In oncology, financial toxicity (FT) is a term that describes the financial distress experienced by cancer patients as they undergo expensive clinical treatment. FT has been shown to have a negative effect on cancer patients’ well-being. The effects of FT can be especially pronounced when patients must undergo complex surgery as part of their treatment to promote survivability. Despite the prevalence of multiple forms of gastrointestinal (GI) cancer, few studies have been conducted to evaluate the impacts of complex GI surgery on FT. Building on recent advances in this important subject, we propose a system to mechanize and streamline the process of FT modeling and prediction in the context of complex GI Surgery. Our aim is to provide healthcare professionals with an easy-to-use and intuitive system to proactively help them develop a personalized GI cancer treatment plan that also mitigates the risks associated with FT for individual cancer patients. We take a modular approach to system design that also includes futureproofing by adopting a plug-in mechanism for the critical machine learning (ML) module. This means the system can readily benefit from, and be in sync with, future advances in ML techniques. This paper describes the technical design of such a system. It demonstrates versatility of the system by exploring application of two popular ML methods for predicting FT formulated alternatively as classification and regression problems. Experimental results show promise in advancing ML for FT modeling and prediction.

Background: Peritoneal relapse after cytoreduction and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is common. Repeat CRS/HIPEC offers the potential for long-term survival in the appropriately selected patient. Methods: We performed a retrospective review of a single institution database to assess perioperative outcomes after repeat CRS/HIPEC for appendiceal (pAC) and colorectal (pCRC) cancers. Kaplan-Meier and Cox estimates were used to assess survival. Results: Of 157 patients, 103 patients underwent initial CRS/HIPEC for pAC (n = 67) or pCRC (n = 36) histologies. Twenty-seven pAC patients (27/67, 40%) and 23/36 pCRC patients (63%) developed disease recurrence. Relapsed patients had a higher burden of disease (PCI), operative length and blood loss and received adjuvant chemotherapy (all p < 0.05). Nine of the 27 relapsed pAC patients and 5 of the 13 relapsed pCRC patients underwent repeat CRS/HIPEC. The median time to repeat CRS/HIPEC was 18 months (4-26 months), and a CCR-0 and CCR-1 were achieved in 79% and 21%, respectively. The 1-, 3- and 5-year OS for pAC patients who underwent repeat CRS/HIPEC was 88.9%, 88.9% and 77.8%, and the 1- and 3-year OS for pCRC patients was 100% and 25%, respectively. Repeat CRS/HIPEC for pAC was associated with significant improvement in OS (p = 0.03), while for pCRC, no significant difference was observed (p = 0.99). Conclusions: Repeat CRS/HIPEC for isolated peritoneal recurrence is safe and offers the potential for long-term survival. Patient selection is key to ensure optimal cytoreduction when considering repeat CRS/HIPEC.

INTRODUCTION:Cancer related mortality amongst the homeless and unhoused has been reported to be significantly higher than the housed population. This study explores cancer screening uptake and barriers in a homeless community in Michigan. METHODS:Questionnaires were administered at two homeless shelters focusing on Hepatitis C (HCV), lung, breast, colon, and cervical cancer screenings. RESULTS:Amongst 143 participants, rates of screening uptake were lowest for breast cancer (44 ​%), followed by colorectal cancer (45 ​%), HCV (55 ​%), and cervical cancer (79 ​%). The three most common barriers to receiving screenings were lack of transportation (21.8 ​%), lack of access to or awareness of screenings (20.5 ​%), and low prioritization of health compared to other insecurities faced while being homeless (17.9 ​%). CONCLUSIONS:Enhancing the unhoused/homeless community's access to cancer screenings is crucial. High willingness to undergo screenings suggests potential targeted interventions, such as providing transportation tokens and comprehensive educational resources, onsite screenings, and potentially employing social work navigators at shelters.

