Current Teaching in United States Feza H. Remzi,M.D. F.A.C.S., F.A.S.C.R.S., F.T.S.S. ( Hon) Department of Colorectal Surgery Digestive Disease Institute Cleveland Clinic, Ohio

Aim: –To demonstrate trends in CR practice from 1989 to 1996 –To compare the 1 year technical experience of a CR resident with the 5 years total of a GS resident CR resident performs –more anorectal operations –more endoscopic procedures –more index abdominal operations in 1 year than GS resident does in 5 years 1 year of training in CR trains a true specialist with unique expertise Schoetz DCR 1998

Data from American Board of Colon and Rectal Surgery (ABCRS) database (1994 to 2005) –CR training programs increased from 28 to 39 (28% increase) –CR residency positions increased from 50 to 66 (24% increase) –Anorectal patients per resident remained constant over the study period –Sigmoidoscopy decreased substantially Rigid (67 to 44 per resident) Flexible (135.5 to 39 per resident) –Colonoscopy increased (209 to 264 per resident) Schoetz J Am Coll Surg 2006

Perineal procedures for rectal prolapse consistently comprise 50% to 60% of the total procedures for prolapse Low anterior resection APR ratio=3/1 Coloanal anastomoses have steadily increased Radical cancer operations continue to make up a sizeable portion of abdominal surgery volume in training programs Surgery for colon cancer have been between 52.4% and 57.9% of the total number of resections for colorectal cancer Schoetz Jr J Am Coll Surg 2006

General Surgery Colorectal Surgery Colectomy IPAA APR Gen Surgery versus Colon Rectal Surgery Residents Colon Procedures

Laparoscopic Colorectal Surgery –3.6% laparoscopic procedures performed in 1994, vs. 24.3% in 2005 –The greatest increase being in diverticular resections (6.5 % in 1994 vs. 44.7% in 2005) –In % of colon resections performed laparoscopically for cancer vs. 41.1% in 2005 Schoetz Jr J Am Coll Surg 2006

Data from Accreditation Council for GME General surgery residents ( ) –The average number of LAP colectomy/GS resident/career increased from 1.84 to 4.61 Colorectal surgery residents ( ) –Number of CR residents steadily increased to 66 by 2005 –The total number of open or LAP cases increased from 8342 to –The average LAP cases/CR resident increased from 6.3 in to 45.3 in Charron DCR 2007

Colorectal surgery residents ( ) –A total of 2987 LAP cases were performed in 2005 Average CR resident recorded 45.3 LAP cases in 2005 (colon=30, rectal=9.4, other=5.9) – , 3098 segmental colectomy performed (LAP=330) – , 4394 segmental colectomy performed (LAP=1771) –LAP low anterior resection increased from 32 to 248 (1999 to 2005) –LAP APR increased from 11 to 48 (1999 to 2005) Charron DCR 2007

Comparison of LAP colon resection experience for GS vs. CR residents – –The average number of laparoscopic colon resections by GS vs. CR (4.61 vs. 20.2) –The majority of GS resident experience was acquired in the chief year, with an average of 2.69 of 4.61 cases Charron DCR 2007

Conclusions –Learning curves for LAP colectomy are reported in the range of 20 to 60 cases –CR resident experience is trending toward this threshold –Recent general surgery graduates may be lacking the appropriate volume to reach proficiency in LAP colorectal surgery Charron DCR 2007

Segmental Colectomy 37 LAR 11 APR 4 IPAA 7 Minimum Numbers ABCRS