Portable hypothermic oxygenated machine perfusion for organ preservation in liver transplantation: A randomized, open-label, clinical trial.

BACKGROUND AND AIMS: In liver transplantation, cold preservation induces ischemia, resulting in significant reperfusion injury. Hypothermic oxygenated machine perfusion (HMP-O 2 ) has shown benefits compared to static cold storage (SCS) by limiting ischemia-reperfusion injury. This study reports outcomes using a novel portable HMP-O 2 device in the first US randomized control trial. APPROACH AND RESULTS: The PILOT trial (NCT03484455) was a multicenter, randomized, open-label, noninferiority trial, with participants randomized to HMP-O 2 or SCS. HMP-O 2 livers were preserved using the Lifeport Liver Transporter and Vasosol perfusion solution. The primary outcome was early allograft dysfunction. Noninferiority margin was 7.5%. From April 3, 2019, to July 12, 2022, 179 patients were randomized to HMP-O 2 (n=90) or SCS (n=89). The per-protocol cohort included 63 HMP-O 2 and 73 SCS. Early allograft dysfunction occurred in 11.1% HMP-O 2 (N=7) and 16.4% SCS (N=12). The risk difference between HMP-O 2 and SCS was -5.33% (one-sided 95% upper confidence limit of 5.81%), establishing noninferiority. The risk of graft failure as predicted by Liver Graft Assessment Following Transplant score at seven days (L-GrAFT 7 ) was lower with HMP-O 2 [median (IQR) 3.4% (2.4-6.5) vs. 4.5% (2.9-9.4), p =0.024]. Primary nonfunction occurred in 2.2% of all SCS (n=3, p =0.10). Biliary strictures occurred in 16.4% SCS (n=12) and 6.3% (n=4) HMP-O 2 ( p =0.18). Nonanastomotic biliary strictures occurred only in SCS (n=4). CONCLUSIONS: HMP-O 2 demonstrates safety and noninferior efficacy for liver graft preservation in comparison to SCS. Early allograft failure by L-GrAFT 7 was lower in HMP-O 2 , suggesting improved early clinical function. Recipients of HMP-O 2 livers also demonstrated a lower incidence of primary nonfunction and biliary strictures, although this difference did not reach significance.

Defining the Disparity: A Multi-Institutional Analysis of Factors Associated With Decreased Resident Operative Experience.

INTRODUCTION: Technical learning in surgical training is multifaceted and existing literature suggests a positive relationship between case volume and proficiency. Little is known about factors associated with a decreased volume of operative experience. This study aimed to identify resident and program factors associated with general surgery residents (GSR) in the bottom quartile of logged case volume upon program completion. METHODS: A post hoc analysis of a multicenter study was used to examine case logs for categorical GSR. Participants included graduates between 2010 and 2020 from 20 programs. Residents below and above the 25th percentile for total operative volume were compared. RESULTS: The present study includes 1343 GSR who graduated over the 11-y period. In total, 336 residents were below the 25th percentile and 1007 residents were above the 25th percentile. Those below the 25th percentile were more likely to be female (41% versus 34%, P = 0.02), identify as underrepresented in medicine (22% versus 14%, P < 0.01), and pursue fellowship (86% versus 80%, P = 0.01) compared to those above the 25th percentile. Residents below the 25th percentile were more likely to have graduated from a low volume program (55% versus 25%, P < 0.01) and from top National Institutes of Health funded institutions (57% versus 52%, P = 0.01). CONCLUSIONS: This study identified individual and program characteristics associated with lower operative volume of GSR. Understanding such characteristics will aid surgical educators to achieve better equity in training.

Microsatellite instability is associated with worse overall survival in resectable colorectal liver metastases.