Introduction American Board of Surgery (ABS) In-Training Examination (ITE), or ABSITE, preparation requires an effective study approach. In 2014, the ABS announced the alignment of ABSITE to the SCORE® Curriculum. We hypothesized that implementing a Plan-Do-Study-Act (PDSA) approach would help surgery residents improve their performance on the ABSITE. Method Over 20 years, in a single institution, residents’ ABSITE performance was evaluated over 3 timeframes: Time A (2004-2013), no specific curriculum; Time B (2014-2019), an annual comprehensive ABSITE-simulated SCORE®-based multiple-choice exam (MCQ) was administered; and Time C (2020-2023), like Time B with the addition of the PDSA approach for those with less than 60% correct on the ABSITE-simulated SCORE®-based exam. At the beginning of the academic year, in July, all residents are encouraged to (1) initiate a study plan for the upcoming ABSITE using SCORE® guided by the published ABSITE outlines content topics (Plan), (2) take an ABSITE-simulated SCORE®-based exam in October (Do), (3) assess the results/scores (Study), and (4) identify appropriate next steps (Act). Correlational analysis was performed to evaluate the association between ABSITE scores and ABSITE-simulated SCORE®-based exam scores in Time B and Time C. The primary outcome was the change in the proportions of ABSITE scores <30th percentile. Results A total of 294 ABSITE scores of 94 residents (34 females and 60 males) were analyzed. We found stronger correlation between the correct percentage on ABSITE and ABSITE-simulated SCORE®-based exam scores in Time C (r = 0.73, p < 0.0001) compared to Time B (0.62, p < 0.0001). The percentage of residents with ABSITE scores lower than 30th percentile dropped significantly from 14.0% to 3.7% (p = 0.016). Conclusion Implementing the Plan-Do-Study-Act (PDSA) approach using the SCORE® curriculum significantly enhances residents’ performance on the ABSITE exam. Surgery residents are encouraged to use this approach and to utilize the SCORE-contents outlined by the ABS in their study plan.

Importance: This study aimed to identify both modifiable and nonmodifiable factors that affect intraoperative-specific surgical education and performance, with an overall goal of increasing cognizance of such factors to improve surgical training.Objective: To determine whether surgery residents prepare adequately for participation in surgical cases and to examine specific variables that affect resident preparation.Design: This study is a retrospective survey-based study that included data from 1945 postoperative case evaluations completed by 59 different general surgery residents over a period of 8 years (2014-2022).Setting: A Midwestern medical school's general surgery residency program.Participants: Fifty-nine general surgery residents at Western Michigan University's medical school; 50 attending surgeons and faculty with whom residents regularly operate. The sample was comprised of residents and attendings who voluntarily filled out postoperative performance surveys after elective cases.Results: This retrospective survey-based study included postoperative evaluation data from 1945 procedures performed by 59 different residents and 50 attendings. Participants included 36 male residents, 23 female residents, 39 male attendings, and 11 female attendings. All included data were for elective cases. Self-reported preoperative communication was worst at the PGY1 level with positive correlation of improvement yearly (r = 0.30, p < 0.001). Positive correlation was seen between overall preparedness and case complexity (r = 0.25, p < 0.001). Positive correlation was seen between case complexity and resident perception of intraoperative teaching quality (r = 0.53, p < 0.001). Preoperative communication initiated by residents was significantly worse when the attending surgeon was female, regardless of resident gender (p < 0.001); this effect was particularly profound with male residents. Male residents overall rated themselves as more prepared compared to their female counterparts (11.13 +/- 1.96 vs. 10.84 +/- 2.03, p = 0.003).Conclusions and Relevance: There is a need to identify and address quantifiable gaps in communication between residents and faculty to optimize surgical education; one of the first steps is characterizing nonmodifiable factors that correlate with differences in pre-operative communication and case preparation.

