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A Quality Profile for U.S. Surgical Residents: Case Participation in the American College of Surgeons National Surgical Quality Improvement Program
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
545
Surgery, Philadelphia, PA, USA; 2Medical University Of South Carolina, Charleston, SC, USA; 3Emory University School Of Medicine, Atlanta, GA, USA
24.9. A Quality Profile for U.S. Surgical Residents: Case Participation in the American College of Surgeons National Surgical Quality Improvement Program. R. L. Hoffman,1 E. K. Bartlett,1 R. L. Medbery,3 J. B. Morris,1 J. V. Sakran,2 R. R. Kelz1; 1Hospital Of The University Of Pennsylvania -
Introduction: There is a national interest in prioritizing patient safety and quality improvement in resident education. Data regarding clinical effectiveness in surgical practice is hard to obtain for surgical trainees. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a nationally validated, outcomes-based program that captures surgical encounters in many academic hospitals. The objective of this study was to provide a profile of the general surgery resident experience with ACS NSQIP cases in order to provide a basis for the use of this data in general surgical education. Methods: We identified general surgery cases using the ACS NSQIP Participant Use File, 2011 (PUF). Cases were classified by the procedure type using CPT codes. Resident participation was determined using the post-graduate year (PGY) as assigned in the PUF. Descriptive statistics were performed regarding patient characteristics and clinical outcomes. Results: We identified 186,251 general surgical cases. Resident status was missing from 107,294 (58%) of cases and residents did not participate in 26,379 (14%) of cases. Of the cases with resident participation recorded (n¼52,578), the type of procedures performed varied by PGY(Table 1). Patients treated with resident involvement were women (59%),Caucasian (70%), inpatient (61%), diabetic (13%), smokers (17%), obese (41%) and emergent (14%). Twenty-eight percent(n¼14,559) of the cases were performed with PGY5 residents, compared to interns, who were involved with 10% (n¼5,448) of the cases. Hernia repairs were performed with residents of all PGY(12153, 2-2120, 3-2057, 4-2243, 5-2812) while mastectomies involved more junior residents(1-1018, 2-1112, 3-868, 4-557, 5-655) and pancreatic resections were performed with more senior residents(1-19, 2-25, 3102, 4-258, 5-805). Of all cases with resident involvement, 15.6% were associated with post-operative morbidity and 0.9% associated with death (n¼470). The most common post-operative occurrence identified was bleeding (5% of cases; n¼2620). A superficial or deep surgical site
546
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
infection (SSI) occurred in 3%(1,764) of cases and an organ space SSI in 2% (n¼883). A urinary tract infection was noted in 2% of cases, sepsis/ septic shock in 2%, and a venous thromboembolus (VTE) in 0.8%. Conclusions: The diversity of the resident experience in case-mix and procedure type within the ACS NSQIP, and the exposure to nationally significant outcome metrics, justifies the use of the program as an educational tool. In order to make the ACS NSQIP reports meaningful for residents, the local NSQIP team must make a commitment to abstract the information regarding resident involvement.
as teaching assistants (TA) remained at zero over this time period. The 90th percentile of cases performed as TA dropped from 2 to 1 for both pancreas and liver. Conclusions: Roughly one-half of GCR have performed fewer than 10 cases in each of the liver, pancreas or biliary categories at time of completion of residency. While the mean number of complex liver and pancreatic operations performed by GCR increased slightly, the median number remained low and the number of TA cases was virtually zero. Most GCR are unlikely to be prepared to perform complex HPB operations.
