SIMPL data, complex procedures: a national analysis of chief resident competency in foregut and bariatric surgery

Advanced foregut and bariatric procedures are technically complex and require high levels of operative autonomy and competency. While bariatric surgery training pathways are well established, foregut training remains less standardized. It is unclear whether graduating general surgery residents achieve readiness for independent practice in these procedures.

We performed a national retrospective analysis of System for Improving and Measuring Procedural Learning (SIMPL) evaluations of postgraduate-year 5 (PGY-5) residents from September 2015 to August 2025. Foregut procedures included fundoplication, Heller myotomy, and hiatal hernia repair; bariatric procedures included sleeve gastrectomy and Roux-en-Y gastric bypass. Outcomes included attending-rated competency and meaningful autonomy. Multivariable logistic regression was used to estimate predicted probabilities of achieving competency and autonomy in a given foregut or bariatric procedure and identify factors associated with performance.

A total of 1694 evaluations were analyzed (620 foregut, 1074 bariatric). Attendings rated residents as autonomous in 50.7% of bariatric cases versus 38.2% of foregut cases (p < 0.001), and as competent in 40.7% versus 32.4%, respectively (p < 0.001). Procedure-level variation was observed, with higher performance in sleeve gastrectomy and fundoplication. Residents consistently rated their autonomy and competency lower than attendings across all procedures (p < 0.001). Multivariable analysis demonstrated that residency program accounted for approximately one-third of variability in both competency and autonomy. Predicted probability of competency was 34.4% for foregut and 38.5% for bariatric procedures, while predicted autonomy was 44.6% and 50.7%, respectively.

Less than half of evaluations of graduating chief residents' performance demonstrate competency or meaningful autonomy in advanced foregut and bariatric procedures. Significant variability exists across procedure type and training programs. These findings highlight potential gaps in readiness for independent practice and support the need for standardized competency-based training and assessment in complex minimally invasive surgery.