New Surgeon Outcomes and the Effectiveness of Surgical Training

Spatial-temporal attention for video-based assessment of intraoperative surgical skill

Accurate, unbiased, and reproducible assessment of skill is a vital resource for surgeons throughout their career. The objective in this research is to develop and validate algorithms for video-based assessment of intraoperative surgical skill. Algorithms to classify surgical video into expert or novice categories provide a summative assessment of skill, which is useful for evaluating surgeons at discrete time points in their training or certification of surgeons. Using a spatial-temporal neural network architecture, we tested the hypothesis that explicit supervision of spatial attention supervised by instrument tip locations improves the algorithm's generalizability to unseen dataset. The best performing model had an area under the receiver operating characteristic curve (AUC) of 0.88. Augmenting the network with supervision of spatial attention improved specificity of its predictions (with small changes in sensitivity and AUC) and led to improved measures of discrimination when tested with unseen dataset. Our findings show that explicit supervision of attention learned from images using instrument tip locations can improve performance of algorithms for objective video-based assessment of surgical skill.

Risk factors for complications in resident-performed cataract surgery: A systematic review

We assessed risk factors for complications associated with resident-performed cataract surgery. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we searched 4databases in September, 2023. We included peer-reviewed, full-text, English-language articles assessing risk factors for complications in resident performed cataract surgery. We excluded studies describing cataract surgeries performed by fellows, combined surgeries, and studies with insufficient information. Our initial search yielded 6244 articles; 15 articles were included after title/abstract and full-text review. Patient-related risk factors included older age, hypertension, prior vitrectomy, zonular pathology, pseudoexfoliation, poor preoperative visual acuity, small pupils, and selected types of cataracts. Surgeon-related risk factors included resident postgraduate year and surgeon right-handedness. Other risk factors included absence of supervision, long phacoemulsification time, and phacoemulsification with high power and torsion. The quality of the studies was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation; most studies graded as moderate, primarily due to risk of bias. When assigning cases to residents, graduate medical educators should consider general and resident-specific risk factors to facilitate teaching and preserve patient safety.

Evaluation of intravitreal injections as a risk factor for capsular rupture during cataract surgery

OBJECTIVE

To determine whether previous intravitreal injections are an independent risk factor for posterior capsular rupture (PCR) during cataract surgery after adjusting for known risk factors.

DESIGN

Single-centre medical records analysis of a population-based cohort at a university-based referral centre. A retrospective cohort study has been conducted with inclusion of cataract surgeries done from January 1, 2005 to December 31, 2020 at the Department of Ophthalmology, Medical University of Graz, Austria.

PARTICIPANTS

All consecutive cataract surgeries done in patients of at least 18 years of age from January 1, 2005 to December 31, 2020 have been included.

METHODS

Association between previous intravitreal injections and PCR rates has been analysed through univariable and multivariable generalized estimating equations (GEE). Other investigated risk factors were age, combined surgery, pseudoexfoliation, surgeon's experience, and type of cataract surgery.

RESULTS

A statistically significant higher rate of posterior capsular rupture during cataract surgery has been found in patients with previous intravitreal therapy compared with patients with no history of intravitreal therapy (OR 1.27, 95% CI 1.10-1.46, p = 0.008). However, after adjusting for confounding risk factors, no statistically significant effect was seen (OR 1.04, 95% CI 0.89-1.21, p = 0.664).

CONCLUSION

We found no association between history of intravitreal injections and PCR during cataract surgery after adjusting for known risk factors. Further studies upon interactions between history of intravitreal injections and known risk factors for PCR, especially pseudoexfoliation, are needed.

Mortality and Severe Complications Among Newly Graduated Surgeons in the United States

OBJECTIVE

To evaluate severe complications and mortality over years of independent practice among general surgeons.

BACKGROUND

Despite concerns that newly graduated general surgeons may be unprepared for independent practice, it is unclear whether patient outcomes differ between early and later career surgeons.

METHODS

We used Medicare claims for patients discharged between July 1, 2007 and December 31, 2019 to evaluate 30-day severe complications and mortality for 26 operations defined as core procedures by the American Board of Surgery. Generalized additive mixed models were used to assess the association between surgeon years in practice and 30-day outcomes while adjusting for differences in patient, hospital, and surgeon characteristics.

RESULTS

The cohort included 1,329,358 operations performed by 14,399 surgeons. In generalized mixed models, the relative risk (RR) of mortality was higher among surgeons in their first year of practice compared with surgeons in their 15th year of practice [5.5% (95% CI: 4.1%-7.3%) vs 4.7% (95% CI: 3.5%-6.3%), RR: 1.17 (95% CI: 1.11-1.22)]. Similarly, the RR of severe complications was higher among surgeons in their first year of practice compared with surgeons in their 15th year of practice [7.5% (95% CI: 6.6%-8.5%) versus 6.9% (95% CI: 6.1%-7.9%), RR: 1.08 (95% CI: 1.03-1.14)]. When stratified by individual operation, 21 operations had a significantly higher RR of mortality and all 26 operations had a significantly higher RR of severe complications in the first compared with the 15th year of practice.

CONCLUSIONS

Among general surgeons performing common operations, rates of mortality and severe complications were higher among newly graduated surgeons compared with later career surgeons.

Modified Medial Incision Small Double-Opposing Z-Plasty for Treating Veau Type I Cleft Palate: Is the Early Result Reproducible?

