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Robotic surgery (RS) has been increasingly incorporated into colorectal surgery (CRS) training. The degree to which RS has been integrated into CRS residency training is not well described. A web-based survey was sent to all 2019 accredited CRS residency programs within the United States and Canada. Program directors (PDs) were queried on how robotic surgery had been integrated into their program, specifics on RS curriculum and opinions on RS training during general surgery residency. We compared survey responses by program type (university-based, university-affiliated programs, or independent programs) and by geographic region. In addition, a chi-square test was used to evaluate differences in survey responses with respect to robotic curriculum components. Of 66 programs, 42 (64%) responded to the survey. Of the responding programs, 35 (83%) were university-based or university-affiliated, while 7 (17%) were independent. Most programs were in the Midwest (33%). Forty-one (98%) reported having a surgical robot in use at their institution, with 95% reporting active participation of CRS residents in RS. While 74% of programs have a formal RS training curriculum for CRS residents, there was considerable variability in the curriculum elements employed by each institution, and the differences in proportions of these elements were significant (χ2 99.8, p 0.05) or among the different regions (p > 0.05). This study demonstrated that almost all CRS residencies have integrated RS and have trainees operating at the robotic console. Most programs have a robotics curriculum and there are expanding indications for RS within CRS. This expansion calls for discussion on implementation of training standards such as curricular requisites, baseline competency assessments, and definitions of minimum case requirements to ensure adequate training.

OBJECTIVE Robotic surgery has been increasingly incorporated into the subspecialties of colorectal (CRS), minimally invasive/bariatric (MIS/Bar), and surgical oncology/hepatobiliary (SO/HPB) surgery, yet its impact on fellowship applicant evaluation and contribution to postresidency training remains undefined. The aim of our study was to evaluate how robotic training during General Surgery (GS) residency affects an applicant's competitiveness from the perspective of fellowship programs. DESIGN A web-based survey was sent to all 235 accredited fellowship programs in CRS (n = 66), MIS/Bar (n = 122), and SO/HPB (n = 47) within the United States and Canada. Fellowship programs were queried on the import of robotic surgery training during GS residency and its impact on an applicant's match potential. RESULTS Of 235 programs, 155 (66%) responded to the survey – 42 (63.6%) CRS, 87 (71.3%) MIS/Bar, and 26 (55.3%) SO/HPB. Of responding programs, 147 (94.8%) have a surgical robot at their institution, and 131 (84.5%) have fellows actively operating at the console. Overall, 107 (69%) fellowship program directors rated robotic training during surgery residency as “somewhat” or “very” important for residents seeking fellowship. While 95 (61.3%) programs said GS residents should not prioritize robotic training, 60 (38.7%) felt they should, and 38 (24.5%) were more likely to rank an applicant higher if they had some console exposure. Still, 69.7% (n = 108) of programs expect no robotic experience for incoming fellows. CONCLUSIONS This study demonstrates that most fellowship programs have low expectations of robotic experience for incoming fellows. Still, it is notable that nearly a quarter of programs would rank an applicant more highly if they had robotic console exposure. While these findings appear reassuring to residents with limited access to robotic training, residency programs should be alerted to the growing importance of robotic exposure.

BACKGROUND: Males and females are known to have varied responses to medical interventions. Our study aimed to determine the effect of sex on surgical outcomes after pyloromyotomy. MATERIALS AND METHODS: Using the Kids’ Inpatient Database for the years 2003–2012, we performed a serial, cross-sectional analysis of a nationally representative sample of all patients aged

