Do Not Blame the Resident: the Impact of Surgeon and Surgical Trainee Experience on the Occurrence of Intraoperative Adverse Events (iAEs) in Abdominal Surgery

Kidney Transplantation Anastomotic Time Is Jointly Associated With Resident and Attending Experience

INTRODUCTION

Few studies evaluate the interplay of attending and resident learning curves in surgical education. Anastomotic time is known to be correlated with transplant outcomes in kidney transplantation. We aimed to evaluate the correlation between the combination of resident and attending experience and anastomotic time in kidney transplantation.

METHODS

We conducted a single-center retrospective cohort study of deceased donor kidney transplants from 2006 to 2019. To analyze the effect of attending and resident experience, dyads were classified as six combinations of early versus later practice attending and resident postgraduate year (PGY-2, PGY-3, and PGY-4/5). Attendings with less than 3 y of postfellowship practice were considered early practice. Linear mixed effects models tested the effects of attending experience, resident PGY, recipient body mass index, and technical operative characteristics (number of donor arteries, operative side) on anastomosis time.

RESULTS

The final linear mixed effects model included 1306 transplants. Compared to later practice attendings with PGY-4/5 residents as reference, early practice attendings paired with PGY-2 or PGY-3 residents had longer anastomotic times (P ≤ 0.005) when adjusted for recipient body mass index, number of donor arteries, and transplant side. When PGY-4/5 residents were paired with early practice attendings, no difference in anastomotic time was demonstrated. When paired with later practice attendings, PGY-2 residents had longer anastomotic times (P < 0.001) while PGY-3 anastomotic times did not differ from PGY-4/5.

CONCLUSIONS

This study demonstrates the correlation between trainee and attending experience jointly and anastomotic time, suggesting that pairing residents and attendings by experience may improve surgical training and potentially patient-related outcomes.

A Narrative Review on Intraoperative Adverse Events: Risks, Prevention, and Mitigation

INTRODUCTION

Adverse events from surgical interventions are common. They can occur at various stages of surgical care, and they carry a heavy burden on the different parties involved. While extensive research and efforts have been made to better understand the etiologies of postoperative complications, more research on intraoperative adverse events (iAEs) remains to be done.

METHODS

In this article, we reviewed the literature looking at iAEs to discuss their risk factors, their implications on surgical care, and the current efforts to mitigate and manage them.

RESULTS

Risk factors for iAEs are diverse and are dictated by patient-related risk factors, the nature and complexity of the procedures, the surgeon's experience, and the work environment of the operating room. The implications of iAEs vary according to their severity and include increased rates of 30-day postoperative morbidity and mortality, increased length of hospital stay and readmission, increased care cost, and a second victim emotional toll on the operating surgeon.

CONCLUSIONS

While transparent reporting of iAEs remains a challenge, many efforts are using new measures not only to report iAEs but also to provide better surveillance, prevention, and mitigation strategies to reduce their overall adverse impact.

The Impact of Trainee Involvement on Outcomes in Metabolic and Bariatric Surgery

BACKGROUND

The number of bariatric operations performed in the USA rises annually. Trainee exposure to this field is necessary to ensure competency in future surgical generations. However, the safety of trainee involvement of these operations has been called into question.

OBJECTIVES

The aim of our study is to describe differences in outcomes between trainees and non-trainees as first assistants (FA) in sleeve gastrectomy (SG).

SETTING

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database METHODS: Patients from the MBSAQIP database who underwent primary SG from 2015 to 2020 were identified. Statistical analysis included two-tailed t-tests and χ2-tests to evaluate the impact of trainees (residents and fellows) compared to non-trainees on post-operative morbidity and operative time.

RESULTS

Of the 559,324 cases, 25.8% were performed with trainees as FA. Operative length was 27.9% longer in trainee cases. In the trainee group, there was a higher risk of conversion to open procedure (OR 1.32), readmission (OR 1.19), and specific complications (cardiac arrest, myocardial infarction, progressive renal insufficiency, pulmonary embolism, sepsis, transfusion, intubation, UTI, VTE, ICU admission, and reintervention), though overall rates were < 1% in each group. Non-trainees had a higher rate of septic shock (OR 1.4). No significant difference was seen in all other perioperative outcomes.