24.10. Assessing the Experience in Complex Hepatopancreatobiliary Surgery Among Graduating Chief Residents: Is the Operative Caseload Enough? T. E. Sachs,1 A. Ejaz,1 M. J. Weiss,1 G. Spolverato,1 N. Ahuja,1 M. A. Makary,1 C. L. Wolfgang,1 K. Hirose,1 T. M. Pawlik1; 1Johns Hopkins University School Of Medicine, Baltimore, MD, USA
GASTROINTESTINAL/NUTRITION 3: BASIC SCIENCE - HPB AND GI MALIGNANCY
Introduction: Resident operative autonomy and case volume is associated with post training confidence and practice plans. ACGME requirements for graduating general surgery residents are 4 liver and 3 pancreas cases. We sought to evaluate trends in resident experience and autonomy for complex hepatopancreatobiliary (HPB) surgery over time. Methods: We queried the ACGME General Surgery Case Log (2003-2012) for all cases performed by graduating chief residents (GCR) relating to liver, pancreas, and the biliary tract (HPB); simple cholecystectomy was excluded. Mean (6standard deviation), median [10th:90th percentiles] and maximum case volumes were compared from 2003 to 2012. R2 was calculated for all trends. Results: A total of 253,148 complex HPB cases (36% liver, 43% pancreas, 21% biliary) were performed by 10,288 GCRs over the 10-year period examined (Mean ¼ 24.6 per GCR). Of these, 57% were performed during the chief year, while 43% were done as post-graduate year (PGY) 1-4. Only 52% of liver cases were anatomic resections, while 71% of pancreas cases were major resections. Total number of cases increased from 22,516 (Mean ¼ 23.0) in 2003 to 27,191(Mean ¼ 24.9) in 2012. Over this same time period, the percentage of HPB cases that were performed during the chief year decreased by 7% (Liver: 13%, Pancreas 8%, Biliary 4%). There was an increasing trend in the mean number of operations logged by GCRs on the pancreas (9.165.9 to 11.364.3; R2¼.85) and liver (8.065.9 to 9.463.4; R2¼.91), while those for the biliary tract decreased (5.962.5 to 3.862.1; R2¼.96). While the median number of cases increased slightly for both pancreas (7.0 [4.0:15] to 8.0 [4:20]) and liver (7.0 [4:13] to 8.0 [5:14]), the maximum number of cases preformed by any given GCR remained stable for pancreas (51 to 53; R2¼.18), but increased for liver (38 to 45; R2¼.32). The median number of HPB cases that GCR’s performed
FIG. 1. The average number of hepatopancreatobiliary cases performed over 5 years by graduating chief residents in surgery (20032012).
25.1. Targeted Delivery of Thailandepsin A using Unimolecular Micelles to Improve Antitumor Effect in Carcinoids. R. Jaskula-Sztul,1 W. Xu,1 A. Dammalapati,1 G. Chen,1 O. Sadak,1 A. Harrison,1 Q. Zheng,1 R. Nair,1 C. Korlesky,1 C. Wang,2 Y. Cheng,2,3 S. Gong,1 H. Chen1; 1University Of Wisconsin - Department of General Surgery, Madison, WI, USA; 2University Of Wisconsin - Milwaukee - Department Of Biological Sciences, Milwaukee, WI, USA; 3University Of North Texas Health Science Center - UNT System College Of Pharmacy, Fort Worth, TX, USA Introduction: Carcinoids are gastrointestinal (GI) neuroendocrine (NE) tumors occurring throughout the GI tract which produce hormones causing the carcinoid syndrome. Although NE tumors are slow growing, they are frequently metastatic at the time of their discovery and no longer amenable to curative surgery. Therefore, there is a great need to develop novel therapeutic strategies both to reduce tumor burden and control symptoms in patients with carcinoid neoplasms. To address this need, we developed and optimized a family of novel unimolecular micelles capable of delivering a newly reported anticancer drug Thailandepsin A (TDP-A).These micelles specifically target the NE cancer cells with overexpressed somatostatin receptors (SSTRs) using octreotide (OCT) as the active-tumor targeting ligand. In the current study we assessed the antitumor effects of TDP-A loaded unimolecular micelles both in vitro and in vivo. Methods: Stable unimolecular micelles were prepared in an aqueous solution using multi-arm star amphiphilic block copolymer. The hydrophobic polyester core (PLA) was used to encapsulate the TDP-A and the polyethylene glycol shell (PEG) was used to provide water solubility and reduce opsonization. OCT was conjugated to the PEG for active tumor-targeting. A human GI carcinoid cell line (BON) was treated with a family of micelles (TDP-A-loaded targeted and non-targeted, and empty targeted and non-targeted) at a TDP-A concentration of 5 nM for 2 or 24, 48 and 72 hours. The cell proliferation and the expression of NE markers (ASCL1 and CgA) were assessed by MTT assay and Western blot, respectively. The effect of the OCT targeting ligands on the cellular uptake of the micelles was measured by flow cytometry and confocal laser scanning microscope (CLSM). The antitumor efficacy of TDP-A loaded micelles was determined in BON xenografts after five intravenous injections performed every 5 days with a dose of 3.125mg/kg BW. Results: The family of pH-responsive unimolecular micelles were developed for targeted delivery of TDP-A to carcinoids. The TDP-A loaded and OCT-conjugated targeted micelles had the strongest inhibitory effect on BON cell proliferation and NE markers expression. Moreover, the targeted micelles exhibited a much higher cellular uptake (4 fold increase) than non-targeted micelles based on flow cytometry and CLSM analyses. Additionally, TDP-A loaded targeted micelles demonstrated the best antitumor efficacy with the highest decrease of tumor volume (76%). Conclusions: The OCT targeting ligands conjugated onto the surface of the micelles substantially increased the cellular uptake of the micelles in BON cells and improved cytotoxic effect of TDP-A both in vitro and in vivo. Thus, targeted delivery of anticancer drug TDP-A, specifically to the tumor tissue could significantly improve the therapeutic outcomes in treating carcinoid disease while reducing systemic toxicity.