Early onset colorectal cancers are increasing in incidence. Studies have reported a left-sided preponderance of cancers in patients50 years, leading some to advocate for screening with flexible sigmoidoscopy at age 40.The purpose of our study was to investigate tumor characteristics and patient outcomes in sporadic right- and left-sided early onset colorectal cancers.This was a retrospective cohort study.This study was conducted at a single, tertiary care institution.Patients50 years diagnosed with colorectal cancer between 2000 and 2018.We analyzed patient demographics, tumor characteristics, overall survival, and disease-free survival.A total of 489 patients aged 20-49 were identified from 2000-2018. The majority of patients were white (90%) and male (57%). The median age at diagnosis was 44 years and 75% were diagnosed between 40-49 years. There was a predominance of left-sided tumors (80%). The majority of patients presented with stage 3 (35%) and stage 4 (35%) disease. Right-sided tumors were more likely to have mucinous (24% vs 7.4%, P0.001) and signet-ring cell (4.4% vs 1.7%, p0.001) histology. There was no difference in age, sex, race, ethnicity, AJCC stage at presentation. Right-sided tumors were associated with lower 5-year overall survival (44% vs 61%, p0.005) with the decrease in survival most prominent in right-sided stage 3 tumors (41% vs 72%, p0.0001) and in ages 40-49 (43% vs 61%, p = 0.03). Sex, tumor location, increasing AJCC stage, and signet-ring cell histology were independent prognostic factors of overall survival. There was no significant difference in disease-free survival.This study was a retrospective review at single institution.The majority of early onset colorectal cancers arise during age 40-49 with a left-sided predominance but higher mortality in right-sided tumors. These findings provide further evidence in favor of recommending earlier initial screening colonoscopy for colorectal cancer. See Video Abstract at http://links.lww.com/DCR/B892.

The purpose of our study was to assess the outcomes and costs of appendectomies performed at rural and urban hospitals.The National Inpatient Sample (2001-2012) was queried for appendectomies at urban and rural hospitals. Outcomes (disease severity, laparoscopy, complications, length of stay (LOS), and cost) were analyzed.Rural patients were more likely to be older, male, white, and have Medicaid or no insurance. Rural hospitals were associated with higher negative appendectomy rates (OR = 1.26,95%CI = 1.18-1.34,p 0.01), less laparoscopy use (OR = 0.65,95%CI = 0.58-0.72,p 0.01), and slightly shorter LOS (OR = 0.98,95%CI = 0.97-0.99,p 0.01). There was no consistent association with perforated appendicitis and no difference in complications or costs after adjusting for hospital volume. Yearly trends showed a significant increase in the cases utilizing laparoscopy each year at rural hospitals.Rural appendectomies are associated with increased negative appendectomy rates and less laparoscopy use with no difference in complications or costs compared to urban hospitals.

Background Robotic surgery is increasingly adopted into surgical practice, but it remains unclear what level of robotic training general surgery residents receive. The purpose of our study was to assess the variation in robotic surgery training amongst general surgery residency programs in the United States. Methods A web-based survey was sent to 277 general surgery residency programs to determine characteristics of resident experience and training in robotic surgery. Results A total of 114 (41%) programs responded. 92% (n = 105) have residents participating in robotic surgeries; 68%(n = 71) of which have a robotics curriculum, 44%(n = 46) track residents’ robotic experience, and 55%(n = 58) offer formal recognition of training completion. Responses from university-affiliated (n = 83) and independent (n = 31) programs were not significantly different. Conclusions Many general surgery residencies offer robotic surgery experience, but vary widely in requisite components, formal credentialing, and case tracking. There is a need to adopt a standardized training curriculum and document resident competency.

Despite policy efforts to support rural hospitals, little is known about the quality and safety of pediatric surgical care in geographically remote areas. Our aim was to determine the outcomes and costs of appendectomies at rural hospitals.The Kids' Inpatient Database (2003-2012) was queried for appendectomies in children18 years at urban and rural hospitals. Outcomes (disease severity, laparoscopy, complications, length of stay (LOS), cost) were analyzed with bivariate and multivariable regression analysis.Rural hospitals performed 13.6% of appendectomies. On multivariable analysis, rural hospitals were associated with higher negative appendectomy rates (OR 1.49, 95% CI 1.39-1.60, p0.001), decreased appendiceal perforation rates (OR 0.86, 95% CI 0.83-0.89, p0.001), less laparoscopy use (OR 0.48, 95% CI 0.47-0.50, p0.001), higher complication rates (OR 1.29, 95% CI 1.19-1.39, p0.001), shorter LOS (IRR 0.90, 95% CI 0.89-0.91, p0.001), and slightly increased costs (exponentiated log$ 1.02, 95% CI 1.01-1.02, p0.001) CONCLUSIONS: Rural hospitals care for fewer patients with advanced appendicitis but are associated with higher negative appendectomy rates, lower laparoscopy use, and higher complication rates. Additional studies are needed to identify factors that drive this disparity to improve the quality of pediatric surgical care in rural settings.Treatment/Cost Study (Outcomes).Level III.