Abstract Background & Methodology: In the United States, the unhoused population experiences disproportionately higher rates of cancer incidence and mortality—double that of the general populace. Despite these startling statistics, there is a notable dearth of research on this topic within medical literature. Our medical student-led pilot study aimed to bridge this knowledge gap by evaluating the uptake of cancer screenings and identifying the barriers faced by the unhoused in Southwest Michigan. Our objective was to enhance the understanding of cancer care disparities and identify factors that hinder access to cancer screenings for this marginalized group. Utilizing questionnaires distributed in homeless shelters, we collected data on the prevalence and impediments to screenings for hepatitis C virus (HCV), and lung, breast, colon, and cervical cancers in a local community. Results: The study encompassed 143 participants, revealing that women reported a shorter median duration of homelessness (5 months) than men (18 months). The primary barriers to cancer screening were access to services and lack of awareness, rather than insurance coverage. Gender disparities were evident in HCV screening, with an overall rate of 55%; however, willingness to screen was higher among women (83%) compared to men (49%). Colon cancer screening showed no significant gender disparity, standing at 45% uptake. The prevalence of smoking was high at 78%, yet a higher proportion of men were amenable to lung cancer screening. Interestingly, Pap smear uptake surpassed national averages, while mammogram rates were below expected at 40%. Discussion & Conclusion: While the discrepancies between genders may not be immediately apparent, our data shows that developing targeted interventions and tailoring the delivery of adequate cancer screenings to the unhoused require consideration of gender as a key factor. Women’s perceived barriers differ slightly from men’s, and generally-speaking, they undergo more cancer screenings per year compared with men. The reluctance among male participants to engage in HCV screening has been observed in other studies as well and as our study demonstrates, it may be related to informational barriers. Although preliminary, our findings shed light on the critical health care issues faced by the unhoused and serves as a steppingstone towards improving our understanding on their challenges in hopes of improving their health outcomes. Comprehensive research is imperative to unravel the complex causes of these gender-based discrepancies. In the interim, the implementation of a navigator social worker system could prove beneficial in facilitating the unhoused with the logistics of screening processes, overcoming transportation hurdles, and reinforcing the importance of ongoing health management. Citation Format: Talal Al-Assil, Claire Kalina, Madison Laird, Nataly Dawood, Raven Riordan, Neya Suresh Kumar, Ryan Olivier, Cheryl Dickson, Gitonga Munene. Hidden epidemics: The gender divide in HCV and cancer screenings among the unhoused [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4799.

This study examines the safety and efficacy of using peak anti-Xa levels to achieve prophylactic enoxaparin (Lovenox, Sanofi-Aventis) levels in patients who underwent hepatic surgery. Prospectively enrolled patients undergoing major and minor hepatic procedures received postoperative enoxaparin dosing. The enoxaparin dose was adjusted to attain a peak anti-Xa level ≥ 0.20 U/ml. This group was compared to a historical cohort of patients who underwent similar procedures and received standard postoperative VTE chemoprophylaxis dosing. Inpatient postoperative VTE rates were higher in the control group when compared to the experimental group (0 patients [0.00%] vs 4 patients [8.16%]; P = .035). There was no statistically significant difference in number of postoperative blood transfusions, discharge hemoglobin, or in-hospital bleeding events. Adjusting enoxaparin dosing to achieve prophylactic peak anti-Xa levels of ≥0.20 IU/ml was associated with a reduced incidence of symptomatic inpatient postoperative VTE in patients who underwent hepatic surgery without increasing postoperative bleeding events.

OBJECTIVES:To describe financial toxicity (FT) in patients who have undergone gastrointestinal (GI) surgery and its correlation with patients' emotional (EWB) and social (SWB) well-being. BACKGROUND:FT describes the financial burden associated with treatment and its impact on patient outcomes. Few prior studies have examined FT in GI surgery and its impact on patient quality of life. METHODS:Patients who underwent GI surgery at our institution were assessed for FT with a validated instrument between January 2022 and January 2023. EWB and SWB were assessed with a validated instrument. Risk factors for FT were determined using a multivariable model. The correlation between FT and patient EWB and SWB was assessed using Pearson correlation. RESULTS:A total of 188 patients were surveyed, the majority had pancreatic resections (n = 90, 47.9%), and 59 (31.4%) patients experienced FT. On multivariable analysis, categories associated with increased likelihood of exhibiting FT included single marital status and not receiving chemotherapy and/or radiation therapy, with an odds ratio (95% CI) of [3.02 (1.07, 8.51), P = 0.037] and [3.86 (1.3, 11.44), P = 0.015) respectively. Higher EWB and SWB scores directly correlated with higher FT scores. CONCLUSIONS:Patients undergoing complex GI surgery often experience FT that affects patient-reported outcomes. FT is associated with identifiable preoperative factors that can be utilized to screen patients for interventions that may mitigate some of the harmful effects of FT.

Background Enhanced recovery after surgery (ERAS) pathways have been shown to improve pancreatic surgery outcomes, though feasibility in a community hospital remain unclear. We hypothesized that an ERAS protocol would reduce hospital length of stay (LOS) without increased morbidity. Methods An ERAS pathway was initiated for patients undergoing pancreatic surgery at a community cancer center and compared to a historical cohort. The primary outcome was hospital LOS. Secondary outcomes included 30-day readmission rates, comprehensive complication index (CCI®), textbook outcomes (TO), and mortality. Results A total of 144 patients were included, with 63 patients in the ERAS group and 81 in the control group. The mean LOS decreased significantly in the ERAS group (6.85 [± 4.8]) vs 9.96 [±6.8] days, P = .001), without an increase in 30-day admission rates or CCI. Conclusions Implementation of an ERAS protocol in a community setting reduced LOS without a corresponding increase in readmission rates or morbidity.

