Training general surgery residents in pediatric surgery: educational value vs time and cost

Background

This study evaluated the educational value of pediatric surgery rotations, the likelihood of performing pediatric operations upon completing general surgery (GS) residency, and time and cost of training GS residents in pediatric surgery.

Methods

A survey was administered to GS residents that evaluated the pediatric surgery rotation and anticipated practice intentions. A retrospective analysis (2005-2006) of operative times for unilateral inguinal hernia repair, bilateral inguinal hernia repair, and umbilical hernia repair was also performed. Procedure times were compared for operations performed by a pediatric surgeon with and without GS residents. Cost analysis was based on time differences.

Results

General surgery residents (n = 19) considered the pediatric surgery rotation to have high educational value (4.7 ± 0.6 of 5) with extensive teaching (4.6 ± 0.7) and operative experience (4.4 ± 0.8). Residents listed pediatric surgery exposure, operative technique, and observed work ethic as most valuable. Upon graduation, residents expect to perform pediatric operations 2 to 3 times annually. Thirty-seven percent of residents felt competent to perform appendectomy (patients >5 years), 32% appendectomy (3-5 years), 21% gastrostomy (>1 year), and 11% inguinal herniorrhaphy (>1 year). Operative times and costs were significantly higher in operative procedures performed with a GS resident.

Conclusion

General surgery residents considered pediatric surgery as a valuable educational experience. Residents anticipate performing pediatric operations a few times annually. Training GS residents in pediatric surgery increased operative time and cost. This information may be useful in determining the appropriate setting for resident education as well as budget planning for pediatric surgical practices.     

What makes a competent surgeon?: Experts' and trainees' perceptions of the roles of a surgeon

Background

Assessment of surgical competence is a priority; however little is known about surgeons' perceptions of competence. We investigated components of competence and adequacy of training in achieving them.

Methods

Using questionnaires, Surgical Attendings and trainees rated the importance of 7 CanMEDS roles that define a competent surgeon (Medical Expert; Communicator; Collaborator; Manager; Health Advocate; Scholar; Professional) and whether training enabled them to achieve competency in each role.

Results

Ninety-two of 125 questionnaires (74%) were completed. Junior trainees attributed lower importance to the roles of Manager, Communicator, Collaborator, and Professional than senior trainees or Attendings. No surgeon stated that they had achieved competency in every role.

Conclusion

Trainee surgeons do not appreciate the importance of all the roles required of a competent surgeon and current training does not ensure competence in all roles. These gaps must be addressed to develop surgeons able to provide the highest quality of care.     

Perception and use of minimal access surgery simulators in pediatric surgery training programs

Background/Purpose

In the current time-restricted training environment, simulator use in surgical teaching is receiving increasing attention. A large body of literature addresses simulators' effectiveness in surgical education. No prior studies assess how widely simulators are actually being used or attitudes about their effectiveness of those involved in training.

Methods

Surveys were e-mailed to all current pediatric surgery trainees and training directors. Queries examined respondents' perceptions about surgical simulators' usefulness and to what extent they are used in their programs. Other questions assessed obstacles to simulator use.

Results

Response rates were high (47% of program directors and 67% of current fellows). Nearly all respondents felt laparoscopic simulators improve training efficiency (88%). About half (55%) report regular simulator availability to trainees. Only 21% of programs have current or planned simulation curricula. Less than half of the training directors (32%) and about half of the fellows (55%) felt they have actually significantly improved trainees' skills.

Conclusions

Trainees and training directors placed significant importance on simulator use in pediatric surgery training. However, most did not feel that simulators had actually improved the trainees' laparoscopic skills. Wider availability of simulation laboratories and protected time for using them would enhance the impact of simulators on pediatric surgery training.     

Skill sets and competencies for the modern military surgeon: Lessons from UK military operations in Southern Afghanistan

Introduction

British military forces remain heavily committed on combat operations overseas. UK military operations in Afghanistan (Operation HERRICK) are currently supported by a surgical facility at Camp Bastion, in Helmand Province, in the south of the country. There have been no large published series of surgical workload on Operation HERRICK. The aim of this study is to evaluate this information in order to determine the appropriate skill set for the modern military surgical team.

Method

A retrospective analysis of operating theatre records between 1st May 2006 and 1st May 2008 was performed. Data was collated on a monthly basis and included patient demographics, operation type and time of operation.