BACKGROUND: Microsatellite instability (MSI) has been associated with improved overall survival (OS) in locoregional colorectal cancer; however, the effects on colorectal liver metastases (CRLM) have not been studied. METHODS: The National Cancer Database (NCDB) was queried for patients with CRLM that underwent metastasectomy. Patients with microsatellite stable tumors (MSS) (n = 2,316, 84.4%) were compared those with MSI (n = 427, 15.6%). RESULTS: Baseline characteristics, including sex, race, and underlying comorbidities, were similar between groups. MSS patients had lower rates of high-risk pathologic features and higher rates of receiving multi-agent chemotherapy. On Kaplan-Meier analysis, median OS in the MSS group was improved compared with the MSI group (41.1 mo vs. 33.2 mo, p < 0.01). On multivariate analysis MSI status remained associated with worse OS (HR: 1.21 95% CI: 1.01-1.46, p = 0.04). CONCLUSIONS: This national analysis of CRLM validates MSI status as a biomarker to guide clinical decision-making due to the associated poor prognosis.

Experience of surgical subspecialty residents on general surgery rotations.

BACKGROUND: Surgical subspecialty residents complete 5-6 years of training which includes general surgery rotations. A lack of data exists evaluating these rotations. This study aims to identify discrepancies in subspecialty training and improve the quality of surgical education. METHODS: Case logs for surgical subspecialty residents and general surgery residents at our institution were analyzed and queried for cases performed on general surgery rotations. A survey was distributed to subspecialty residents regarding their perceptions of these rotations. RESULTS: 50 residents were included in the study and the majority were male (n = 27, 54%). Subspecialty residents perform fewer cases per month compared to general surgery residents (13 vs 21, p < 0.001). 75% of subspecialty residents were satisfied with their experience on general surgery rotations. CONCLUSIONS: Subspecialty residents perform fewer operations on general surgery rotations. Despite this, most are satisfied with off-service rotations and believe they are an important part of their education.

A National Assessment of T2 Staging for Intrahepatic Cholangiocarcinoma and the Poor Prognosis Associated with Multifocality.

BACKGROUND: T2 intrahepatic cholangiocarcinoma (ICC) is defined as a solitary tumors with vascular invasion or multifocal tumors including satellite lesions, multiple lesions, and intrahepatic metastases. This study aimed to evaluate the prognosis associated with multifocal tumors. METHODS: The National Cancer Database was queried from 2004 to 2017 for patients with non-metastatic ICC. The patients were grouped based on T2 staging, multifocality, and lymph node involvement. RESULTS: The study enrolled and classified 4887 patients into clinical (c) stage groups as follows: 15.2% with solitary T2N0 (sT2N0) tumors, 21.3% with multifocal T2N0 (mT2N0) tumors, and 63.5% with node-positive (TxN1) disease. Patients with (c)sT2N0 tumors had higher rates of surgical resection than those with (c)mT2N0 or (c)TxN1 disease (33.5% vs 19.7% vs 15.0%; p < 0.01). Median overall survival (OS) was better for the patients with (c)sT2N0 tumors than for those with multifocal and node-positive disease (15.4 vs 10.4 vs 10.4 months; p < 0.01). On multivariate analysis, (c)sT2N0 tumors were associated with better OS than (c)mT2N0 tumors [hazard ratio (HR), 1.31; 95% confidence interval (CI), 1.17-1.46; p < 0.01] or (c)TxN1 disease (HR,1.41; 95% CI 1.28-1.56; p < 0.01). In a subset analysis based on pathologic (p) staging of patients who underwent surgical resection with regional lymphadenectomy, multivariate analysis demonstrated that (p)sT2N0 tumors were associated with better OS than (p)mT2N0 tumors (HR,1.40; 95% CI 1.03-1.92; p = 0.03) or (p)TxN1 disease (HR, 2.05; 95% CI 1.62-2.58; p < 0.01). CONCLUSIONS: Multifocal T2N0 ICC is associated with poor OS and has a disparate prognosis compared with solitary T2N0 disease, even among patients who undergo resection. Future staging criteria should account for the poor outcomes associated with multifocal ICC.

