Surgeon specialty significantly affects outcome of asymptomatic patients after carotid endarterectomy

Surgical Specialty Impacts Quality of Operative Training in Carotid Endarterectomy

BACKGROUND

Carotid endarterectomy (CEA) is currently performed by multiple surgical specialties. The impact of surgical specialty and operative volume on post-CEA outcomes has been well described. However, it is unclear whether trainees of different surgical specialties have similar quality of operative training.

METHODS

Data from Accreditation Council for Graduate Medical Education annual reports were collected and compared between graduating vascular surgery (VS) residents, VS fellows, and neurological surgery (NS) residents. Only cases reported as chief/senior/lead resident, surgeon junior, or surgeon fellow were included in analysis. Linear regression analysis was utilized to evaluate trends in case-mix and volume.

RESULTS

From 2013 to 2022, total CEA case volume was higher among VS residents and fellows, compared to NS residents (52.8 ± 0.8 vs. 44.3 ± 1.4 vs. 12.9 ± 0.6, P < 0.0001). Additionally, VS residents and fellows performed other carotid operations including transfemoral or transcarotid artery stenting (11.1 ± 0.9 vs. 11.2 ± 0.8 vs. 0), carotid body tumor resection (0.7 ± 0.1 vs. 0.7 ± 0.0 vs. 0), and extracranial cervical bypass (6.7 ± 0.3 vs. 6.3 ± 0.3 vs. 0) that were not reported by the NS resident cohort (P < 0.0001 each). On linear regression analysis, total CEA procedures did not change for VS residents (R2 = 0.03, P = 0.62), decreased for VS fellows (-1.29 cases/yr, R2 = 0.75, P < 0.0001), and decreased among NS residents (-0.41 cases/yr, R2 = 0.44, P = 0.01) over the study period.

CONCLUSIONS

Although residents of multiple surgical specialties are trained in CEA, vascular training offers significantly greater numbers and diversity of extracranial carotid cases. It also appears that CEA volume is decreasing among neurosurgical trainees. In light of recent reports on the volume-outcome effect in carotid surgery, these data may have implications for future practice patterns in the domain of extracranial carotid artery disease.

Specialty Mediated 30-Day Complications in First Rib Resection for Thoracic Outlet Syndrome

BACKGROUND

Thoracic outlet syndrome (TOS) takes on heterogenous upper extremity manifestations depending on whether the artery, vein or brachial plexus is primarily compressed. As a result of these variable vascular and neurogenic symptoms, these patients present to surgeons of various training backgrounds for surgical decompression. Surgeon specialty is known to correlate with outcomes for numerous vascular procedures, but its role in TOS is unclear. In this work we examine the association of surgeon specialty with short-term outcomes following first rib resection (FRRS) for TOS.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, 3,070 patients were identified who underwent FRRS for TOS between 2006-2017. The primary outcomes of the study were 30-d complications, including postoperative hemorrhage requiring transfusion, wound complications, pneumothorax and deep venous thrombosis. Arterial, venous, and neurogenic TOS were distinguished with ICD-9 and 10 codes while patient characteristics, provider specialty, and postoperative outcomes were classified through a combination of standard National Surgical Quality Improvement Program variables and ICD data.

RESULTS

Most FRRS were performed by vascular surgeons (87.9%), general (6.9%) and thoracic surgeons (4.4%). The relative distribution of vascular TOS between the specialties was not significantly different, with non-vascular surgeons performing an equivalent amount of FRRS for arterial (1.1% versus 2.4%) and venous TOS (8.6% versus 9.1%, both P> 0.05). Patients who underwent FRRS with non-vascular surgeons experienced more frequent perioperative transfusions (3.2% versus 1.2%, P = 0.001) and wound infections (1.9% versus 0.8%, P= 0.04). On multivariable regression, patients undergoing FRRS for venous TOS were more likely to require blood transfusion (odds ratios:3.63, 95% CI 1.43-9.25). Patients operated on by surgeons whose specialty was not among the top three most common specialties performing FRRS had a 40% longer operative time (incidence rate ratios:1.42, 95% CI 1.15-1.74) as well as a significantly increased odds of requiring a transfusion (odds ratios:9.87, 95% CI 2.28-42.68).