Robotic surgery (RS) has been increasingly incorporated into colorectal surgery (CRS) training. The degree to which RS has been integrated into CRS residency training is not well described.A web-based survey was sent to all 2019 accredited CRS residency programs within the United States and Canada. Program directors (PDs) were queried on how robotic surgery had been integrated into their program, specifics on RS curriculum and opinions on RS training during general surgery residency. We compared survey responses by program type (university-based, university-affiliated programs, or independent programs) and by geographic region. In addition, a chi-square test was used to evaluate differences in survey responses with respect to robotic curriculum components.Of 66 programs, 42 (64%) responded to the survey. Of the responding programs, 35 (83%) were university-based or university-affiliated, while 7 (17%) were independent. Most programs were in the Midwest (33%). Forty-one (98%) reported having a surgical robot in use at their institution, with 95% reporting active participation of CRS residents in RS. While 74% of programs have a formal RS training curriculum for CRS residents, there was considerable variability in the curriculum elements employed by each institution, and the differences in proportions of these elements were significant (χ2 99.8, p 0.001). The median operative approach to abdominopelvic cases was estimated to be 33% robotic, 40% laparoscopic and 20% open. There were no significant differences in the survey responses between university/university-affiliated and independent programs (p 0.05) or among the different regions (p 0.05).This study demonstrated that almost all CRS residencies have integrated RS and have trainees operating at the robotic console. Most programs have a robotics curriculum and there are expanding indications for RS within CRS. This expansion calls for discussion on implementation of training standards such as curricular requisites, baseline competency assessments, and definitions of minimum case requirements to ensure adequate training.

Variations in the management of pediatric patients at children's hospitals (CHs) and non-CHs (NCHs) have been well described, especially within the trauma literature. However, little is known about the outcomes and costs of common general surgical procedures at NCHs. The purpose of this study was to evaluate the effect of CH designation on the outcomes and costs of appendectomy and cholecystectomy.The Kids' Inpatient Database (2003-2012) was queried for patients aged under 18 y who underwent appendectomy or cholecystectomy at CHs and NCHs. Outcomes analyzed included disease severity, complications, laparoscopy, length of stay (LOS), and cost.Most of appendectomies and cholecystectomies were performed at NCHs. Overall, CHs cared for younger children were more likely to be teaching hospitals, had higher costs, and longer LOS. On multivariate analysis for appendectomies, CHs were associated with higher rates of perforated appendicitis (OR = 1.53, 95% CI = 1.42-1.66, P 0.001), less complications (OR = 0.68, 95% CI = 0.61-0.75, P 0.001), increased laparoscopy (OR = 2.93, 95% CI = 2.36-3.64, P 0.001), longer LOS (RR = 1.13, 95% CI = 1.09-1.17, P 0.001), and higher costs (exponentiated log $ = 1.19, 95% CI = 1.13-1.24, P 0.001). Multivariate analysis for cholecystectomies revealed that CHs were associated with less laparoscopy (OR = 0.58, 95% CI = 0.50-0.67, P 0.001), longer LOS (RR = 1.26, 95% CI = 1.19-1.34, P 0.001), and higher costs (exponentiated log $ = 1.29, 95% CI = 1.22-1.37, P 0.001) with similar complications. Independent predictors of LOS and cost included CH designation, negative appendectomy, perforated appendicitis, complications, younger age, black patients, and public insurance.Variations in surgical management, outcomes, and costs after appendectomy and cholecystectomy exist between CHs and NCHs. CHs excelled in treating complicated appendicitis. NCHs effectively performed cholecystectomies. These differences in outcomes require further investigation to identify modifiable factors to optimize care across all hospitals for these common surgical diseases.