CONCLUSION

Trainee involvement in SG leads to longer operative times without a clinically significant increase in morbidity and mortality. Such findings should be used to counsel patients and shape expectations for surgeons and hospitals. A focused bariatric surgery trainee curriculum may lessen this gap.

The Safe Cholecystectomy: Evaluating the Use of Laparoscopic Subtotal Cholecystectomy Between Junior and Senior Faculty

BACKGROUND

Laparoscopic Subtotal Cholecystectomy (SC) is a technique for performing safe cholecystectomy when excessive inflammation prevents exposure of the Critical View of Safety. Studies have evaluated outcomes and complications of laparoscopic cholecystectomy (LC), with mixed results in terms of surgeon experience. It is unclear if the rate of SC is associated with experience. We hypothesized that the rate of SC would decrease as surgical experience increased.

METHODS

We performed a retrospective review of LC performed at an academic medical center. Demographics were analyzed using descriptive statistics. We performed a multivariable logistic regression to examine the relationship between years in practice and performance of SC. We performed a sensitivity analysis comparing those in their first year on faculty with all others.

RESULTS

Between November 1, 2017, and November 1, 2021, there were 1222 LC performed. 771 patients (63%) were female. 89 patients (7.3%) underwent SC. There were no bile duct injuries requiring reconstruction. Controlling for age, sex, and ASA class, there was no difference in the rate of SC by years of experience (OR .98, 95% CI .94-1.01). In a sensitivity analysis comparing first-year faculty to those beyond their first year, there was also no difference (OR .76, 95% CI 0.42-1.39).

DISCUSSION

We find no difference in the rate of performance of SC between junior and senior faculty. This reflects consistency, in keeping with best practice guidelines. This could be confounded by junior faculty requesting assistance during difficult operations. Further investigation into factors affecting decision-making may clarify this.

Resident training in colorectal laparoscopic surgery: A retrospective morbidity, mortality and survival analysis of 408 cases in our environment

INTRODUCTION

Colorectal cancer has a growing incidence in our society. However, the performance of laparoscopic interventions in this field is still not included in the National Training Program. Given the lack of references, our objective was to analyze the resident's participation in laparoscopic colorectal surgery and its possible effect on morbidity and mortality and oncological prognosis.

METHODS

A retrospective longitudinal single-center study that included all laparoscopic colorectal surgical procedures performed by residents (R group) and by attending surgeons (A group) between 01/01/2009 and 12/31/2017, maintaining follow-up until 12/31/2018. Postoperative morbidity and mortality, overall survival (OS) and disease- free survival (DFS), as well as their relationship with the resident involvement as first surgeon were analyzed.

RESULTS

408 patients were analyzed, of which 138 (33.8%) were operated by a supervised resident and 270 (66.2%) by the attending surgeon. No differences were detected in the rate of postoperative complications between both groups (OR: 1.536; 95% CI: 0.947-2.409; p = 0.081). Furthermore, resident participation had no influence on tumor recurrence rate (R Group: 14.2% vs. A Group: 16.9%; p = 0.588) or on overall (p = 0.562) or disease-free survival (p = 0.305).

CONCLUSION

Resident involvement in laparoscopic colorectal surgery had no influence on morbidity and mortality or oncological prognosis in our center. Conducting prospective studies in this regard will provide greater knowledge, enabling a progressive improvement of the training program.

Intraoperative Deaths: Who, Why, and Can We Prevent Them?

INTRODUCTION

Intraoperative deaths (IODs) are rare but catastrophic. We systematically analyzed IODs to identify clinical and patient safety patterns.

METHODS

IODs in a large academic center between 2015 and 2019 were included. Perioperative details were systematically reviewed, focusing on (1) identifying phenotypes of IOD, (2) describing emerging themes immediately preceding cardiac arrest, and (3) suggesting interventions to mitigate IOD in each phenotype.