Background: As announced by the Federation of State Medical Boards (FSMB) and National Board of Medical Examiners (NBME), the United States Medical Licensing Examination (USMLE) Step 1 score reporting has transitioned to pass/fail outcomes instead of the traditional numeric score after January 26, 2022. USMLE Step 1 scores have been used widely as a crucial tool in screening and selecting applicants for residency programs. This study aims to determine the role of USMLE Step 2 in the selection of applicants for general surgery residency. Methods: A retrospective study was conducted over six recruiting cycles from 2016 to 2021. The data from 334 interviewed applicants from one general surgery residency program were assessed. Data analyzed included USMLE Step 1 and Step 2 scores, applicant gender, Alpha Omega Alpha (AOA) status, letters of recommendation (LOR), and research/publications (RS). Results: Of the 334 interviewed applicants, 209 (62.6%) were male. The mean [SD] USMLE Step 1 and USMLE Step 2 C K (Clinical Knowledge) scores were 239.6 [+/- 10.4] and 249.2 [+/- 11.4], respectively. The mean (SD) LOR and RS scores were 4.24 [+/- 0.4] and 3.9 [+/- 0.7], respectively. A positive correlation was observed between USMLE Step 1 and USMLE Step 2 C K (Clinical Knowledge) scores (r = 0.60, p < .001), LOR scores (r = 0.24, p = .008), and AOA status (r = 0.19, p = .038). There was a negligible correlation between USMLE scores and applicant gender. Conclusion: Transitioning USMLE Step 1 to pass/fail will make the initial screening and selection process of applications challenging for residency programs. In the short term, USMLE Step 2 scores, LOR, and AOA status are important as screening assessments. Valid measures to ensure appropriate, equitable, and fair assessments are needed.

Background Recommended prophylactic doses of enoxaparin (Lovenox) are associated with subprophylactic anti-Factor Xa (anti-Xa) levels. This study examines the safety and efficacy of anti-Xa-guided dosing of enoxaparin in pancreatic surgery. Methods Prospectively enrolled patients undergoing pancreatic surgery received enoxaparin dosing adjusted based on peak anti-Xa levels and were compared to a historical cohort of patients. Results Baseline characteristics were similar between the intervention and control groups. In the intervention group, 73.9% initially had subprophylactic peak anti-Xa levels. There were no differences in the venous thromboembolism (VTE) rates between the intervention and control groups (0% vs. 7.69%; P = .084), major bleeding events (4.35% vs. 2.56%; P = .627), RBC transfusion (15.2% vs. 25.6%; P = .257), or Hgb on discharge (9.82 vs. 9.44 g/dL; P = .244). Subtherapeutic anti-Xa levels were correlated with a higher BMI (P = .033), longer OR time (P = .011), and length of stay (P = .018). Conclusions Enoxaparin 40 mg once daily is associated with subprophylactic peak anti-Xa levels. Dose adjustment based on anti-Xa levels trended toward a lower rate of in-hospital VTE without an increase in bleeding or transfusion requirement.

BACKGROUND:Femoral hernias are associated with significant morbidity and mortality due to risk of strangulation. Frailty has shown to be strongly associated with adverse outcomes. A modified five-factor frailty index (mFI-5) is a simple validated predictor of postoperative complications and mortality within the ACS-NSQIP® database. This study aims to evaluate the impact of frailty and age on 30-day outcomes after femoral hernia repair.METHODS:Patients who underwent femoral hernia repair were queried using the ACS-NSQIP database (2017) and divided into two groups based on frailty score (FS): Frail (FS = 1-5) and Non-frail (FS = 0). We evaluated the association between postoperative outcomes and frailty, age, sex, presentation, ASA class, timing of surgery, and surgical approaches. Univariate analysis followed by a multivariable logistic regression model was performed to evaluate postoperative morbidity.RESULTS:Of a total of 1,295 patients, 540 (42.7%) were in the Frail group. No differences in sex and race proportions were observed between groups. The Frail group had a higher rate of serious morbidity (4.4% vs 1.9%, P < .001), overall morbidity (7.8% vs 3.4%, P < .010), readmission rate (5.4% vs 2.3%, P = .003), and median (IQR) hospital length of stay (1 [0, 4] vs 0 [0, 1] days, P < .001). In multivariable analysis, male sex, presentation with complication, emergency surgery, and FS were associated with increased odds of overall morbidity. All deaths were in the Frail group.CONCLUSION(S):Frailty, male sex, presentation with obstruction/strangulation, and emergency surgery are independent predictors of increased 30-day morbidity. Thirty-day mortality was noted in the Frail group.