Historically, hernias were repaired before peritoneal dialysis (PD) catheter placement to obviate hernia complications, or after PD catheter placement once hernias became symptomatic or complicated. The aim of this study was to evaluate the outcomes and safety of combined hernia repair and PD catheter placement (HPD) compared with PD catheter placement alone. Within the NSQIP databases (2005–2014), 4406 patients who underwent PD catheter placement alone and 330 patients who underwent HPD were identified. Thirty-day outcomes were compared. Overall, HPD patients were older (61 vs 57 years, P < 0.001), male (72.4% vs 56.1%, P < 0.001), and more likely to have ascites (3.6% vs 1.0%, P < 0.001). Umbilical hernias (87.9%) were most commonly repaired. There was no significant difference in mortality, morbidity, superficial surgical site infection, deep SSI, organ/space SSI, readmission, or reoperation rates. HPD was associated with shorter length of stay (1.1 vs 1.7 days, P = 0.010) and longer mean operative time (66.1 vs 43.7 minutes, P < 0.001). On multivariate analyses, HPD was not an independent predictor of morbidity or mortality. In conclusion, HPD can be safely performed to prevent future complications and additional operations.

Variations in the management of adolescents at children's hospitals (CHs) and nonchildren's hospitals (NCHs) have been well described in the trauma literature. However, the effects of CH designation on outcomes after common general surgical procedures have not been investigated. The purpose of this study was to compare the outcomes and costs of adolescent cholecystectomies performed at CHs and NCHs. Within the California State Inpatient Database (2005–2011), we identified 8117 cholecystectomy patients aged 13 to 18 years at CHs and NCHs. Outcomes (laparoscopy, intraoperative cholangiogram, length of stay (LOS), and complications) and costs were analyzed. CHs cared for younger patients, more uninsured patients, and more black patients. NCHs were associated with higher laparoscopy use (95.7% vs 88.3%, P < 0.01), higher intra-operative cholangiogram rates (28.8% vs 11.9%, P < 0.001), shorter LOS (3.2 vs 5.0 days, P < 0.01), and lower costs by $5797 per patient ($11,219 vs $17,016, P < 0.01). Although there was no significant difference in overall complication rates, CHs had higher rates of infectious complications (2.0% vs 1.0%, P = 0.004). Adolescent cholecystectomies are safely performed at NCHs while achieving increased laparoscopy use, shorter LOS, and lower costs compared with CHs.

Historically, hernias were repaired before peritoneal dialysis (PD) catheter placement to obviate hernia complications, or after PD catheter placement once hernias became symptomatic or complicated. The aim of this study was to evaluate the outcomes and safety of combined hernia repair and PD catheter placement (HPD) compared with PD catheter placement alone. Within the NSQIP databases (2005-2014), 4406 patients who underwent PD catheter placement alone and 330 patients who underwent HPD were identified. Thirty-day outcomes were compared. Overall, HPD patients were older (61

Variations in the management of adolescents at children's hospitals (CHs) and nonchildren's hospitals (NCHs) have been well described in the trauma literature. However, the effects of CH designation on outcomes after common general surgical procedures have not been investigated. The purpose of this study was to compare the outcomes and costs of adolescent cholecystectomies performed at CHs and NCHs. Within the California State Inpatient Database (2005-2011), we identified 8117 cholecystectomy patients aged 13 to 18 years at CHs and NCHs. Outcomes (laparoscopy, intraoperative cholangiogram, length of stay (LOS), and complications) and costs were analyzed. CHs cared for younger patients, more uninsured patients, and more black patients. NCHs were associated with higher laparoscopy use (95.7%

Prior studies have shown racial and gender differences with respect to maturation of arteriovenous fistulas. Women and minorities have lower maturation rates for unclear reasons. Small arterial diameter and high brachial artery bifurcation (HBB) are also implicated in reduced maturation rates. We sought to correlate differences in upper extremity arterial anatomy to race and gender. All upper extremity vascular mapping ultrasounds from 2013 to 2014 were retrospectively reviewed. A total of 509 arms in 284 patients were evaluated. Men had significantly higher mean arterial diameters than women at the elbow brachial (4.7 vs 3.9 mm, P < 0.01) and wrist radial arteries (2.1 vs 1.9 mm, P = 0.03). There were 20 (7%) patients with HBB of at least one arm, and 7 (2.5%) patients with bilateral HBB. African-American patients had significantly higher rates of both unilateral HBB (15.9% vs 5.4%, P = 0.02) and bilateral HBBs (9.1% vs 1.3%, P = 0.01). In conclusion, men had significantly larger arteries than women, and African-Americans had a higher rate of HBB than non-African-Americans. Consideration should be given for routine preoperative ultrasound to assess arterial anatomy before arteriovenous fistulas creation, particularly in women and in African-Americans.