RESULTS

Forty-one patients were included. Three IOD phenotypes were identified: trauma (T), nontrauma emergency (NT), and elective (EL) surgery patients, each with 2 sub-phenotypes (e.g., ELm and ELv for elective surgery with medical arrests or vascular injury and bleeding, respectively). In phenotype T, cardiopulmonary resuscitation was initiated before incision in 42%, resuscitative thoracotomy was performed in 33%, and transient return of spontaneous circulation was achieved in 30% of patients. In phenotype NT, ruptured aortic aneurysms accounted for half the cases, and median blood product utilization was 2,694 mL. In phenotype ELm, preoperative evaluation did not include electrocardiogram in 12%, cardiac consultation in 62%, stress test in 87%, and chest x-ray in 37% of patients. In phenotype ELv, 83% had a single peripheral intravenous line, and vascular injury was almost always followed by escalation in monitoring (e.g., central/arterial line), alert to the blood bank, and call for surgical backup.

CONCLUSIONS

We have created a framework for IOD that can help with intraoperative safety and quality analysis. Focusing on interventions that address appropriateness versus futility in care in phenotypes T and NT, and on prevention and mitigation of intraoperative vessel injury (e.g., intraoperative rescue team) or preoperative optimization in phenotype EL may help prevent IODs.

The Resident-Run Minor Surgery Clinic: A Four-Year Analysis of Patient Outcomes, Satisfaction, and Resident Education

OBJECTIVE

A resident-run minor surgery clinic was developed to increase resident procedural autonomy. We evaluated whether 1) there was a significant difference between complications and patient satisfaction when procedures were independently performed by surgical residents vs. a surgical attending and 2) if participation was associated with an increase in resident procedural confidence.

DESIGN

Third year general surgery residents participated in a weekly procedure clinic from 2014-2018. Post-procedure complications and patient satisfaction were compared between patients operated on by residents vs. the staff surgeon. Residents were surveyed regarding their confidence in independently performing a variety of clinic-based patient care tasks.

SETTING

Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program.

PARTICIPANTS

Post-graduate year three general surgery residents that ran the clinic as part of a general surgery rotation.

RESULTS

1230 patients underwent 1592 procedures (612 in resident clinic, 980 in attending clinic). There was no significant difference in the 30-day complication rate between patients operated on by the resident vs. attending (2.5% vs. 1.9%, p = 0.49). 459 patient satisfaction surveys were administered with a 79.1% response rate. There was no significant difference in the overall quality of care rating between residents and the attending surgeon (87.5% top-box rating vs. 93.1%, p = 0.15). Twenty-one residents completed both a pre- and post-rotation survey (77.8% response rate). The proportion of residents indicating that they could independently perform a variety of patient care tasks significantly increased across the rotation (all p < 0.05).

CONCLUSION

Mid-level general surgery residents can independently perform office-based procedures without detriment to safety or patient satisfaction. The resident-run procedure clinic serves as an environment for residents to grow in confidence in both technical and non-technical skills. Given the high rate at which patients provide resident feedback, future work may investigate how to best incorporate patient derived evaluations into resident assessment.

Resident training in colorectal laparoscopic surgery: A retrospective morbidity, mortality and survival analysis of 408 cases in our environment

INTRODUCTION

Colorectal cancer has a growing incidence in our society. However, the performance of laparoscopic interventions in this field is still not included in the National Training Program. Given the lack of references, our objective was to analyze the resident's participation in laparoscopic colorectal surgery and its possible effect on morbidity and mortality and oncological prognosis.

METHODS

A retrospective longitudinal single-center study that included all laparoscopic colorectal surgical procedures performed by residents (R group) and by attending surgeons (A group) between 01/01/2009 and 12/31/2017, maintaining follow-up until 12/31/2018. Postoperative morbidity and mortality, overall survival (OS) and disease-free survival (DFS), as well as their relationship with the resident involvement as first surgeon were analyzed.

RESULTS

408 patients were analyzed, of which 138 (33.8%) were operated by a supervised resident and 270 (66.2%) by the attending surgeon. No differences were detected in the rate of postoperative complications between both groups (OR: 1.536; 95% CI: 0.947-2.409; p=0.081). Furthermore, resident participation had no influence on tumor recurrence rate (R Group: 14.2% vs. A Group: 16.9%; p=0.588) or on overall (p = 0.562) or disease-free survival (p = 0.305).

