Comparison of a dual-surgeon versus single-surgeon approach for scoliosis surgery: a systematic review and meta-analysis

Co-surgeon versus Single-surgeon Outcomes in Free Tissue Breast Reconstruction: A Meta-analysis

BACKGROUND

 Autologous breast reconstruction offers superior long-term patient reported outcomes compared with implant-based reconstruction. Universal adoption of free tissue transfer has been hindered by procedural complexity and long operative time with microsurgery. In many specialties, co-surgeon (CS) approaches are reported to decrease operative time while improving surgical outcomes. This systematic review and meta-analysis synthesizes the available literature to evaluate the potential benefit of a CS approach in autologous free tissue breast reconstruction versus single-surgeon (SS).

METHODS

 A systematic review and meta-analysis was conducted using PubMed, Embase, and MEDLINE from inception to December 2022. Published reports comparing CS to SS approaches in uni- and bilateral autologous breast reconstruction were identified. Primary outcomes included operative time, postoperative outcomes, processes of care, and financial impact. Risk of bias was assessed and outcomes were characterized with effect sizes.

RESULTS

 Eight retrospective studies reporting on 9,425 patients were included. Compared with SS, CS approach was associated with a significantly shorter operative time (SMD -0.65, 95% confidence interval [CI] -1.01 to -0.29, p < 0.001), with the largest effect size in bilateral reconstructions (standardized mean difference [SMD] -1.02, 95% CI -1.37 to -0.67, p < 0.00001). CS was also associated with a significant decrease in length of hospitalization (SMD -0.39, 95% CI -0.71 to -0.07, p = 0.02). Odds of flap failure or surgical complications including surgical site infection, hematoma, fat necrosis, and reexploration were not significantly different.

CONCLUSION

 CS free tissue breast reconstruction significantly shortens operative time and length of hospitalization compared with SS approaches without compromising postoperative outcomes. Further research should model processes and financial viability of its adoption in a variety of health care models.

Dual Versus Single Attending Surgeon Performance of Spinal Deformity Surgery? A Meta-Analysis

BACKGROUND

The inclusion of 2 surgeons in spinal deformity surgery is considered beneficial by some. In fact, select studies indicate advantages such as reduced operation time and blood loss. Another observed decreased patient morbidity with a dual-surgeon approach, attributed to shorter operative times and reduced intraoperative blood losses. Therefore, this meta-analysis will assess the benefits of a having 2 surgeons compared to 1 surgeon during spine surgeries.

METHODS

PubMed, Cochrane, and Google Scholar (page 1-20) were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, the rate of transfusion, reoperation, and surgery-related parameters such as operative room time, length of stay (LOS), and estimated blood loss.

RESULTS

Thirteen studies were included. A greater rate of complications was seen in patients operated upon by 1 surgeon (odds ratio = 0.50; 95% confidence intervals [CI]: 0.25-0.99, P = 0.05). Furthermore, operative room time (mean differences = -82.73; 95% CI: -111.42 to -54.03, P < 0.001) and LOS (mean differences = -0.91; 95% CI: -1.12 to -0.71, P < 0.001) were reduced in the dual surgeon scenario. No statistically significant difference was shown in the remaining analyzed outcomes.

CONCLUSIONS

The presence of 2 surgeons in the odds ratiowas shown to reduce complications, operative room time, and LOS. More cost-effectiveness studies are needed in order to substantiate the financial advantages associated with the dual-surgeon approach.

Optimising operating theatre (OT) efficiency while maintaining the standardised patient care in adolescent idiopathic scoliosis (AIS) surgery with the dedicated spine team approach: a specialised spine unit experience

PURPOSE

To report the efficiency of OT utilisation and perioperative outcomes with a dedicated spine team approach in AIS patients who underwent posterior spinal fusion (PSF) surgeries in a consecutive case operation list.

METHODS

Three AIS patients operated in a day (8:00 AM-8:00 PM) by a dedicated spine team were recruited between 2021 and 2022. The dedicated team comprised of three senior spine consultants who operated using a dual attending surgeon strategy, an anaesthetic consultant, dedicated surgical scrub nurses, anaesthesiology nurses, radiographers, and neuromonitoring technicians. Patients were categorised according to the sequence of operation list of the day (Case 1, Case 2, and Case 3). OT efficiency was represented by OT time in five stages (preoperative time, operative time, postoperative time, total OT time, and turnover time). OT time and perioperative outcomes were compared.