Impact of Integrated Thoracic Residency on General Surgery Residents' Thoracic Operative Volume.

BACKGROUND: Integrated thoracic surgery (I-6) programs have become popular over traditional general surgery (GS) pathways since their inception in 2007. However the effect of I-6 programs on GS resident training remains unknown. The purpose of this study was to evaluate the effect of I-6 programs on the thoracic operative experience of co-located GS residents. METHODS: Thoracic surgery cases recorded by residents in GS programs co-located with I-6 programs until 2019 were analyzed. Cases were reviewed 5 years before (TSR-5) through 5 years after (TSR-5) the matriculation of the first thoracic resident in the co-located I-6 program. To contextualize the overall trends in the field Accreditation Council for Graduate Medical Education GS resident case logs from 1990 to 2018 were analyzed and total thoracic surgery cases recorded. Statistical analysis was performed with linear regression. RESULTS: Residents in 19 GS programs with co-located I-6 programs showed an increase in total thoracic cases from 3710 to 4451 (Δ/year of +85.05 cases a year; P = .03) balanced by an increase in GS residents from 107 to 126 (Δ/year of +1.45; P = .01) with no significant overall change in the median thoracic operative case volume (31.00 at both thoracic residency before and after 5 years). Nationally from 1990 to 2018 there was no change in the total thoracic operative experience for GS graduates. CONCLUSIONS: The introduction of I-6 programs did not negatively impact thoracic operative experience for residents in co-located GS programs. Adequate training of both I-6 and GS residents at the same institution is feasible.

Utilization and effectiveness of the organ procurement and transplantation network "safety-net" policy.

BACKGROUND: Liver transplant recipients with persistent renal dysfunction may be prioritized on the kidney transplant waitlist based on the Organ Procurement and Transplantation Network "safety-net" policy implemented in 2017. The aim of this study was to evaluate the utilization of kidney transplant and posttransplant outcomes, of liver transplant recipients with persistent renal dysfunction before and after implementation of the Organ Procurement and Transplantation Network kidney safety-net policy and standardization of simultaneous liver-kidney requirements. METHODS: Using the United Network for Organ Sharing database from January 2015 to March 2019, outcomes of liver transplant recipients listed for kidney transplant and the subset who received kidney after liver transplants were compared before and after policy implementation. RESULTS: Liver transplant recipients listed for kidney transplant increased from 58 to 200, and kidney after liver transplants increased from 29.3% to 42.5% after safety-net policy implementation. Post-policy kidney after liver transplants received more local organs (91.8% vs 70.6%, P = .03) and trended toward shorter waitlist time (47 [17-123] vs 84 [37-226] days, P = .051). The pre- and post-policy cohorts had similar (P > .05) kidney donor profile index (0.43 [0.27-0.69] vs 0.42 [0.28-0.58]) and delayed graft function (11.8% vs 14.1%). Patient, kidney graft, and liver graft survival were similar (P > .05) between pre and post-policy cohorts. Patient and kidney graft survival were similar between kidney after liver transplants and propensity score-matched kidney transplant alone recipients. Patient, kidney, and liver graft survival were similar between kidney after liver transplants and propensity score-matched simultaneous liver-kidney transplant recipients. CONCLUSION: This study demonstrates that after Organ Procurement and Transplantation Network "safety-net" policy implementation, there has been an increase in liver transplant recipients with renal dysfunction who are listed for and undergo kidney transplant with excellent short-term results.

An analysis of applicant competitiveness to general surgery, surgical subspecialties, and integrated programs.