CONCLUSION

Resident involvement in laparoscopic colorectal surgery had no influence on morbidity and mortality or oncological prognosis in our center. Conducting prospective studies in this regard will provide greater knowledge, enabling a progressive improvement of the training program.

Impact of fellow compared to resident assistance on outcomes of minimally invasive surgery

INTRODUCTION

As fellowship training after general surgery residency has become increasingly common, the impact on resident education must be considered. Patient safety and procedure outcomes are often used as justification by attendings who favor fellows over residents in certain minimally invasive surgery (MIS) operations. The aim of the present study was to compare the impact of trainee level on the outcomes of selected MIS operations to determine if giving preference to fellows on grounds of outcomes is warranted.

METHODS

Patients who underwent elective laparoscopic hiatal hernia repair (LHHR), laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic splenectomy (LS), laparoscopic cholecystectomy (LC), or laparoscopic ventral hernia repair (LVHR) with assistance of a general surgery chief resident or fellow were identified from the American College of Surgeon's National Surgical Quality Improvement Program database (2007-2012). Patients were matched 1:1 based on propensity score for the odds of undergoing operations assisted by a fellow.

RESULTS

5145 patients underwent LHHR, 1396 LSG, 9656 LRYGB, 863 LS, 13,434 LC, and 3069 LVHR. Fellows assisted in 41.7% of LHHR, 49.2% of LSG, 56.4% of LRYGB, 25.7% of LS, 17.1% of LC, and 27.0% of LVHR cases. After matching, overall and severe complication rates were comparable between cases performed with assistance of a fellow or chief resident. Median operative time was longer for LSG, LRYGB, and LC when a fellow assisted.

CONCLUSIONS

Surgical outcomes were similar between fellow and chief resident assistance in MIS operations, arguing that increased resident participation in basic and complex laparoscopic operations is appropriate without compromising patient safety.

Factors that Predict the Need for Subtotal Cholecystectomy

BACKGROUND

Subtotal cholecystectomy is a "damage control" or "bailout procedure" that is used in difficult gallbladder cases when severe inflammation distorts the local anatomy resulting in increased risk in damage to surrounding structures. Subtotal cholecystectomy rates increased nationally over the past decade. We aimed to determine provider experience and patient factors associated with the performance of subtotal cholecystectomies.

METHODS

All cholecystectomies from 2016 to 2019 were reviewed. Patient demographics, laboratory values, imaging, preoperative diagnosis, surgical technique (fenestrating vs. reconstituting), and years of attending and resident experience were collected. Multivariable regression analysis was performed to evaluate for factors that increase the likelihood of subtotal cholecystectomy.

RESULTS

Of 916 cholecystectomies, 86 were subtotal. The likelihood of subtotal cholecystectomy did not increase based on attending experience of ≤5 vs. > 5 years (odds ratio (OR) .66, P = .09). Older age (adjusted odds ratio (aOR) 1.23, P = .03), male sex (aOR 2.59, P < .01), white blood cells (WBC) above 10.3 (aOR 2.02, P = .02), and preoperative diagnosis of acute on chronic cholecystitis (aOR 5.47, P < .01) were associated with increased likelihood of subtotal cholecystectomy.

DISCUSSION

Older age, male sex, WBC above 10.3, and preoperative diagnosis of acute on chronic cholecystitis were associated with the increased likelihood of subtotal cholecystectomies. The performance of subtotal cholecystectomy was not impacted by attending years of experience. In cases of severe gallbladder pathology, this technique is being used as an operative strategy among all surgeon levels.

Peri-operative Mortality Following Cholecystectomy in Australia: Potential Preventability of Adverse Events

BACKGROUND

Cholecystectomy is a commonly performed procedure; however, it is not without risks. It is crucial to constantly audit surgical outcomes in order to improve quality of care. The aim of this retrospective population-based cohort study is to identify preventable issues of clinical management associated with adverse occurrences in order to reduce mortality of cholecystectomy patients.

METHODS

Data were obtained from the Australian and New Zealand Audit of Surgical Mortality (ANZASM). It encompasses peer-reviewed first and second line assessments of management of cholecystectomy patients who died from 2005 to 2015 in Australia. Clinical Management Issues (CMIs) were identified from text in assessments and grouped into communication failures, pre-operative, intra-operative and post-operative categories. These were further classified into subthemes using thematic analysis with a data-driven approach.