Results

During the study period 1668 cases required 2210 procedures. Thirty-two per cent were coalition forces (ISAF), 27% were Afghan security forces (ANSF) and 39% were civilians. Paediatric casualties accounted for 14.7% of all cases. Ninety-three per cent of cases were secondary to battle injury and of these 51.3% were emergencies. The breakdown of procedures, by specialty, was 66% (1463) orthopaedic, 21% (465) general surgery, 6% (139) head and neck, 5% (104) burns surgery and a further 4% (50) non-battle, non-emergency procedures. There was an almost twofold increase in surgical workload in the second year (1103 cases) compared to the first year of the deployment (565 cases, p < 0.05).

Discussion

Surgical workload over the study period has clearly increased markedly since the initial deployment of ISAF forces to Helmand Province. A 6-week deployment to Helmand Province currently provides an equivalent exposure to penetrating trauma as 3 years trauma experience in the UK NHS. The spectrum of injuries seen and the requisite skill set that the military surgeon must possess is outside that usually employed within the NHS. A number of different strategies; including the deployment of trainee specialist registrars to combat hospitals, more focused pre-deployment military surgery training courses, and wet-laboratory work are proposed to prepare for future generations of surgeons operating in conflict environments.     

Pediatric ovarian malignancies: how efficacious are current staging practices?

Purpose

Conventional staging is not routinely practiced because of a lack of preoperative indicators for pediatric ovarian malignancy. Children's Oncology Group (COG) developed guidelines for germ cell tumors to revise staging to correlate with primary pediatric ovarian pathology. Are COG guidelines being used, and are they applicable to all pediatric ovarian malignancies?

Methods

A 15½-year retrospective review of operative ovarian masses from a single academic center was performed.

Results

There were 424 patients identified, with 46 malignancies (11%). Most were stage I (73%). Complete COG staging was performed in 24%. Each staging component performed was as follows: oophorectomy (91%), examination with or without biopsy of omentum (72%), peritoneum (67%), retroperitoneum (63%), contralateral ovary (56%), and washings (46%). Advanced stages had visible findings at exploration to guide biopsies. Of site-directed biopsies, 40.5% were positive, whereas all random biopsies (n = 38) were negative. Two recurrences and all mortalities (n = 4) had complete initial COG operative staging. Mean duration of follow-up was 3.62 ± 0.365 years.

Conclusion

The COG staging is not consistently followed. All cases of advanced disease were visibly obvious and confirmed with site-directed biopsies. Random samplings were all negative and did not impact stage. Negative outcomes reflected inherent tumor biology not deviation from COG staging. The COG guidelines appear to be sufficient for all pediatric ovarian malignancies.     

Elective intestinal operations in infants and children without mechanical bowel preparation: a pilot study

Background/Purpose

Preoperative mechanical bowel preparation (MBP) for elective intestinal operations has been a long accepted practice. However, MBP is often unpleasant and time-consuming for patients, and clinical trials in adults have not shown improved outcomes. We conducted this pilot study to test whether omitting MBP before elective intestinal operations in infants and children would increase the risk of infectious or anastomotic complications.

Methods

Retrospective review was performed of 143 patients who had an elective colon or distal small bowel procedure performed at our children's hospital between 1990 and 2003.

Results

Thirty-three patients (No PREP) were managed by a single surgeon who routinely omitted MBP, whereas another 110 patients (PREP) were prepared with enemas, laxatives, or both. Both groups received 24 hours of preoperative dietary restriction to clear liquids and perioperative parenteral antibiotics. The No PREP group had one anastomotic leak and no wound infections, whereas the PREP group had 2 anastomotic leaks and 1 wound infection (P = .58). These results occurred despite greater duration of antibiotic therapy and incidence of delayed wound closures in the PREP group.

Conclusion

The results of this pilot study suggest that omitting MBP before elective intestinal operations in infants and children carries no increased risk of infectious or anastomotic complications. Eliminating MBP may reduce health care costs and inconvenience to patients. These findings warrant a large, prospective, randomized clinical trial to validate our findings and to investigate further the necessity of MBP in the pediatric population.     