BACKGROUND: General surgery was once the gateway into a career in surgery. Over time, surgical subspecialties developed separate residency programs, and recently, integrated programs have emerged. It is unknown what impact the presence of surgical subspecialties and integrated programs have had on general surgery. Our objective was to evaluate match trends and quantify competitiveness of the general surgery, integrated programs, and surgical subspecialties matches. METHODS: National Residency Matching Program match data and applicant characteristics from 2010 through 2020 were analyzed for US senior allopathic applicants. Integrated programs were defined as plastic and vascular surgery, and surgical subspecialties were defined as otolaryngology, orthopedic surgery, and neurosurgery. Trends were evaluated using linear regression, programs were compared on 10 metrics by Wilcoxon rank-sum tests, and a logistic regression was used to rank each specialty match. RESULTS: The number of US senior applicants per position to integrated programs decreased and approached that of general surgery and surgical subspecialties, but the median number of applicants per position to general surgery was lower than to surgical subspecialties or integrated programs (1.21 interquartile range). Our logistic regression showed United States Medical Licensing Examination scores, research experience, Alpha Omega Alpha Honor Society membership, and graduation from a top medical school to be the most important factors in the match, and our weighted rank score found general surgery (2.85) to be less competitive than surgical subspecialties (1.92) or integrated programs (1.17). CONCLUSION: Throughout the last decade, integrated programs and surgical subspecialties have matched more competitive applicants based on the most significant predictors of the match. Moving forward, it is important that general surgery strives to attract the best and brightest out of medical school.

Where Has All the Complexity Gone? An Analysis of the Modern Surgical Resident Operative Experience.

OBJECTIVES: The operative experience of today's general surgery (GS) residents are changing. The Surgical Council on Resident Education (SCORE) was founded to provide a standardized, competency-based curriculum. We set out to evaluate resident operative experience in core and advanced operations. DESIGN: Accreditation Council for Graduate Medical Education (ACGME) national operative log reports from 2010 to 2018 were reviewed. Operative volume data for 344 operations were extracted and analyzed. Operations were designated as core, advanced, or undefined as listed by SCORE, and stratified as GS or subspecialty. SETTING: National analysis utilizing ACGME operative log reports. PARTICIPANTS: All graduating general surgery residents between 2010 and 2018. RESULTS: A total of 10,118 residents completed GS training with an average of 1121.5 ± 29.3 total cases. Core operations comprised 80.5% of total volume while advanced comprised only 8.0%. The total core experience increased (+7.0 cases/year), while total advanced experience decreased (-1.4 cases/year) (p < 0.01 each). Compositional analysis among core operations revealed an increase in 9/13 GS domains and a decrease in 8/10 subspecialty domains (all p < 0.05). CONCLUSIONS: There has been an increase in core operative experience with a concurrent decrease in advanced operative experience of graduating GS residents. These findings highlight the continued narrowing of the operative experience for trainees, with increasing focus on GS and less on subspecialty domains. Ongoing efforts to look beyond operative volume to ensure competency of graduates will prove beneficial.

Impact of side-to-side cavocavostomy versus traditional piggyback implantation in liver transplantation.

BACKGROUND: Traditional piggyback implantation has often been used in liver transplant; however, this technique may be hindered by difficult visualization and postoperative incidences of outflow obstruction. Side-to-side cavocavostomy is an alternative approach, but perioperative outcomes associated with this technique remain largely unknown. METHODS: In July 2017, side-to-side cavocavostomy was adopted as the standard implantation technique at our institution by all surgeons (n = 4). A prospective cohort of patients undergoing liver transplant with side-to-side cavocavostomy after July 2017 until October 2018 was compared with a historical cohort of patients who underwent liver transplant with traditional piggyback previously from January 2016 to October 2018. RESULTS: Of 290 liver transplant patients, 50% (n = 145) underwent side-to-side cavocavostomy, while the remainder underwent traditional piggyback. There were no differences in recipient age, sex, race, Model for End-Stage Liver Disease score, or donor characteristics between groups. Side-to-side cavocavostomy was associated with decreased mean number intraoperative, red blood cell transfusions (2 vs 5 units), fresh frozen plasma (5 vs 10 units), cell saver (1.0 vs 2.0 L), and rates of temporary abdominal closure (8.3% vs 24.1%) compared with traditional piggyback (all P < .05). The side-to-side cavocavostomy group had lesser Rt3s of postoperative transfusion rates of red blood cells (21.4% vs 35.9%; P = .01). CONCLUSION: Side-to-side cavocavostomy may be superior to traditional piggyback implantation with regard to technical ease and perioperative transfusion requirements. To determine the optimal implantation technique, futures studies should evaluate side-to-side cavocavostomy versus traditional piggyback in a prospective, multicenter, randomized approach.