RESULTS

There were 359 deaths in the study period. CMIs were present in 71 cases, with a reported total of 124 concerns or adverse events. Post-operative CMIs were the most prevalent issue [50% (62/124)], with the most common theme being delay to recognise complications (19/124). Pre-operative concerns were the second most common (n = 34). Decision to operate was questioned in 14 cases, and delay to surgery was reported in 12 cases.

CONCLUSION

ANZASM analysis has allowed us to identify modifiable adverse occurrences. This audit shows that delay to recognise complications is the most common assessment recorded. Preventive measures should be taken to improve outcomes and reduce peri-operative mortality, with an emphasis on post-operative management and enhancing communication between members of the multidisciplinary team.

Impact of intra-operative hypotension on mortality rates and post-operative complications in dogs undergoing cholecystectomy

OBJECTIVES

To report the mortality rate within a cohort of dogs undergoing cholecystectomy and investigate the impact of intra-operative hypotension on mortality.

MATERIALS AND METHODS

Clinical records at five UK referral centres were reviewed for dogs undergoing cholecystectomy. Data collected included presenting signs, pre-operative blood test results, intra-operative data including frequency and duration of hypotension and the incidence and type of post-operative complications.

RESULTS

Data from 119 dogs were included. Sixteen dogs (13%) died before discharge and by 28 days after surgery the total mortality was 19 dogs (17%). Hypotension lasting over 10 minutes during general anaesthesia occurred in 65 dogs (54.6%), with a mean ± sd duration of 36.1 ± 30.0 minutes. Intra-operative hypotension or the number of hypotensive episodes did not appear to be associated with in-hospital or 28-day mortality. American Society of Anaesthesiologists grade (of fitness for surgery) was significantly associated with both in-hospital and 28-day mortality on univariable analysis, as were post-operative hypoproteinaemia, ileus and pancreatitis. However on multivariable analysis, only ileus and pancreatitis were found to significantly impact mortality.

CLINICAL SIGNIFICANCE

Dogs presenting with a higher American Society of Anaesthesiologists grade appear to have a higher risk of mortality, although intra-operative hypotension did not appear to be part of this risk.

Supervision of Resident Physicians

Supervision of resident physicians is a high-risk area of emergency medicine, and what constitutes appropriate supervision is a complex question. In this article, policies and procedures for appropriate supervision of resident physicians and the implications for billing are reviewed. Recommendations on supervision of resident physicians in the emergency department are detailed, with attention paid to addressing challenges in balancing patient safety with resident autonomy and education during the course of patient care and graduate medical education.

Consensus recommendations on balancing educational opportunities and service provision in surgical training: Association of Surgeons in Training Delphi qualitative study

BACKGROUND

Ensuring the highest quality of surgical training remains a challenge as demands on health service provision rise. This study aimed to explore the differences and potential conflicts between service provision and dedicated training activity provided by surgical trainees, and recommend solutions.

METHODS

Participants were drawn from the Association of Surgeons in Training (ASiT) national council. Nominal Group Technique (NGT) was employed by members of the ASiT executive addressing 3 key domains (1) defining differences between training and service tasks, (2) impact of service-provision on training and (3) ways to improve training. A two-round Delphi process was conducted via electronic survey to ASiT council. Consensus was considered achieved for any statement where 80% or more of respondents indicated agreement.

RESULTS

47 statements were generated through NGT which were put to the Delphi process. Consensus was reached on a total of 24/47 statements. Educational or training tasks were identified as being activities which progressed a trainee's skill set, could be tailored to a trainee's own ability, and involved acting as a trainer to more junior colleagues. The negative impact of excess service provision included training quality, trainee mental health, and surgical trainee recruitment. Potential measures to improve training included increasing hospital staffing and resources, protected training times, trainee-specific or competency-based learning and training or incentivising trainers.

CONCLUSION

This trainee-based study provides several consensus recommendations on the characteristics that define surgical training and how a balance between service provision and training can potentially be achieved. Policy makers and health systems may be guided by these to ensure high quality training and a satisfied workforce.