Military General Surgical Training Opportunities on Operations in Afghanistan

INTRODUCTION

In the UK, general surgical specialist trainees have limited exposure to general surgical trauma. Previous work has shown that trainees are involved in only two blunt and one penetrating trauma laparotomies per annum. During their training, nearly half of trainees will not be involved in the surgical management of liver injury, 20% will not undertake a trauma splenectomy and only a quarter will see a trauma thoracotomy. Military general surgical trainees require training in, and exposure to, the surgical management of trauma and specifically military wounding patterns that is not available in the UK. The objective of this study was to determine whether operative workload in the sole British surgical unit in Helmand Province, Afghanistan (Operation HERRICK) would provide a training opportunity for military general surgical trainees.

PATIENTS AND METHODS

A retrospective theatre log-book review of all surgical cases performed at the Role 2 (Enhanced) treatment facility at Camp Bastion, Helmand Province on Operation HERRICK between October 2006 and October 2007, inclusive. Operative cases were analysed for general surgical trauma, laparotomy, thoracotomy, vascular trauma and specific organ injury management where available.

RESULTS

A total of 968 operative cases were performed during the study period. General surgical procedures included 51 laparotomies, 17 thoracotomies and 11 vascular repairs. There were a further 70 debridements of general surgical wounds. Specific organ management included five cases of liver packing for trauma, five trauma splenectomies and four nephrectomies.

CONCLUSIONS

A training opportunity currently exists on Operation HERRICK for military general surgical specialist trainees. If the tempo of the last 12 months is maintained, a 2-month deployment would essentially provide trainees with the equivalent trauma surgery experience to the whole of their surgical training in the UK NHS. Trainees would gain experience in military trauma as well as specific organ injury management.     

The changing face of the general surgeon: national and local trends in resident operative experience

Background

The authors hypothesized that the increasing use of nonoperative management, percutaneous and endoscopic intervention, minimally invasive surgery, and endovascular surgery has radically altered case mix and resident training.

Methods

A review was performed of the Nationwide Inpatient Sample and Accreditation Council for Graduate Medical Education reports from 1993 to 2007 and of local resident operative logs for 2002 to 2008.

Results

For all nationwide procedures, there have been major increases in percutaneous interventions, angiographic embolizations, and endovascular surgery, with corresponding sharp declines in major open biliary, aortic, colon, and trauma cases. In training programs, there have been small decreases in total case numbers but major changes in the operative case mix at the expense of traditional open surgery. A profound decline in open vascular surgery is noted. At the authors' institution, similar radical changes in the operative case mix were demonstrated.

Conclusions

Nationwide trends toward the increased use of nonoperative, minimally invasive, endoscopic, and endovascular techniques are altering the operative experience of surgeons and residents in training. This may radically change the abilities and expectations for the field of general surgery and what it means to be a “general surgeon.”     

Can medical students achieve skills proficiency through simulation training?

Background

The purpose of this study was to determine whether third-year medical students can become proficient in open technical skills through simulation laboratory training.

Methods

A total of 204 students participated in a structured curriculum including bladder catheterization, breast examination, and knot-tying. Proficiency was documented using global rating scales and validated, objective, model-based metrics.

Results

For catheterization and breast examination, all trainees showed proficiency, and self-rated comfort increased in more than 90%. For knot-tying, 83% completed the curriculum; 57% and 44% of trainees showed proficiency for 2- and 1-handed tasks, respectively. Objective performance scores improved significantly for 2- and 1-handed knot-tying (62.9-94.4 and 49.2-89.6, respectively; P < .001) and comfort rating also increased (28%-91% and 19%-80%, respectively; P < .001).

Conclusions

Objective scores and trainee self-ratings suggest that this structured curriculum using simulator training allows junior medical students to achieve proficiency in basic surgical skills.     

Laparoscopic hernia repair in infancy and childhood: evaluation of 2 different techniques

Purpose

Laparoscopic hernia repair in infancy and childhood is still debatable. There are many techniques available for laparoscopic hernia repair in children. The objective of this study was to compare intracorporeal suturing and knotting with extracorporeal knotting for repair of congenital inguinal hernia in infants and children about operative time, recurrence rate, hydrocele formation, and postoperative cosmetic results. A randomized controlled study was carried out in the Pediatric Surgery Unit of Al-Azhar University Hospitals (Cairo, Egypt) over a 3-year period.