Does Intentional Support of Degree Programs in General Surgery Residency Affect Research Productivity or Pursuit of Academic Surgery? A Multi-Institutional Study.

OBJECTIVE: To determine whether pursuit of an advanced degree during dedicated research time (DRT) in a general surgery residency training program impacts a resident's research productivity. DESIGN: A retrospective, multi-institutional cohort study. SETTING: General surgery residency programs that were approved to graduate more than 5 categorical residents per year and that offered at least 1 year of DRT were contacted for participation in the study. A total of 10 general surgery residency programs agreed to participate in the study. PARTICIPANTS: Residents who started their residency between 2000 and 2012 and spent at least one full year in DRT (n = 511) were included. Those who completed an advanced degree were compared on the following parameters to those who did not complete one: total number of papers, first-author papers, the Journal Citation Reports impact factors of publication (2018, or most recent), and first position after residency or fellowship training. RESULTS: During DRT, 87 (17%) residents obtained an advanced degree. The most common degree obtained was a Master of Public Health (MPH, n = 42 (48.8%)). Residents who did not obtain an advanced degree during DRT published fewer papers (median 8, [interquartile range 4-12]) than those who obtained a degree (9, [6-17]) (p = 0.002). They also published fewer first author papers (3, [2-6]) vs (5, [2-9]) (p = 0.002) than those who obtained a degree. Resident impact factor (RIF) was calculated using Journal Citation Reports impact factor and author position. Those who did not earn an advanced degree had a lower RIF (adjusted RIF, 84 ± 4 vs 134 ± 5, p < 0.001) compared to those who did. There was no association between obtaining a degree and pursuit of academic surgery (p = 0.13) CONCLUSIONS: Pursuit of an advanced degree during DRT is associated with increased research productivity but is not associated with pursuit of an academic career.

Is Surgery Necessary? Endoscopic Management of Post-transplant Biliary Complications in the Modern Era.

BACKGROUND: Biliary complications are common following liver transplantation (LT) and traditionally managed with Roux-en-Y hepaticojejunostomy. However, endoscopic management has largely supplanted surgical revision in the modern era. Herein, we evaluate our experience with the management of biliary complications following LT. METHODS: All LTs from January 2013 to June 2018 at a single institution were reviewed. Patients with biliary bypass prior to, or at LT, were excluded. Patients were grouped by biliary complication of an isolated stricture, isolated leak, or concomitant stricture and leak (stricture/leak). RESULTS: A total of 462 grafts were transplanted into 449 patients. Ninety-five (21%) patients had post-transplant biliary complications, including 56 (59%) strictures, 28 (29%) leaks, and 11 (12%) stricture/leaks. Consequently, the overall stricture, leak, and stricture/leak rates were 12%, 6%, and 2%, respectively. Endoscopic management was pursued for all stricture and stricture/leak patients, as well as 75% of leak patients, reserving early surgery only for those patients with an uncontrolled leak and evidence of biliary peritonitis. Endoscopic management was successful in the majority of patients (stricture 94%, leak 90%, stricture/leak 90%). Only six patients (5.6%) received additional interventions-two required percutaneous transhepatic cholangiography catheters, three underwent surgical revision, and one was re-transplanted. CONCLUSIONS: Endoscopic management of post-transplant biliary complications resulted in long-term resolution without increased morbidity, mortality, or graft failure. Successful endoscopic treatment requires collaboration with a skilled endoscopist. Moreover, multidisciplinary transplant teams must develop treatment protocols based on the local availability and expertise at their center.