545
Surgery, Philadelphia, PA, USA; 2Medical University Of South Carolina, Charleston, SC, USA; 3Emory University School Of Medicine, Atlanta, GA, USA
24.9. A Quality Profile for U.S. Surgical Residents: Case Participation in the American College of Surgeons National Surgical Quality Improvement Program. R. L. Hoffman,1 E. K. Bartlett,1 R. L. Medbery,3 J. B. Morris,1 J. V. Sakran,2 R. R. Kelz1; 1Hospital Of The University Of Pennsylvania -
Introduction: There is a national interest in prioritizing patient safety and quality improvement in resident education. Data regarding clinical effectiveness in surgical practice is hard to obtain for surgical trainees. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a nationally validated, outcomes-based program that captures surgical encounters in many academic hospitals. The objective of this study was to provide a profile of the general surgery resident experience with ACS NSQIP cases in order to provide a basis for the use of this data in general surgical education. Methods: We identified general surgery cases using the ACS NSQIP Participant Use File, 2011 (PUF). Cases were classified by the procedure type using CPT codes. Resident participation was determined using the post-graduate year (PGY) as assigned in the PUF. Descriptive statistics were performed regarding patient characteristics and clinical outcomes. Results: We identified 186,251 general surgical cases. Resident status was missing from 107,294 (58%) of cases and residents did not participate in 26,379 (14%) of cases. Of the cases with resident participation recorded (n¼52,578), the type of procedures performed varied by PGY(Table 1). Patients treated with resident involvement were women (59%),Caucasian (70%), inpatient (61%), diabetic (13%), smokers (17%), obese (41%) and emergent (14%). Twenty-eight percent(n¼14,559) of the cases were performed with PGY5 residents, compared to interns, who were involved with 10% (n¼5,448) of the cases. Hernia repairs were performed with residents of all PGY(12153, 2-2120, 3-2057, 4-2243, 5-2812) while mastectomies involved more junior residents(1-1018, 2-1112, 3-868, 4-557, 5-655) and pancreatic resections were performed with more senior residents(1-19, 2-25, 3102, 4-258, 5-805). Of all cases with resident involvement, 15.6% were associated with post-operative morbidity and 0.9% associated with death (n¼470). The most common post-operative occurrence identified was bleeding (5% of cases; n¼2620). A superficial or deep surgical site
546
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
infection (SSI) occurred in 3%(1,764) of cases and an organ space SSI in 2% (n¼883). A urinary tract infection was noted in 2% of cases, sepsis/ septic shock in 2%, and a venous thromboembolus (VTE) in 0.8%. Conclusions: The diversity of the resident experience in case-mix and procedure type within the ACS NSQIP, and the exposure to nationally significant outcome metrics, justifies the use of the program as an educational tool. In order to make the ACS NSQIP reports meaningful for residents, the local NSQIP team must make a commitment to abstract the information regarding resident involvement.
as teaching assistants (TA) remained at zero over this time period. The 90th percentile of cases performed as TA dropped from 2 to 1 for both pancreas and liver. Conclusions: Roughly one-half of GCR have performed fewer than 10 cases in each of the liver, pancreas or biliary categories at time of completion of residency. While the mean number of complex liver and pancreatic operations performed by GCR increased slightly, the median number remained low and the number of TA cases was virtually zero. Most GCR are unlikely to be prepared to perform complex HPB operations.
24.10. Assessing the Experience in Complex Hepatopancreatobiliary Surgery Among Graduating Chief Residents: Is the Operative Caseload Enough? T. E. Sachs,1 A. Ejaz,1 M. J. Weiss,1 G. Spolverato,1 N. Ahuja,1 M. A. Makary,1 C. L. Wolfgang,1 K. Hirose,1 T. M. Pawlik1; 1Johns Hopkins University School Of Medicine, Baltimore, MD, USA
GASTROINTESTINAL/NUTRITION 3: BASIC SCIENCE - HPB AND GI MALIGNANCY
Introduction: Resident operative autonomy and case volume is associated with post training confidence and practice plans. ACGME requirements for graduating general surgery residents are 4 liver and 3 pancreas cases. We sought to evaluate trends in resident experience and autonomy for complex hepatopancreatobiliary (HPB) surgery over time. Methods: We queried the ACGME General Surgery Case Log (2003-2012) for all cases performed by graduating chief residents (GCR) relating to liver, pancreas, and the biliary tract (HPB); simple cholecystectomy was excluded. Mean (6standard deviation), median [10th:90th percentiles] and maximum case volumes were compared from 2003 to 2012. R2 was calculated for all trends. Results: A total of 253,148 complex HPB cases (36% liver, 43% pancreas, 21% biliary) were performed by 10,288 GCRs over the 10-year period examined (Mean ¼ 24.6 per GCR). Of these, 57% were performed during the chief year, while 43% were done as post-graduate year (PGY) 1-4. Only 52% of liver cases were anatomic resections, while 71% of pancreas cases were major resections. Total number of cases increased from 22,516 (Mean ¼ 23.0) in 2003 to 27,191(Mean ¼ 24.9) in 2012. Over this same time period, the percentage of HPB cases that were performed during the chief year decreased by 7% (Liver: 13%, Pancreas 8%, Biliary 4%). There was an increasing trend in the mean number of operations logged by GCRs on the pancreas (9.165.9 to 11.364.3; R2¼.85) and liver (8.065.9 to 9.463.4; R2¼.91), while those for the biliary tract decreased (5.962.5 to 3.862.1; R2¼.96). While the median number of cases increased slightly for both pancreas (7.0 [4.0:15] to 8.0 [4:20]) and liver (7.0 [4:13] to 8.0 [5:14]), the maximum number of cases preformed by any given GCR remained stable for pancreas (51 to 53; R2¼.18), but increased for liver (38 to 45; R2¼.32). The median number of HPB cases that GCR’s performed
FIG. 1. The average number of hepatopancreatobiliary cases performed over 5 years by graduating chief residents in surgery (20032012).