Patients and Methods

One hundred fifty patients with congenital inguinal hernia were randomized into 2 equal groups (n = 75). Group A was subjected to intracorporeal purse string suture around the internal inguinal ring (IIR) using 2 needle holders. Group B was subjected to insertion of purse string suture around IIR using a Reverdin needle (RN) and extracorporeal knotting. Inclusion criteria included bilateral inguinal hernia, recurrent hernia, hernia in obese children, incarcerated hernia, and ipsilateral hernia with questionable hernia on the contralateral side. Exclusion criteria included unilateral inguinal hernia and hernia with undescended testicles. The main outcome measurements were operative time, length of hospital stay, postoperative hydrocele formation, recurrence rate, and cosmetic results.

Results

There were no significant differences about age, sex, and mode of presentation between both groups. All cases were completed successfully without conversion. There were significant statistical differences in the operative time, recurrence rate, and cosmetic results between the studied groups, whereas there were no significant statistical differences in the hospital stay and postoperative hydrocele formation.

Conclusion

Laparoscopic hernia repair by RN is an effective method of hernia repair in infants and children. It resulted in a marked reduction of operative time and excellent cosmetic results with low recurrence.     

Necessity for improvement in endoscopy training during surgical residency

Background

The Residency Review Committee for Surgery has recently increased the required number of cases needed to achieve competency in endoscopy training.

Methods

A 10-question survey was sent to program directors for general surgery residencies. Endoscopic training patterns, facilities, perspectives, and residents' performance were examined.

Results

Seventy-one surgery programs (30%) responded to the survey. Of these, 42% (n = 30) had a program size of 3 to 4 residents. Ten percent (n = 7) of all programs could not fulfill the minimum Accreditation Council for Graduate Medical Education (ACGME) requirements. Only 55% (n = 39) of programs had a dedicated rotation in endoscopy and an endoscopic skills training laboratory in their program. Few programs had their residents performing more than 100 cases of gastroscopy (18%) and colonoscopy (21%).

Conclusions

Future endoscopy training for surgical residents needs to be improved to comply with the new requirements. This would include provision of an endoscopic skills laboratory, dedicated endoscopic rotations, and increasing the number of staff surgeons who perform endoscopic procedures.     

Transfer of training in the development of intracorporeal suturing skill in medical student novices: a prospective randomized trial

Background

To help optimize the use of limited resources in trainee education, we developed a prospective randomized trial to determine the most effective means of teaching laparoscopic suturing to novices.

Methods

Forty-one medical students received rudimentary instruction in intracorporeal suturing, then were pretested on a pig enterotomy model. They then were posttested after completion of 1 of 4 training arms: laparoscopic suturing, laparoscopic drills, open suturing, and virtual reality (VR) drills. Tests were scored for speed, accuracy, knot quality, and mental workload (National Aeronautics and Space Administration [NASA] Task Load Index).

Results

Paired t tests were used. Task time was improved in all groups except the VR group. Knot quality improved only in the open or laparoscopic suturing groups. Mental workload improved only for those practicing on a physical laparoscopic trainer.

Conclusions

For novice trainees, the efficacy of VR training is questionable. In contrast, the other training methods had benefits in terms of time, quality, and perceived workload.     

Pediatric surgery workforce: supply and demand

Introduction

Recent studies report a shortage of pediatric surgeons in the United States. We surveyed members of the American Pediatric Surgical Association (APSA) to estimate current workforce and demand and to provide data for workforce planning.

Methods

We conducted a survey of 849 APSA members to provide workforce data on their communities as follows: the number of active, retired, or inactive APSA surgeons; non-APSA fellowship graduates; surgeons without accredited fellowship training; and the estimated demand for additional pediatric surgeons. Internet search engines identified surgeons and practices offering pediatric surgical services. The US Census Metropolitan Statistical Areas (MSAs) defined service areas with populations of 100,000 or more.

Results

Of 137 MSAs with APSA members in practice, we obtained data from 113 (83%), with 247 (29%) of 849 surgeons responding. We estimate that the current pediatric surgical workforce consists of 1150 surgeons, with APSA members in active practice (60%) forming the single largest group, followed by general surgeons (21%). The percentage of active APSA surgeons was greater than the percentage of general surgeons in the 50 largest MSAs (76% vs 2%, respectively), whereas the opposite was observed in the smaller MSA ranked more than 51 in population (37% vs 46%, respectively). American Pediatric Surgical Association respondents estimated a national demand for 280 additional pediatric surgeons. Active APSA surgeons plan to delay retirement (8% of respondents) because it would leave their group or community shorthanded; 2% reported that retirement would leave the community without a pediatric surgeon.