CONCLUSIONS

The significantly increased operative times and transfusion requirements associated with specialties who uncommonly perform FRRS suggest the role of surgeon experience and volume in this procedure may play more of a role than specialty training. These data also suggest that vascular TOS carries unique risks that should be kept in mind when performing FRRS.

The Impact of Plastic Surgery Volume on Inpatient Burn Outcomes

BACKGROUND

Acute burn care involves multiple types of physicians. Plastic surgery offers the full spectrum of acute burn care and reconstructive surgery. The authors hypothesize that access to plastic surgery will be associated with improved inpatient outcomes in the treatment of acute burns.

METHODS

Acute burn encounters with known percentage total body surface area were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Edition, codes. Plastic surgery volume per facility was determined based on procedure codes for flaps, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators, and mortality. Regression models included the following variables: age, percentage total body surface area, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status of hospital.

RESULTS

The weighted sample included 99,510 burn admissions with a mean percentage total body surface area of 15.5 percent. The weighted median plastic surgery volume by facility was 245 cases per year. Compared with the lowest quartile, the upper three quartiles of plastic surgery volume were associated with increased likelihood of undergoing flap procedures (p < 0.03). The top quartile of plastic surgery volume was also associated with decreased odds of patient safety indicator events (p < 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death.

CONCLUSIONS

Burn encounters treated at high-volume plastic surgery facilities were more likely to undergo flap operations. High-volume plastic surgery centers were also associated with a lower likelihood of inpatient complications. Therefore, where feasible, acute burn patients should be triaged to high-volume centers.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Epidemiology of atherosclerotic carotid artery disease

Atherosclerotic carotid artery disease is a significant cause of stroke in the United States and globally. Its prevalence increases with age and it is more prevalent in men and White and Native-American populations. However, the outcomes related to carotid disease are worse in women and Black patients. Research suggests the disparities exist due to a multitude of factors, including disease pathophysiology, access to care, provider bias, and socioeconomic status. The prevalence of carotid stenosis in the general population is low (3%), and routine screening for carotid stenosis is not recommended in adults. Randomized clinical trials have shown benefits of stroke risk reduction with surgery (carotid endarterectomy or stenting) for symptomatic patients. Management is controversial in asymptomatic patients, as modern medical management has results equivalent to those of surgery and ongoing randomized clinical trials will address this important question. Carotid surgery is not appropriate in asymptomatic patients with limited life expectancy. Future work should explore comprehensive care models for care of patients with carotid disease and assessment of patient-reported outcomes to measure quality of care.

Longitudinal Survey of Trainee Case Log Entry for Carotid Endarterectomy: Trends in Neurologic, General, and Vascular Surgery

BACKGROUND

Multiple surgical specialties perform carotid endarterectomy (CEA). As indications for CEA narrows, neurosurgery residents are less exposed to this procedure. This study aims to determine trends in CEA training among graduating trainees in neurosurgery and compare these to general and vascular surgery.

METHODS

ACGME case log reports were retrospectively reviewed from 2013 to 2019 for neurologic, general, and vascular surgery residencies and vascular surgery fellowship. These annual reports contain the mean number of logged cases for graduating trainees and their level of participation. We analyzed trends in logged cases over the study period and compared mean number of logged cases between specialties and their respective required minimum numbers.

RESULTS

Neurosurgery residents (13.5 ± 0.76) performed significantly more CEAs than their counterparts in general surgery (9.4 ± 0.34, P < 0.01) but less in integrated vascular surgery (57.7 ± 0.88) and vascular surgery fellowship (47.9 ± 0.79, both P < 0.001). The only statistically significant change over the study period was a decline in mean number of cases logged by general surgery residents at -0.4 cases/year (P < 0.001). Trainees in all specialties reported around twice as many cases as the respective Accreditation Council for Graduate Medical Education required minimum numbers. Neurosurgery residents demonstrated increasing participation as lead surgeons by 0.7 cases/year (P = 0.04) and a concurrent decline as senior surgeons by 1.4 cases/year (P < 0.01).

CONCLUSIONS

Neurosurgery residents exceeded their minimum requirements for CEA, with increasing trend in higher level of participation. But neurosurgery residents' exposure to this procedure was far less significant than their colleagues in vascular surgery, a gap that may widen over time and should be addressed proactively.