RESULTS

102 cases were analysed. On average, Case 1 began at 8:38 AM whereas Case 3 ended by 5:54 PM. OT efficiency was consistent throughout the day of operation with comparable OT time in all five stages between groups (p > 0.05). The mean turnover time was 15.1 ± 13.5 min and the mean operative time was 123.0 ± 28.1 min. Intraoperative arterial blood gas (ABG) parameters were maintained in an optimal range. The complication rate was 2.0% (N = 2/102).

CONCLUSION

Consistent OT efficiency was demonstrated with a dedicated spine team approach. Despite performing three AIS cases in a consecutive case operation list, patients' safety was not compromised as perioperative outcomes between groups were comparable.

Benefits and limitations of a dual faculty neurosurgeon approach to resection of pediatric craniopharyngioma

PURPOSE

The utility and safety of including two neurosurgeons for tumor resections is unknown. This study compares outcomes among pediatric patients with craniopharyngiomas operated on with a dual or single surgeon approach (DSA, SSA).

METHODS

A single-center review identified all craniopharyngioma transsphenoidal or craniotomy resections from 2000 to 2020. Surgical years of experience (YOE) and rates of 5-year reoperations, complications, recurrence, and postoperative radiotherapy were analyzed.

RESULTS

Twenty-six transsphenoidal and 68 craniotomies were identified among 62 patients. Eleven transsphenoidal (42.3%) utilized DSA and 15 utilized (57.7%) SSA. Eight craniotomies (11.8%) were DSA and 60 (88.2%) were SSA. The surgeon for SSA transsphenoidal procedures had a median of 10.7 YOE (IQR: 9.9-13.7) versus 6.6 (IQR: 2.7-16; p = 0.058) for the lead surgeon in DSAs. The co-surgeon in transsphenoidal DSAs had a median of 27 YOE (IQR: 11.8-35.7). The surgeon for SSA craniotomies had a median of 19.3 YOE (IQR: 12.1-26.4) versus 4.5 years (IQR: 1.3-15.3; p = 0.017) for the lead surgeon in DSA cases. The co-surgeon in DSA craniotomies had a median of 23.2 YOE (IQR: 12.6-31.4). Case complexity was similar across transsphenoidal groups. DSA transsphenoidal resections had fewer complications (18% DSA vs. 33% SSA), reoperations (45% vs. 53%), and radiation therapy (9.1% DSA vs. 33% SSA) than SSA.

CONCLUSION

Lead surgeons in DSAs are frequently junior surgeons while SSAs typically employ senior surgeons. Outcomes did not significantly differ between DSA and SSA. Mentorship through DSAs does not negatively affect patient care.

Do two operators improve outcomes in left main percutaneous coronary intervention? Insights from the ORPKI Registry

BACKGROUND

Significant left main coronary artery (LMCA) disease is prevalent in 7% of patients undergoing angiography. Limited data exists on the impact of double scrubbing in LMCA PCI. We sought to assess periprocedural outcomes in two-operator LMCA percutaneous coronary intervention (PCI).

METHODS

Using data from the Polish National Registry of PCI (ORPKI), we collected data on 28,745 patients undergoing LMCA PCI from 154 centers. Patients were divided into two groups based on the number of operators performing PCI (one vs. two operators).

RESULTS

LMCA PCI was performed by a single operator in 86% of the cases and by two operators in 14% of cases. Patients treated by two operators had a greater comorbidity burden including diabetes mellitus, arterial hypertension, previous myocardial infarction, and previous revascularization. In addition, these were more likely to be treated in high-volume centers, by operators with higher volume of LMCA PCIs. The risk of periprocedural death (2.37% vs. 2.44%; P=0.78), as well as cardiac arrest, coronary artery perforation, no-reflow, and puncture site bleeding was comparable between the two groups. On multivariable analysis, we found that a two-operator strategy was an independent predictor of periprocedural death, with this effect being much more profound in an elective setting (OR=5.13 [1.37-19.26]; P=0.015), compared to an urgent (ACS) setting (OR=1.32 [1.00-1.73]; P=0.047).

CONCLUSIONS

Our study suggests that a two-operator approach is not necessarily routinely recommended for LMCA interventions, although it can be considered for more complex cases.