The impact of medical student interest in surgery on clerkship performance and career choice.

BACKGROUND: Interest in surgery has declined for two decades. This study aimed to evaluate the impact of one's interest in surgery on career choice. METHODS: Students who completed the surgical clerkship (2016-2017) were invited to complete surveys assessing rotation experience, learning style, burnout, and grit. Students were grouped according to interest or no interest in surgery after the clerkship. RESULTS: Surveys were completed by 62 students of whom 51.6% reported an interest in surgery. No minority students expressed interest compared with Caucasian (51.1%) and Asian (71.4%) students (p = 0.02). Disinterested students had higher emotional exhaustion (EE, 20 vs 25, p = 0.03). There was no difference in clerkship grade between groups (86.3% vs 85.3%, p = 0.56). Students who matched into surgery had lower EE and higher grit. CONCLUSIONS: Interest in surgery was not associated with improved clerkship performance. Disinterested students had higher EE, suggesting interest may play a role in adapting to clerkship challenges.

Exploring the relationship between burnout and grit during general surgery residency: A longitudinal, single-institution analysis.

BACKGROUND: How burnout changes during general surgery residency remains unknown. METHODS: From 2015 to 2018, general surgery residents completed the Maslach Burnout Inventory and Grit Scale. Statistical analyses were adjusted for repeated measures and compared to the incoming intern level. RESULTS: Fifty-five residents participated in this study. Burnout rates varied by program level, with an increased risk occuring in the third clinical year (OR = 11.7, p = 0.03). Emotional exhaustion (EE) peaked during the first and third clinical years, depersonalization (DP) peaked during the first and second clinical years, and personal achievement (PA) reached a nadir during the third clinical year (all p < 0.05). Residents with burnout had lower grit scores compared to those without burnout (3.71 vs 4.02, p < 0.01). Increasing grit was linearly associated with decreasing EE, decreasing DP, and increasing PA (all p < 0.05). CONCLUSIONS: Burnout varies throughout surgical residency, and grit is inversely related to burnout.

The Impact of Medical Student Burnout on Surgery Clerkship Performance.

OBJECTIVE: Increasing reports on resident burnout have resulted in efforts to improve trainee well-being. Medical student burnout, however, is not well understood. We set out to evaluate burnout among third-year medical students and explore its impact on clerkship performance. DESIGN: Analysis of prospectively-collected survey data from medical students on the third-year surgery clerkship was performed. Surveys included an institution-specific pre- and postclerkship survey, the 12-item Grit Scale, and the Maslach Burnout Inventory. SETTING: University of Cincinnati College of Medicine. PARTICIPANTS: Between 2016 and 2017, 166 students completed the surgery clerkship and were asked to complete the surveys. Sixty-two students (37.4%) completed all surveys and were included in this study. RESULTS: Among the third-year medical student participants, there was no difference in burnout before vs after the clerkship (22.6% vs 17.7%, p = 0.41). Students with burnout had significantly lower grit scores (3.10 ± 0.66) compared to those without burnout (3.63 ± 0.50, p = 0.01). Linear regression analysis demonstrated that increasing grit was associated with decreasing emotional exhaustion (p = 0.01), decreasing depersonalization (p = 0.04), and increasing personal achievement (p = 0.03). Finally, 75% of students with resolution of burnout developed an interest in surgery, whereas all students who developed burnout after the clerkship had no interest in surgery (p = 0.03). Upon completion of the rotation, burnout was not associated with poorer quality of clerkship experience or decreased clerkship performance (p > 0.05 for each). CONCLUSIONS: Although traditionally considered a difficult rotation, we found no increase in medical student burnout following the surgery clerkship. Higher grit scores were associated with decreased burnout, though burnout did not have a negative impact on student experience or performance. Clerkships should continue to set high expectations and maximize educational opportunities without significant apprehension that it may have a negative impact on students.