Resident involvement in minimally-invasive vs. open procedures

BACKGROUND

The objective of this study was to evaluate the impact of resident involvement on surgical outcomes in laparoscopic compared to open procedures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program 2007-2012 was queried for open and laparoscopic ventral hernia repair (VHR), inguinal hernia repair (IHR), splenectomy, colectomy, or cholecystectomy (CCY). Multivariable regression analyses were performed to assess the impact of resident involvement on surgical outcomes.

RESULTS

In total, 88,337 VHR, 20,586 IHR, 59,254 colectomies, 3301 splenectomies, and 95,900 CCY were identified. Resident involvement was predictive for major complication during open VHR (AOR, 1.29; p < 0.001), but not during any other procedure. Resident participation significantly prolonged operative time for open, as well as laparoscopic VHR, IHR, colectomy, splenectomy, and CCY (all p < 0.01).

CONCLUSIONS

The results of this study suggest that resident participation has a similar impact on surgical outcomes during laparoscopic and open surgery, and is generally safe.

Impact of Intra-Operative Adverse Events on the Risk of Surgical Site Infection in Abdominal Surgery

BACKGROUND

Intra-operative adverse events (iAEs) recently were shown to correlate independently with an increased risk of post-operative death, morbidity, re-admissions, and length of hospital stay. We sought to understand further the impact of iAEs on surgical site infections (SSIs) in abdominal surgical procedures and delineate which patient populations are most affected. We hypothesized that all patients with iAEs have an increased risk for SSI, especially those with pre-existing risk factors for SSI.

PATIENTS AND METHODS

To identify iAEs, a well-described three-step methodology was used: (1) the 2007-2012 American College of Surgeons-National Surgical Quality Improvement Program database was merged with the administrative database of our tertiary academic center, (2) the merged database was screened for iAEs in abdominal surgical procedures using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator "Accidental Puncture/Laceration," and (3) each flagged record was systematically reviewed to confirm iAE occurrence. Uni-variable and backward stepwise multi-variable analyses (adjusting for demographics, co-morbidities, type and complexity of operation) were performed to study the independent correlation between iAEs and SSIs (superficial, deep incisional, and organ-space). The correlation between iAEs and SSIs was investigated especially in patients deemed a priori at high risk for SSIs, specifically those older than age 60 and those with diabetes mellitus, obesity, cigarette smoking, steroid use, or American Society of Anesthesiologists class ≥III.

RESULTS

A total of 9,288 operations were included, and iAEs were detected in 183 (2.0%). Most iAEs consisted of bowel (44%) or vessel (29%) injuries and were addressed intra-operatively (92%). SSI occurred in 686 (7.4%) cases and included 331 (3.5%) superficial, 32 (0.34%) deep incisional, and 333 (3.6%) organ/space infections. iAEs were correlated independently with SSI (odds ratio [OR] = 1.67; 95% confidence interval [CI], 1.11-2.52, p = 0.013), and more severe iAEs were associated with a higher risk of infection. Analysis by SSI type revealed a significant association with organ/space SSI (OR = 1.81, 95% CI 1.07-3.05; p = 0.027), but not incisional infections. Most interestingly, the occurrence of an iAE was correlated with increased SSI rate in the low-risk but not the high-risk patient populations. Specifically, iAEs increased SSI in patients younger than 60 (OR = 2.69, 95% CI 1.55-4.67, p < 0.001), non-diabetic patients (OR = 1.64, 95% CI 1.04-2.58, p = 0.034), non-obese patients (OR = 2.9, 95% CI 1.81-4.66, p < 0.001), non-smokers (OR = 1.67, 95% CI 1.08-2.6, p = 0.022), with no steroid use (OR = 1.73, 95% CI 1.15-2.6, p < 0.008), and with ASA class <III (OR = 2.26, 95% CI 1.31-3.87, p = 0.003).

CONCLUSIONS

The iAEs are associated independently with increased SSIs, particularly in patients with less pre-existing risk factors for SSI. Preventing iAEs or mitigating their impact, once they occur, may help decrease the rate of SSIs.