiotic regimens and associated infection rates in breast reconstruction.Systematic electronic searches were performed in the PubMed, Ovid, and Cochrane databases using Medical Subject Headings terms for studies reporting antibiotic use and infection in all forms of breast reconstruction. Studies between 1970 and 2011 were reviewed. Included publications were required to report an antibiotic protocol and infection rate.A total of 834 abstracts were identified, 81 of which met inclusion criteria and were included in the review. The overall reported infection rates in the included studies varied between 0 and 29 percent (average, 5.8 percent). When comparing combined patient cohorts receiving no antibiotics, less than 24 hours, and greater than 24 hours, the average infection rates were 14.4, 5.8, and 5.8 percent, respectively.There is no consensus on the necessary duration of antibiotic prophylaxis following breast reconstruction. No benefit was found in patients who received more than 24 hours of postoperative antibiotics. Standardized definitions for antibiotic regimens, unit of analysis reporting, and a new breast reconstruction surgical-site infection grading system are offered to improve standardized outcome documentation. Randomized controlled trials are warranted to best determine an optimal antibiotic regimen.Therapeutic, III.

Aim A randomized controlled trial was conducted to test the hypothesis that there is no difference in complications in patients receiving intravenous (iv) water and electrolyte, based on either stroke volume or clinical indicators at bowel surgery. Method Eligible patients were randomized either to intra-operative iv administration of fluid boluses based on stroke volume measured by oesophageal Doppler (probe arm) or to iv fluid based on clinical indicators (no-probe arm). The end-point was the complication rate, defined as deviation from an uneventful postoperative course. Surgery was defined as elective bowel resection with primary anastomosis. All patients were on an enhanced recovery protocol. A randomized controlled trial suggested a sample size of 91 patients. Results Ninety-one patients were randomized. Seventeen were excluded because of withdrawal of consent, failure of the procedure or cancellation of surgery. Patients were comparable for age (P = 0.89), gender (P = 0.14), body mass index (BMI) (P = 0.7), American Society of Anesthesiology (ASA) score (P > 0.9), race (P = 0.55), colorectal POSSUM score (P = 0.11), comorbidity (P = 0.4), previous operations (P = 0.45) and diagnosis (P = 0.50). Physiological and Operative Severity Score for the Enumeration of Morbidity and Mortality (POSSUM)-predicted mortality was higher in the test (probe) arm (P = 0.011). No differences were observed in epidural analgesia (P = 0.16), type of resection (P = 0.43), incision length (P = 0.40), type of incision (P = 0.47), operation time (P = 0.92), estimated blood loss (EBL) (P = 0.56), time to ambulation (P = 0.95), flatus (P = 0.37), diet (P = 0.17), removal of the epidural anaesthesia (P = 0.26) and length of hospital stay (LOS) (P = 0.575). Intra-operative fluids administered were 3.1 (0.7–77) vs 4 (0.9–6.2) liters (P = 0.53). Postoperative fluids administered were 12.5 (5.5–84.6) vs 11.3 (3.4–49.8) (P = 0.42). Overall and septic complication rates were significantly decreased in the test arm (7/32 (22%) vs 19/40 (49%) (P = 0.022) and 2/32 (6.2%) vs 12/40 (30%) (P = 0.05), respectively). Conclusion Intra-operative administration of iv water and electrolyte during bowel surgery, based on stroke volume measured using oesophageal Doppler, was associated with decreased complication rates.

Cellular cardiomyoplasty describes the administration of extraneous, relatively undifferentiated cells which may integrate structurally and/or functionally into infarcted myocardium for the purpose of improving ventricular function or stabilizing/reversing adverse ventricular remodeling. The first cell type to enter clinical trials was skeletal myoblast. Preclinical studies demonstrated improved ventricular function in small-animal and large-animal models. The results from clinical trials have been mixed, with many studies documenting improved ventricular function. Preclinical and clinical studies are reviewed in this chapter, along with guidance for the next steps and future directions.

The validity of current animal colon cancer models is questionable. This study was performed to evaluate whether colonoscopic injection of a murine colon cancer cell line into the cecal wall of immunocompetent rats leads to a solid tumor. A bolus of bowel prep was given to BD-IX rats. Anesthesia was injected intraperitoneally. Video fiberscope allowed for irrigation and suction. Failure was inability to reach/inject cecum. Procedure was performed by four surgeons; 100 μl of colon tumor cell suspension (DHD/K12TRb; 10 million cells in 0.1 ml) was injected into cecal wall with 23-gauge needle placed on 3 mm wire resulting in a blister. Rats were allowed to recover. Solid tumor growth was measured at scheduled necropsy at 4 weeks. Sample size (107 rats: type I error 0.05; power 80%) was based on a pilot study. Data were presented as median (range). A total of 107 male BD-IX retired breeders weighing 356 g (range 256–432 g) underwent colonoscopy with submucosal injection of cecal wall. A single solid cecal cancer was identified in 98 (91.5%) rats at scheduled necropsy. Histology confirmed adenocarcinoma with tumor size of 4 mm (range 2.6–8.4 mm). Peritoneal carcinomatosis was found in ten (9.3%) rats. Distant metastases were found in three (2.8%) rats. Complications occurred in four (3.8%) rats: two aspirations and two colon perforations. A solid cecal tumor without carcinomatosis or metastasis has been developed by colonoscopic injection of a rat colon cancer cell line in 79% of immunocompetent rats.