Proceedings of the United Kingdom Periprosthetic Joint Infection Meeting 2022: Combined and Arthroplasty Sessions

Considerable variation in practice exists in the prevention, diagnosis, and treatment of periprosthetic joint infection (PJI), which is a devastating complication for patients and surgeons. The consensus principle has been increasingly embraced by the orthopaedic community to help guide practice, especially where high-level evidence remains unavailable. The third United Kingdom Periprosthetic Joint Infection (UK PJI) Meeting was held in Glasgow on April 1, 2022, with more than 180 delegates in attendance, representing orthopaedics, microbiology, infectious diseases, plastic surgery, anesthetics, and allied health professions, including pharmacy and arthroplasty nurses. The meeting comprised a combined session for all delegates, and separate breakout sessions for arthroplasty and fracture-related infection. Consensus questions for each session were prepared in advance by the UK PJI working group, based upon topics that were proposed at previous UK PJI Meetings, and delegates participated in an anonymized electronic voting process. We present the findings of the combined and arthroplasty sessions of the meeting in this article, and each consensus topic is discussed in relation to the contemporary literature.

The Surgical Outcomes of Pedicle Subtraction Osteotomy per Different First Assistant: Retrospective Analysis of 312 Cases

INTRODUCTION

Pedicle subtraction osteotomies (PSOs) are complex spinal deformity surgeries that are associated with high complication rates. They are typically done by an experienced spine surgeon with another attending, resident, or physician assistant serving as the first assistant. The purpose of this study was to determine whether selecting a surgical team for single-level PSO based on case difficulty and fusion length could equalize intraoperative and perioperative outcomes among three groups: dual-attending (DA), attending and orthopaedic resident (RS), and attending and physician assistant (PA).

METHODS

This study was a retrospective cohort analysis of 312 patients undergoing single-level thoracic or lumbar PSO from January 2007 to December 2020 by a fellowship-trained orthopaedic spine surgeon. Demographic, intraoperative, and perioperative data within 30 days and 2 years of the index procedure were analyzed.

RESULTS

Patient demographics did not markedly differ between surgical groups. The mean cohort age was 64.5 years with BMI 31.9 kg/m 2 . Patients with the DA approach had a significantly longer surgical time (DA = 412 min vs. resident = 372 min vs. physician assistant = 323 min; P < 0.001). Patients within the DA group experienced a significantly lower rate of infection (DA = 2.1% [3/140] vs. RS = 7.9% [9/114] vs. PA = 1.7% [1/58], P = 0.043), surgical complication rate (DA = 26% [37/140] vs. RS = 41% [47/114] vs. PA = 33% [19/58], P < 0 .001), and readmission rate (DA = 6.4% [9/140] vs. RS = 12.3% [14/114] vs. PA = 19% [11/58] P = 0.030) within 30 days of surgery. No notable differences were observed among groups in 2-year complication, infection, readmission, or revision surgery rates.

CONCLUSIONS

These study results support the DA surgeon approach. Resident involvement, even in less complex cases, can still negatively affect perioperative outcomes. Additional selection criteria development is needed.

Utilizing two surgeons for neuromuscular scoliosis suggests improved operative efficiency

PURPOSE

Neuromuscular scoliosis (NMS) patients tend to have significant comorbidities with complex medical and surgical histories. When undergoing posterior spinal fusion (PSF), NMS risks can be much higher than the idiopathic population. This study aimed to identify the impact of two experienced pediatric cosurgeons (CS) compared to a single spine surgeon (SS) on the intra- and postoperative results of NMS PSF.

METHODS

A database of NMS patients who had undergone PSF 2016-2021 identified 53 patients, of which 32 were CS, while 21 were SS. Patients' sex, age, weight, diagnosis, curve severity, fusion performed, estimated blood loss (EBL), transfusion rates, hemoglobin, anesthesia and surgical times, length of stay, and complications were collected.

RESULTS

Patient demographics were similar between groups. Curves were more severe in the CS group (p = 0.013). Intraoperatively, CS patients underwent larger corrections (p = 0.089) but in significantly shorter anesthetic (p = 0.0018) and operative (p = 0.0025) times. Blood loss and transfusions were similar. Postoperatively, intensive-care unit (ICU) admission and length of stay (LOS) were similar, but SS had higher rates of both unplanned ICU admissions (p = 0.36) and 30 day readmissions (p = 0.053). Complications overall were similar between the groups both within 30 days (p = 0.40) and in the short-term period (31-90 days, p = 0.76), though the CS cohort had less Grade 2 immediate postoperative pulmonary complications (p = 0.16).

CONCLUSION

Utilizing CS for NMS PSF has been found to reduce operative times. Downstream, additional potential impacts trended toward fewer unplanned ICU admissions, less-frequent postoperative pulmonary complications, and reduced 30-day readmission rates.