Discussion

Workforce shortage in pediatric surgery is a problem of number and distribution. Incentives to direct trainees to underserved areas are needed. General surgeons provide pediatric services in many communities. Surgical training should include additional training in pediatric surgery.     

An alternative to open incision and drainage for community-acquired soft tissue abscesses in children

Background

The continually rising incidence of soft tissue abscesses in children has prompted us to seek an alternative to the traditional open incision and drainage (I&D) that would minimize the pain associated with packing during dressing changes and eliminate the need for home nursing care.

Study Design

A retrospective review of all patients with soft tissue abscesses from November 2007 to June 2008 was conducted after institutional review board approval. Patients who were treated with open I&D were compared to those treated with placement of subcutaneous drains through the abscess cavities. Both groups received equivalent antibiotic treatment, and all patients were followed in outpatient clinics until infection resolved. The demographics, presenting temperature, culture results, and outcomes were compared between these 2 groups.

Results

A total of 219 patients were identified; 134 of them underwent open I&D, whereas 85 were treated with subcutaneous drains. The demographics, anatomical location of the abscesses, and bacteriology were comparable between the 2 groups. There were equal number of patients in each group who presented with fever initially. Of those treated with open I&D, 4 had metachronous recurring abscesses within the same anatomical region and 1 patient required an additional procedure because of incomplete drainage. There were no recurrences or incomplete drainages in the subcutaneous drain group. The cosmetic appearance of the healed wound from subcutaneous drain placement during the immediate follow-up period is better than that of an open I&D.

Conclusions

Placement of a subcutaneous drain for community-acquired soft tissue abscesses in children is a safe and equally effective alternative to the traditional I&D.     

Operative performance in laparoscopic cholecystectomy using the Procedural-Based Assessment tool

Aims

The Intercollegiate Surgical Curriculum Project (ISCP) has devised assessment tools for index operations to assess trainee technical skills. In this study we used the Procedural-Based Assessment (PBA) tool to evaluate operations performed by trainees.

Methods

Live and simulated laparoscopic cholecystectomies were performed by trainees. Two experienced surgeons assessed each operation blindly and independently.

Results

Eighty-four live (supervised) and 112 simulated (unsupervised) operations were performed by 28 trainees. Mean inter-rater reliability was kappa = .86 and .84 for live and simulated operations, respectively. Construct validity using Mann-Whitney for generic technical skills was significant for live and simulated operations, P ≤ .05. Assessing specific technical skills showed construct validity for simulated unsupervised operations only, Mann-Whitney P < .05, but not for supervised live operations, Mann-Whitney P > .05.

Conclusions

The PBA showed good inter-rater reliability. Assessing generic technical skills, PBA showed construct validity for both types of operations and for specific technical skills in the unsupervised simulated operations. We conclude that the PBA seems to be a reliable and valid assessment tool for generic technical skills in unsupervised simulated and live supervised laparoscopic cholecystectomies.     

Distractions and surgical proficiency: an educational perspective

Background

Surgery training requires residents to focus on tasks while minimizing the effect of distractions. There is a need to develop training methodologies that can enable surgical residents to hone this ability.

Methods

Fourteen surgical residents were divided into 2 groups. They were trained to perform simulated tasks in a noiseless environment and subsequently performed these tasks in a distractive one. In a follow-up experiment, an experimental group was trained in noisy and distractive conditions and was compared with a control group trained in noiseless conditions.

Results

Residents who trained in noiseless environments possessed decreased surgical proficiency when performing the identical tasks in realistic environments (P < .05). Pretraining in a noisy environment improves surgical proficiency.

Conclusions

Noise and distractions can significantly impede performance of surgical residents, but this effect can be nullified by introduction of noise and distractions in the training environment.     

Graduating general surgery resident operative confidence: perspective from a national survey

Background

General surgical training has changed significantly over the last decade with work hour restrictions, increasing subspecialization, the expanding use of minimally invasive techniques, and nonoperative management for solid organ trauma. Given these changes, this study was undertaken to assess the confidence of graduating general surgery residents in performing open surgical operations and to determine factors associated with increased confidence.