Objective Controversy exists regarding ideal approaches in teaching residents complex and/or new surgical techniques in part because consequences on patient outcomes are largely unknown. This study compared patient outcomes for cases in which residents (rather than attending surgeons) performed most of the distal anastomoses as primary surgeons, during on- and off-pump coronary artery bypass grafting (CABG). Methods This preapproved substudy of the Randomized On/Off Bypass (ROOBY) trial compared clinical outcomes and 1-year graft patency for cases in which residents versus attending surgeons were the primary operator. Comparisons were made between on-pump and off-pump techniques. Results From July 2003 through May 2007, a total of 1272 ROOBY nonemergent CABG patients were randomized at 16 Veterans Affairs centers where residents were active participants. Residents were the primary surgeon (ie, performed ≥50% of the distal anastomoses) more frequently in on-pump (77.9%) than in off-pump (67.4%) cases. Between these 2 techniques, no were found differences in baseline patient characteristics; short-term and 1-year morbidity and mortality rates were no different for residents versus attendings in CABG cases. FitzGibbon A graft patency rates were similar for resident versus attendings completed distal anastomoses for on-pump (83.0% vs 82.4%) compared with off-pump (77.2% vs 76.6%) procedures. Conclusions In the ROOBY trial, short-term and 1-year patient outcomes and graft patency rates did not differ between resident and attending surgeons, demonstrating that with appropriate patient selection and resident supervision, residents can perform advanced, novel surgical techniques with outcomes similar to those of attending surgeons.

In patients with multivessel coronary artery disease, bypass surgery improves long-term angina symptoms compared to percutaneous coronary intervention, presumably by providing a more complete revascularization (CR). However, data correlating patient-reported symptoms and CR post-bypass are lacking

Su1463 Simulated NOTES Sigmoidectomy Training Improves the Responsiveness Over Time of Surgical Endoscopists Jonathan Buscaglia*, Seth A. Stein, Nicholas Palladino, Joshua Karas, Paula Denoya, Juan Carlos Bucobo, Satish Nagula, Muath Bishawi, Roberto Bergamaschi Medicine, Stony Brook University, Stony Brook, NY; Surgery, Stony Brook University, Stony Brook, NY Background: Transanal sigmoid colon resection by natural orifice transluminal endoscopic surgery (NOTES) may be a feasible clinical procedure if performed by highly-skilled, trained endoscopists. A model and training protocol has yet to be established for a completely incissionless NOTES sigmoidectomy. Objective: 1) to develop a model for simulated NOTES sigmoidectomy training; 2) to validate the model by assessing the responsiveness of endoscopists over time during a series of training sessions. Methods: Attending endoscopists (2 colorectal surgeons, 2 interventional gastroenterologists) underwent simulated NOTES sigmoidectomy training using disposable abdominal trays with tattooed sigmoid cancers in a hybrid simulator model (Fig 1). The 8-step standardized technique was performed transanally with a double-channel therapeutic upper endoscope, a single adult colonoscope, endoscopic hemoclips, & endoscopic scissors in the following order: 1) viscerotomy with balloon dilation from the rectum; 2) retroperitoneal access/dissection; 3) left ureter identification, inferior mesenteric artery and vein division; 4) colonoscopy to the right colon to provide traction & aide in subsequent splenic flexure mobilization; 5) flexure mobilization; 6) left colon and rectal mobilization; 7) transanal specimen transection; 8) extracorporeal colorectal anastomosis. After a baseline testing procedure, endoscopists underwent 4 training sessions mentored by an expert surgical endoscopist before proceeding to an unmentored final test with predetermined proficiency criteria. Responsiveness was defined as change in performance over time, & was assessed by comparing baseline testing with unmentored final test times. Results: 4 physicians successfully completed 21 resections. Tumors were located at a median distance of 29.2cm from the anal verge (range 26-32.5). Overall, there was a 42% reduction in total operating time (median 127.5v74min, p 0.068). A non-significant trend towards improvement in median time values (in min) was noted for the following variables: successful viscerotomy (17.5v9,p 0.197), access to retroperitoneum (21.5v11.5,p 0.144), identification/ligation of ureter/vessels (9v0.5,p 0.068), colonoscopy (4.5v3.5, p 0.655), mobilization of splenic flexure (19.5v10, p 0.144), mobilization of left colon (20v14.5, p 0.461), specimen retrieval (9.5v8.5,p 0.465), & creation of anastomosis (14v11,p 0.715). During training there were 2 conversions to laparotomy (9.5%) due to left iliac artery injury and colonic perforation. No complications occurred during final test procedures. Conclusions: Simulated NOTES sigmoidectomy training is feasible and impacted responsiveness in attending physicians with a 42% reduction in operating time. Further studies are warranted to assess the utility of simulator training when NOTES sigmoidectomy is performed in human models.