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 SurgeryDigestive 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 14.9 62.2

IPAA 1.5 10.7

APR 3.2 7.3

Gen Surgery versus Colon Rectal Surgery Residents Colon Procedures 1995-1996

• 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 1994 5.6% 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 (2000-2004)

– The average number of LAP colectomy/GS resident/career increased from 1.84 to 4.61

• Colorectal surgery residents (1994-2005)– Number of CR residents steadily increased to 66 by

2005– The total number of open or LAP cases increased

from 8342 to 13267– The average LAP cases/CR resident increased from

6.3 in 1993-1994 to 45.3 in 2004-2005Charron DCR 2007

• Colorectal surgery residents (1994-2005)– 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)

– 1999-2000, 3098 segmental colectomy performed (LAP=330)

– 2004-2005, 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– 2003-2004

– 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