Methods

A survey was developed and sent to general surgery residents nationally. We queried them regarding demographics and program characteristics, asked them to rate their confidence (rated 1–5 on a Likert scale) in performing open surgical procedures and compared those who indicated confidence with those who did not.

Results

We received 653 responses from the fifth year (postgraduate year 5) surgical residents: 69% male, 68% from university programs, and 51% from programs affiliated with a Veterans Affairs hospital; 22% from small programs, 34% from medium programs, and 44% from large programs. Anticipated postresidency operative confidence was 72%. More than 25% of residents reported a lack of confidence in performing eight of the 13 operations they were queried about. Training at a university program, a large program, dedicated research years, future fellowship plans, and training at a program that performed a large percentage of operations laparoscopically was associated with decreased confidence in performing a number of open surgical procedures. Increased surgical volume was associated with increased operative confidence. Confidence in performing open surgery also varied regionally.

Conclusions

Graduating surgical residents indicated a significant lack of confidence in performing a variety of open surgical procedures. This decreased confidence was associated with age, operative volume as well as type, and location of training program. Analyzing and addressing this confidence deficit merits further study.     

Leading an academic health center in the 21st century: a pediatric surgeon's perspective

Purpose

At present, there is a gathering storm that is threatening the very practice of the art of medicine for future generations as never before. This article gives successful examples and calls for approaches that support improvements in education and health care for low-income and minority populations.

Methods

To address this problem, the University of Texas Health Science Center at San Antonio established the Regional Academic Health Center (RAHC) along the Texas/Mexico border, which provides educational opportunities, clinical partnerships, and facilities to attract faculty to research and examine the health problems that are common in the Hispanic population.

Results

In less than 4 years at the RAHC, nearly 100 medical students have been educated and 60% of residents are staying in the border area to practice. The creation of the RAHC has also has stimulated interest in students who are largely Hispanic to pursue health professional education. The University of Texas Health Science Center at San Antonio is now the number one public medical school graduating the most Hispanics in the nation.

Conclusions

The concept of the RAHC is an important means of addressing access to health care while serving as a catalyst to increase opportunities for students of all backgrounds to pursue health professional education.     

The Kolb learning cycle in American Board of Surgery In-Training Exam remediation: the Accelerated Clinical Education in Surgery course

Background

Surgical training integrates the 4 steps of the Kolb learning cycle. Residents who scored at 30th percentile or less on the American Board of Surgery In-Training Exam (ABSITE) were enrolled in the Accelerated Clinical Education in Surgery (ACES) course that incorporated the Kolb cycle.

Methods

For concrete experience, Surgical Education and Self-Assessment Program (SESAP-13) was completed according to the syllabus. For reflective consideration, further reading was done on SESAP 13 topics and corresponding ABSITE Keywords. For the abstract hypotheses step; these keywords and topics were reviewed with the mentor. Active testing involved a required weekly on-line quiz based on the syllabus.

Results

Correct scores on the ABSITE increased for 78.6% of residents in the ACES course, with 28.6% scoring 30th percentile or greater. Senior percent correct scores increased by 7.3% and junior percentile scores by 12.5%.

Conclusions

Remediation using the Kolb cycle improved ABSITE performance for a majority of participants.     

Positive peritoneal lavage cytology is a predictor of worse survival in locally advanced pancreatic cancer

Background

Peritoneal lavage cytology in the staging of pancreatic cancer is not widely used given improvements in computed tomography (CT). The aim of this study was to determine the utility of peritoneal lavage cytology in predicting survival in locally advanced pancreatic cancer.

Methods

Between 2000 and 2008, 202 patients with biopsy-proven pancreatic cancer who were determined by pancreas protocol CT to be locally advanced and not currently resectable underwent diagnostic laparoscopy and peritoneal lavage for cytology (DL-PLC).

Results

DL-PLC upstaged 58 of 202 patients (29%) to stage IV, who had a significantly worse median survival of 11 months versus 16 months (P = .03). Positive cytology was an independent predictor of worse survival (P = .02).

Discussion

Positive peritoneal cytology (stage IV disease) in locally advanced pancreatic cancer is common and predicts worse survival. This survival difference suggests that peritoneal cytology status might be useful in deciding treatment regimens in patients with locally advanced disease based on CT.