Background: Surgical site infection (SSI) is a common, morbid post-operative complication. We hypothesized the presence of racial differences in SSI rates, comparing black/African American (BAA) to white non-Hispanic (WNH) patients. Patients and Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), BAA and WNH surgery patients across 10 surgical specialties were identified: general surgery (GS), vascular surgery (VS), cardiac surgery (CS), thoracic surgery (TS), orthopedics (OS), neurosurgery (NS), urology (US), otolaryngology (ENT), plastic surgery (PS), and gynecology (GYN). The primary outcome was SSI rate (superficial, deep incisional, or organ/space). The secondary outcome was rate of non-surgical infection. Pearson χ2 and Fisher exact tests were used to test group differences of categorical variables. Continuous variables were tested with the Student t-test, or Mann-Whitney U test, with statistical significance set at a value of p < 0.05. Multivariable logistic regression models were conducted to analyze the association between race/ethnicity and the infection outcomes. Results: A total of 740,144 patients were included: 99,425 (13.4%) BAA and 640,749 (86.6%) WNH, distributed as follows; 32,2976 GS, 17,6175 OS, 44,383 VS, 2,227 CS, 9,645 TS, 42,298 NS, 42,726 US, 18,518 ENT, 20,709 PS, and 60,517 GYN cases. Surgical site infection rates were higher among WNH in GS (4.4% vs. 4.1%; p = 0.003) and TS (3.1% vs. 1.7%; p = 0.015); lower in VS (3.2% vs. 4.4%; p < 0.001), OS (1.2% vs.1.6%; p < 0.001), and GYN (2.4% vs. 3%; p < 0.001); and similar between WNH and BAA in ENT (1.8% vs 1.8%; p = 0.76), and US (1.9% vs. 1.9%; p = 0.90). Non-surgical infection was higher in BAA in NS (3.2% vs. 2.5%; p = 0.003), and higher in WNH in GYN (2.6% vs. 2%; p < 0.001), OS (1.7% vs. 1.1%; p < 0.001), US (4.4% vs. 3.6%; p = 0.014), and VS (3.4% vs. 2.6%; p < 0.001). Conclusions: Variation exists in SSI rates between WNH and BAA patients among surgical subspecialties. Further research is required to understand these differences and address racial disparities in outcomes.

Hepatic undifferentiated embryonal sarcoma of the liver (UESL) is a rare hepatic malignancy found more commonly in pediatric patients. It has been associated with poor outcomes in adults and the role and timing of systemic therapy is unclear. There have been very few case reports detailing combination neoadjuvant and adjuvant chemotherapy use for hepatic undifferentiated embryonal sarcoma in adults. In this report, a 22-year-old male admitted with right upper quadrant pain was diagnosed with a 20 x 10 x 10 cm well-circumscribed, highly vascularized hepatic mass in the entirety of the left lobe. Biopsy confirmed the diagnosis of UESL. PET/CT showed no evidence of metastatic disease, and he received four cycles of Doxorubicin and Ifosfamide with demonstrated reduction in size and decrease in PET avidity. He underwent left hepatectomy with periportal lymphadenectomy, cholecystectomy, and partial gastrectomy with negative margins and received adjuvant Doxorubicin, Ifosfamide and Mesna. At 48 months, the patient was alive without evidence of disease. We hereby emphasize the potential advantages of combination chemotherapy and surgical resection in the management of UESL in adults.