The National Comprehensive Cancer Network recommends that patients who are newly diagnosed with rectal cancer undergo staging CT scan of the chest. It is unclear whether posteroanterior and lateral chest radiography (X-ray) alone would provide adequate staging for most of these patients. A retrospective review was performed on all patients who had a two-view chest X-ray along with a chest CT for rectal cancer staging from 2007 to 2015. A total of 74 patients had both modalities. Sixty-three (85%) had a normal chest X-ray and 11 (15%) had an abnormal chest X-ray. Of the 63 patients with a normal chest X-ray, 40 (63%) had a corresponding normal chest CT and 23 (37%) had a lesion only noted on chest CT. Four patients (17%) in the latter group had metastatic cancer to the lung at the time of workup and four out of five of the tumors found to metastasize were within 5 cm from the anal verge. Our data suggest that a staging chest X-ray is unlikely to diagnose metastatic lungs lesions from a primary rectal cancer. Conversely, staging chest CT will accurately stage metastatic disease but will also reveal benign lung lesions in this patient population.

There is a well-established relationship between surgical volume and outcomes after complex pediatric operations. However, this relationship remains unclear for common pediatric procedures. The aim of our study was to investigate the effect of hospital volume on outcomes after hypertrophic pyloric stenosis (HPS).The Kid's Inpatient Database (2003-2012) was queried for patients with congenital HPS, who underwent pyloromyotomy. Hospitals were stratified based on case volume. Low-volume hospitals performed the lowest quartile of pyloromyotomies per year and high-volume hospitals managed the highest quartile. Outcomes included complications, mortality, length of stay (LOS), and cost.Overall, 2137 hospitals performed 51,792 pyloromyotomies. The majority were low-volume hospitals (n = 1806). High-volume hospitals comprised mostly children's hospitals (68%) and teaching hospitals (96.1%). The overall mortality rate was 0.1% and median LOS was 2 d. High-volume hospitals had lower overall complications (1.8% versus 2.5%, P 0.01) and fewer patients with prolonged LOS (17.0% versus 23.5%, P 0.01) but had similar rates of individual complications, similar mortality, and equivalent median LOS as low-volume hospitals. High-volume hospitals also had higher costs by $1132 per patient ($5494 versus $4362, P 0.01). Regional variations in outcomes and costs exist with higher complication rates in the West and lower costs in the South. There was no association between mortality or LOS with hospital volume or region.Patients with pyloric stenosis treated at high-volume hospitals had no clinically significant difference in outcomes despite having higher costs. Although high-volume hospitals offer improved outcomes after complex pediatric surgeries, they may not provide a significant advantage over low-volume hospitals in managing common pediatric procedures, such as pyloromyotomy for congenital HPS.

The National Comprehensive Cancer Network recommends that patients who are newly diagnosed with rectal cancer undergo staging CT scan of the chest. It is unclear whether posteroanterior and lateral chest radiography (X-ray) alone would provide adequate staging for most of these patients. A retrospective review was performed on all patients who had a two-view chest X-ray along with a chest CT for rectal cancer staging from 2007 to 2015. A total of 74 patients had both modalities. Sixty-three (85%) had a normal chest X-ray and 11 (15%) had an abnormal chest X-ray. Of the 63 patients with a normal chest X-ray, 40 (63%) had a corresponding normal chest CT and 23 (37%) had a lesion only noted on chest CT. Four patients (17%) in the latter group had metastatic cancer to the lung at the time of workup and four out of five of the tumors found to metastasize were within 5 cm from the anal verge. Our data suggest that a staging chest X-ray is unlikely to diagnose metastatic lungs lesions from a primary rectal cancer. Conversely, staging chest CT will accurately stage metastatic disease but will also reveal benign lung lesions in this patient population.