A cost analysis of treating postoperative periprosthetic femoral fractures following hip replacement surgery in a UK tertiary referral centre

AIM

This study aims to evaluate costs associated with periprosthetic femoral fracture (PFF) treatment at a UK tertiary referral centre.

METHODS

This study included 128 consecutive PFFs admitted from 02/04/2014-19/05/2020. Financial data were provided by Patient Level Information and Costing Systems. Primary outcomes were median cost and margin. Secondary outcomes were length of stay, blood transfusion, critical care, 30-day readmission, 2-year local complication, 2-year systemic complication, 2-year reoperation and 30-day mortality rates. Statistical comparisons were made between treatment type. Statistical significance was set at p<0.05.

RESULTS

Across the cohort, median cost was £15,644.00 (IQR £11,031.00-£22,255.00) and median loss was £3757.50 (£599.20-£8296.20). The highest costs were ward stay (£3994.00, IQR £1,765.00-£7,013.00), theatre utilisation (£2962.00, IQR £0.00-£4,286.00) and overheads (£1705.10, IQR £896.70-£2432.20). Cost (£17,455.00 [IQR, £13,194.00-£23,308.00] versus £7697.00 [IQR £3871.00-£10,847.00], p<0.001) and loss (£4890.00 [IQR £1308.00-£10,009.00] versus £1882.00 [IQR £313.00-£3851.00], p = 0.02) were greater in the operative versus the nonoperative group. There was no difference in cost (£17,634.00 [IQR £12,965.00-£22,958.00] versus £17,399.00 [IQR £13,394.00-£23,404.00], p = 0.98) or loss (£5374.00 [IQR £1950.00-£10,143.00] versus £3860.00 [IQR -£95.50-£7601.00], p = 0.21) between the open reduction and internal fixation (ORIF) and revision groups. More patients required blood transfusion in the operative versus the nonoperative group (17 [17.9%] versus 0 [0.0%], p = 0.009). There was no difference in any clinical outcome between the ORIF and revision groups (p>0.05).

CONCLUSION

PFF treatment costs are high with inadequate reimbursement from NHS tariff. Work is needed to address this disparity and reduce hospital costs. Cost should not be used to decide between ORIF and revision surgery.

Surgeon perceptions of volume threshold and essential practices for pediatric thyroidectomy✰

INTRODUCTION

The topics of sub-specialization and regionalization of care have garnered increased attention among pediatric surgeons. Thyroid surgeries are one such sub-specialty and are commonly concentrated within practices. A national survey was conducted examining current surgeon practices and beliefs surrounding pediatric thyroid surgery.

METHODS

Non-resident members of the American Pediatric Surgical Association (APSA) were surveyed in October 2020. Respondents were stratified based on self-reported thyroid surgical experience. Those who performed thyroid surgery were asked about surgical technique and operative practices; those who did not were asked about referral patterns. All respondents were asked about perceptions surrounding the volume-outcome relationship for pediatric thyroid surgery.

RESULTS

Among 1015 APSA members, 405 (40%) responded, with 79% (317/400) practicing at academic hospitals, 58% (232/401) practicing in major metropolitan area, and 41% (161/392) with over 10 years of attending pediatric surgery experience. Most respondents (88%, n = 356) agreed that thyroid surgery volume affects outcome, though wide variation was reported in the annual case threshold for "high volume" surgery. Eighty-four respondents (21%) reported performing ≥ 1 pediatric thyroid surgery in the past year. Of these, 82% routinely use recurrent laryngeal nerve monitoring, 32% routinely send hemithyroidectomy patients home the same day, and there was little consensus surrounding postoperative hypocalcemia management. The majority of respondents endorse performing thyroid procedures with a colleague.

CONCLUSIONS

Pediatric thyroid surgery appears to be performed by a subset of active pediatric surgeons, most of whom endorse the use of a dual operating team. More evidence is needed to build consensus around additional perioperative practices.

Effect of surgeon volume on pediatric thyroid surgery outcomes: A systematic review

BACKGROUND

Pediatric thyroidectomy has been identified as a surgical procedure that may benefit from concentrating cases to high-volume surgeons. This systematic review aimed to address the definition of "high-volume surgeon" for pediatric thyroidectomy and to examine the relationship between surgeon volume and outcomes.

METHODS

PubMed, Embase, Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov, and OpenGrey databases were searched for through February 2020 for studies which reported on pediatric thyroidectomy and specified surgeon volume and surgical outcomes.