Objective:. The objective of this study is to determine the factors influencing pancreatic surgery patients’ perceptions of the shared decision-making process (SDM). Background:. Decision-making in pancreatic surgery is complicated by the risk of morbidity and mortality and risk of early recurrence of disease. Improvement in SDM has the potential to improve the receipt of goal- and value-concordant care. Methods:. This cross-sectional survey included patients who underwent pancreatic surgery. The following components were studied in relation to SDM: modified satisfaction with decision scale (SWD), modified decisional regret scale (DRS), quality of physician and patient interaction, and the impact of quality of life (FACT-Hep). Correlations were computed using Pearson’s correlation score and a regression model. Results:. The survey completion rate was 72.2% (of 40/55) and the majority (72.5%) of patients underwent pancreaticoduodenectomy. There were significant positive relationships between the SDM measure and (DRS, SWD; r = 0.70, P < 0.001) and responses to questions regarding how well the patient’s actual recovery matched their expectations before treatment (r = 0.62, P < 0.001). The quality of the physician–patient relationship correlated with how well recovery matched expectations (r = 0.53, P = 0.002). SDM measure scores were significant predictors of the decision evaluation measure (R2(adj) = 0.48, P < 0.001), FACT-Hep (R2(adj) = 0.15, P < 0.001), and recovery expectations measure (R2(adj) = 0.37, P < 0.001). Conclusions:. Improved SDM in pancreatic surgery is associated with more realistic recovery expectations, decreased decisional regret, and improved quality of life.

Background The extent to which age impacts surgical outcomes remains poorly characterized. This study aims to evaluate the impact of age on 30-day outcomes in patients after distal pancreatectomy. Methods Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), distal pancreatectomy patients were identified and age-stratified, groups A (<= 75 years) and B (>75 years). Outcomes included 30-day mortality, morbidity, readmissions, operative time (min), and hospital length of stay (LOS, days). Results Of 3042 total patients identified, 1686 (55.4%) were women. A total of 2649 patients (87.1%) were in group A. Overall, both groups had similar baseline characteristics with the exception of the following: diabetes mellitus (24.8% vs. 30.0%, P = .03), smoking (19.3% vs. 4.8%, P < .001), congestive heart failure (.5% vs. 1.8%, P = .010), hypertension (HTN) (47.9% vs. 72.5%, P < .001), bleeding disorders (3.1% vs. 5.3%, P = .036), the American Society of Anesthesiologists (ASA) (III-V) scores (67.6% vs. 85.5%, P < .001), and body mass index (29.2 [+/- 6.7] vs. 27.4 [+/- 5.6], P = .001). Deep surgical site infection was higher in group A (12.1% vs. 6.6%, P = .001), while acute renal failure (ARF) and postoperative myocardial infarction (MI) were higher in group B. 30-day readmissions were higher in group A (17.4% vs. 12.2%, P = .011) despite no statistically significant difference in LOS (7.10 [+/- 6.36] vs. 7.30 [+/- 4.93] days, P = .553) or overall morbidity (29.4% vs. 28.8%, P = .859). Conclusion(s) Those undergoing distal pancreatectomy experienced similar overall morbidity and mortality outcomes regardless of age. However, those older than 75 years had more cardiovascular risk factors, which may have contributed to their higher rates of postoperative ARF and MI.

Introduction: Appropriate faculty supervision and conditional independence of residents during training are required for autonomous and independent postgraduate practice. However, there is a growing concern that competence for transition to independent practice is not universally met. We hypothesize that surgery residents play a significant and active role in achieving their own independent status.Methods: Over seven academic years (July 2014 through June 2021), 46 surgeons supervised and intraoperatively assessed the performance of 51 residents using validated Objective Structured Assessment of Technical Skill (OSATS) and Zwisch Operative Autonomy (ROA) assessments. Resident readiness to perform procedures independently (RRI) was graded as yes, no, or not applicable. Data were analyzed using descriptive statistics with categorical variables reported as frequencies and percentages. Results: A total of 1657 elective procedures were performed by residents supervised by faculty. Association between RRI and postgraduate year (PGY), OSATS scores, ROA, resident and faculty gender, and case complexity was analyzed.Results indicated positive corre-lation between RRI and summative OSATS score (r = 0.510, P < 0.001), PGY (r = 0.535, P < 0.001) and ROA (r = 0.473, P < 0.001). Percentage of overall RRI increased from 7% at PGY1 to 87.4% at PGY5. Meaningful autonomy ratings increased from 23.6% at PGY1 to 92.5% at PGY5. Variations in ratings was observed when considering case category and complexity. Conclusions: RRI increases with years of training with variation when considering the specialty/The Accreditation Council for Graduate Medical Education procedure category and the complexity of cases. Specialty fellowships are a viable option to address the gap in