Predictors of medical student success on the surgery clerkship.

INTRODUCTION: Predictors of student performance on clerkship rotations are limited. In this study, we aim to identify predictors of success on the surgery clerkship. METHODS: 62 third-year medical students completed an institution-specific clerkship survey. Students were grouped according to clerkship grade of honors (HG) versus high-pass or pass (PG). Statistical analyses were performed using Student's t-test, Pearson's Chi-square/Fisher's exact test, and linear regression analysis. Multivariate logistic regression was performed to identify predictors of achieving an honors on the clerkship. RESULTS: HG students were more likely to be individual-based learners with higher grit and USMLE Step 1 scores compared with PG students. Moreover, USMLE Step 1 score was associated with quiz, shelf examination, and final clerkship grades, but not clinical evaluations. There were few differences with regard to preferred learning modalities, but overall, medical students favored active learning activities. CONCLUSIONS: We found that higher USMLE Step 1 score, higher grit score, and an individual-based learning style were associated with a higher grade on the surgery clerkship. However, these factors may not fully capture the less objective components of high performance. Additional methods by which educators can measure students' clinical competency are needed.

Narrowing of the surgical resident operative experience: A 27-year analysis of national ACGME case logs.

BACKGROUND: Although overall operative volume has remained stable since the implementation of duty hours, more detailed analyses suggest shifts in the resident operative experience. Understanding these differences allows educators to better appreciate the impact of the current training environment on resident preparation for practice. METHODS: National Accreditation Council for Graduate Medical Education case logs from 1990 to 2016 were reviewed. Statistical analysis was performed using analysis of variance and linear regression analysis. RESULTS: Over the study period there was no change in total major cases. Subcategory analysis revealed an increase in skin and soft tissue, alimentary tract, abdomen, and endocrine with a concurrent decrease in breast, pediatrics, and trauma. During this time, residents completed fewer cases during their chief year, operated more during non-chief years, taught fewer operations, and assisted in minimal cases. Finally, a decrease in the variability of overall operative volume for total major cases was found as a result of 90th and 10th percentiles converging toward the median. CONCLUSION: Although total major cases logged by residents have remained stable, the operative experience of general surgery residents has narrowed significantly. Residents are operating earlier and performing fewer teaching and first assistant cases. Surgical educators must look beyond total case numbers and be aware of these changes to ensure all residents achieve technical competency on graduation.

Not all operative experiences are created equal: a 19-year analysis of a single center's case logs.

BACKGROUND: Although national operative volumes have remained stable, surgical educators should appreciate the changing experience of today's surgical residents. We set out to evaluate operative volume trends at our institution and study the impact of resident learning styles on operative experience. MATERIALS AND METHODS: The Accreditation Council for Graduate Medical Education operative log data from 1999 to 2017 for a single general surgery residency program were examined. All residents completed the Kolb Learning Style Inventory. Statistical analyses were performed using linear regression analysis, Student's t-test, and Fischer's exact test. RESULTS: Over the study period, 106 general surgery residents graduated from our program. There were 87% action learners and 13% observation learners. Although there was no change in total major, total chief, or total non-chief cases, a decrease in teaching assistant cases was observed. Subcategory analysis revealed that there was an increase in operative volume on graduation in the following categories: skin, soft tissue, and breast; alimentary tract; abdomen; pancreas; operative trauma; pediatric; basic laparoscopy; complex laparoscopy; and endoscopy with a concurrent decrease in liver, vascular, and endocrine. Learning style analysis found that action learners completed significantly more cases than observation learners in most domains in which operative volume increased. CONCLUSIONS: While the operative volume at our center remained stable over the study period, the experience of general surgery residents has become narrowed toward a less subspecialized, general surgery experience. These shifts may disproportionally impact trainees as observation learners operate less than action learners. Residency programs should therefore incorporate methods such as learning style assessment to identify residents at risk of a suboptimal experience.