RESULTS

Ten studies, encompassing 6430 patients, were included in the review. Five single-center retrospective studies reported only on high-volume surgeons, one single center retrospective study reported on only low-volume surgeons, and four national database studies (2 cross sectional, 2 retrospective reviews) reported outcomes for both high-volume and low-volume surgeons. Majority of patients underwent total thyroidectomy (54.9%); common indications for surgery were malignancy (41.7%) and hyperthyroidism/thyroiditis (40.5%). Rates of transient hypocalcemia (11.4% - 74.2%), transient recurrent laryngeal nerve injury (0% - 9.7%), and bleeding (0.5% - 4.3%) varied across studies. Definitions for high-volume pediatric thyroid surgeons ranged from ≥9 annual pediatric thyroid operations to >200 annual thyroid operations (with >30 pediatric cases). Four studies reported significantly better outcomes, including lower post-operative complications and shorter length of hospital stay, for patients treated by high-volume surgeons.

CONCLUSIONS

Despite significant variation in caseloads to define volume, pediatric thyroid patients have generally better outcomes when operated on by higher volume surgeons. Concentration thyroidectomy cases to a smaller cohort of surgeons within pediatric practices may confer improved outcomes.

LEVEL OF EVIDENCE

Systematic Reviews and Meta-Analyses; Level IV.

The benefits of dual-consultant operating in complex breast reconstruction: A retrospective cohort comparison study

BACKGROUND

Dual-consultant operating (DCO) has been introduced in a multitude of surgical specialities. This retrospective cohort comparison study seeks to delineate any benefits DCO may confer on list utilisation, patient safety and training opportunities.

METHODS

A retrospective cohort comparison of all free-flap breast reconstruction cases conducted at a single centre by five consultant plastic surgeons in the period May 2016-May 2020.

RESULTS

A total of 281 patient records were used for analysis; 146 cases were dual consultants compared with 135 single consultants, representing 186 and 158 free flaps, respectively. Patient demographics were near identical in terms of patient age, BMI and ASA grade. Operating times were significantly reduced for both unilateral (mean reduction 59.49 min) and bilateral cases (mean reduction 38.14 min) with the presence of dual consultants. The mean length of stay for dual-consultant cases was on average 0.35 days less than for single consultant cases (p = 0.04). Dual-consultant case complications were less severe than those of single consultant cases (mean Clavien-Dindo severity 1.35 vs 0.96, p = 0.05). The rates of trainee one-to-one consultant training were increased in dual-consultant cases when preparing vessels (0.08 vs 0.35, p=<0.01) and performing anastomosis (0.63 vs 0.77, p = 0.03).

CONCLUSIONS

DCO for complex breast reconstruction confers significant benefits to operating time, list utility and patient safety whilst protecting training opportunities for trainees. Plastic surgery departments looking to redesign services in the post-SARS-CoV-19 era should consider its adoption into their enhanced recovery protocols.

OUP accepted manuscript

Background

Following therapeutic mammoplasty (TM), the contralateral breast may require a later balancing procedure to optimize shape and symmetry. The alternative is to offer patients simultaneous TM with immediate contralateral symmetrization via a dual-surgeon approach, with the goal of reducing costs and minimizing the number of subsequent hospital appointments in an era of COVID-19 surges. The aim of this cost–consequence analysis is to characterize the cost–benefit of immediate bilateral symmetrization dual-operator mammoplasty versus staged unilateral single operator for breast cancer surgery.

Method

A prospective single-centre observational study was conducted at an academic teaching centre for breast cancer surgery in the UK. Pseudonymized data for clinicopathological variables and procedural care information, including the type of initial breast-conserving surgery and subsequent reoperation(s), were extracted from the electronic patient record. Financial data were retrieved using the Patient-Level Information and Costing Systems.

Results

Between April 2014 and March 2020, 232 women received either immediate bilateral (n = 44), staged unilateral (n = 57) for breast cancer, or unilateral mammoplasty alone (n = 131). The median (interquartile range (i.q.r.)) additional cost of unilateral mammoplasty with staged versus immediate bilateral mammoplasty was €5500 (€4330 to €6570) per patient (P < 0.001), which represents a total supplementary financial burden of €313 462 to the study institution. There was no significant difference between groups in age, Charlson comorbidity index, operating minutes, time to adjuvant radiotherapy in months, or duration of hospital stay.

Conclusion

Synchronous dual-surgeon immediate bilateral TM can deliver safe immediate symmetrization and is financially beneficial, without delay to receipt of adjuvant therapy, or additional postoperative morbidity.