25.1. Targeted Delivery of Thailandepsin A using Unimolecular Micelles to Improve Antitumor Effect in Carcinoids. R. Jaskula-Sztul,1 W. Xu,1 A. Dammalapati,1 G. Chen,1 O. Sadak,1 A. Harrison,1 Q. Zheng,1 R. Nair,1 C. Korlesky,1 C. Wang,2 Y. Cheng,2,3 S. Gong,1 H. Chen1; 1University Of Wisconsin - Department of General Surgery, Madison, WI, USA; 2University Of Wisconsin - Milwaukee - Department Of Biological Sciences, Milwaukee, WI, USA; 3University Of North Texas Health Science Center - UNT System College Of Pharmacy, Fort Worth, TX, USA Introduction: Carcinoids are gastrointestinal (GI) neuroendocrine (NE) tumors occurring throughout the GI tract which produce hormones causing the carcinoid syndrome. Although NE tumors are slow growing, they are frequently metastatic at the time of their discovery and no longer amenable to curative surgery. Therefore, there is a great need to develop novel therapeutic strategies both to reduce tumor burden and control symptoms in patients with carcinoid neoplasms. To address this need, we developed and optimized a family of novel unimolecular micelles capable of delivering a newly reported anticancer drug Thailandepsin A (TDP-A).These micelles specifically target the NE cancer cells with overexpressed somatostatin receptors (SSTRs) using octreotide (OCT) as the active-tumor targeting ligand. In the current study we assessed the antitumor effects of TDP-A loaded unimolecular micelles both in vitro and in vivo. Methods: Stable unimolecular micelles were prepared in an aqueous solution using multi-arm star amphiphilic block copolymer. The hydrophobic polyester core (PLA) was used to encapsulate the TDP-A and the polyethylene glycol shell (PEG) was used to provide water solubility and reduce opsonization. OCT was conjugated to the PEG for active tumor-targeting. A human GI carcinoid cell line (BON) was treated with a family of micelles (TDP-A-loaded targeted and non-targeted, and empty targeted and non-targeted) at a TDP-A concentration of 5 nM for 2 or 24, 48 and 72 hours. The cell proliferation and the expression of NE markers (ASCL1 and CgA) were assessed by MTT assay and Western blot, respectively. The effect of the OCT targeting ligands on the cellular uptake of the micelles was measured by flow cytometry and confocal laser scanning microscope (CLSM). The antitumor efficacy of TDP-A loaded micelles was determined in BON xenografts after five intravenous injections performed every 5 days with a dose of 3.125mg/kg BW. Results: The family of pH-responsive unimolecular micelles were developed for targeted delivery of TDP-A to carcinoids. The TDP-A loaded and OCT-conjugated targeted micelles had the strongest inhibitory effect on BON cell proliferation and NE markers expression. Moreover, the targeted micelles exhibited a much higher cellular uptake (4 fold increase) than non-targeted micelles based on flow cytometry and CLSM analyses. Additionally, TDP-A loaded targeted micelles demonstrated the best antitumor efficacy with the highest decrease of tumor volume (76%). Conclusions: The OCT targeting ligands conjugated onto the surface of the micelles substantially increased the cellular uptake of the micelles in BON cells and improved cytotoxic effect of TDP-A both in vitro and in vivo. Thus, targeted delivery of anticancer drug TDP-A, specifically to the tumor tissue could significantly improve the therapeutic outcomes in treating carcinoid disease while reducing systemic toxicity.