OBJECTIVE

An inspiring early result with no oronasal fistula formation was recently described for a modified medial incision small double-opposing Z-plasty (MIsDOZ) for treating Veau type I cleft palate. This study describes an early single-surgeon experience in applying this newly proposed surgical approach.

DESIGN

Retrospective single-surgeon study.

PATIENTS

Consecutive nonsyndromic patients (n  =  27) with Veau I cleft palate.

INTERVENTIONS

Topographic anatomical-guided MIsDOZ palatoplasty with pyramidal space dissection (releasing of the ligamentous fibers in the greater palatine neurovascular bundle and pyramidal process region, in-fracture of the pterygoid hamulus, and widening of space of Ernst) performed by a novice surgeon (RD).

MEAN OUTCOME MEASURES

Age at surgery, the presence of cleft lip, palatal cleft width, use of lateral relaxing incision, and 6-month complication rate (bleeding, dehiscence, fistula, and flap necrosis). A published senior surgeon-based outcome dataset (n  =  24) was retrieved for comparison purposes.

RESULTS

Twenty-two (81.5%) and 5 (18.5%) patients received the medial incision only technique and lateral incision technique, respectively (P  =  .002). Age, presence of cleft lip, and cleft width were not associated (all P > .05) with the use of lateral incision. Comparative analysis between the novice surgeon- and senior surgeon-based datasets revealed no significant differences for sex (females: 74.1% vs 62.5%; P  =  .546), age (10.2  ±  1.7 vs 9.6  ±  1.2 months; P  =  .143), rate of lateral incision (18.5% vs 4.2%; P  =  .195), and postoperative complication rate (0% vs 0%).

CONCLUSION

This modified DOZ palatoplasty proved to be a reproducible procedure for Veau I cleft palate closure, with reduced need for lateral incision and with no early complication.

Retinal detachment after refractive lens exchange: A narrative review

Refractive lens exchange (RLE) allows to correct ametropias and presbyopia by replacing the crystalline lens with an extended depth of focus or multifocal intraocular lens (IOL). Retinal detachment (RD) is one of the most serious adverse events after RLE. This study aimed to review the evidence related to the risk of RD after RLE and clinical outcomes. A search using PubMed and a snowball search approach was conducted to identify articles and case reports. According to the literature, the risks of RD should be considered in patients <60 years old with axial lengths >23 mm. Only nine articles reported visual acuity (VA) after RD in RLE, and only 25% of eyes had a VA > 20/40. Considering that the decrease in VA might be uniform for all types of IOLs after RD, surgeons should focus on selecting the patient to prevent RD rather than on a particular IOL optical design based on the potential risk of DR.

Role of Prophylactic Oral Antibiotics in the Prevention of Post-cataract Surgery Acute Infective Endophthalmitis

Purpose To evaluate the role of perioperative oral antibiotics in the prevention of acute infective endophthalmitis (IE) after cataract surgery. Methods A prospective cohort study of patients older than 18 years of age undergoing uncomplicated phacoemulsification was conducted. Group A was given post-op oral ciprofloxacin for three days, whereas Group B was not. Both groups received 5% povidone-iodine (PVI) preparation for five minutes in the conjunctival cul-de-sac, and intracameral (IC) 0.5% moxifloxacin was administered at the end of the procedure as prophylaxis. The minimum post-op follow-up period was six weeks. Results Out of 2161 patients, 859 (39.8%) were included in Group A, and 1302 (60.2%) were included in Group B. No significant difference in anterior chamber (AC) reaction was found on day 1 (p = 0.67), day 14 (p = 0.03), or day 45 (p = 0.1). One patient developed acute post-op IE (0.04%) and two patients developed toxic anterior segment syndrome (TASS) from Group A. The non-oral antibiotic group had no serious complications. Conclusion Perioperative oral antibiotic use in routine clinical practice is not recommended for the prevention of acute post-op IE. Pre-op conjunctival PVI 5% for five minutes and IC moxifloxacin at the end of surgery were proven to be effective prophylactic measures in our study.

Cataracts

94 million people are blind or visually impaired globally, and cataract is the most common cause of blindness worldwide. However, most cases of blindness are avoidable. Cataract is associated with decreased quality of life and reduced life expectancy. Most cases of cataract occur after birth and share ageing and oxidative stress as primary causes, although several non-modifiable and modifiable risk factors can accelerate cataract formation. In most patients, phacoemulsification with intraocular lens implantation is the preferred treatment and is highly cost-effective. There has been an increase in the use of comprehensive cataract surgical services, including diagnoses, treatment referrals, and rehabilitation. However, global inequity in surgical service quality is still a limitation. Implementation of preoperative risk assessment, risk reduction strategies, and new surgical technologies have made cataract surgery possible at an earlier stage of cataract severity with the expectation of good refractive outcomes. The main challenge is making the service that is currently available to some patients accessible to all by use of universal health coverage.

Assessing Resident Cataract Surgical Outcomes Using Electronic Health Record Data

Objective

To demonstrate that electronic health record (EHR) data can be used in an automated approach to evaluate cataract surgery outcomes.

Design

Retrospective analysis.

Subjects

Resident and faculty surgeons.

Methods

Electronic health record data were collected from cataract surgeries performed at the Johns Hopkins Wilmer Eye Institute, and cases were categorized into resident or attending as primary surgeon. Preoperative and postoperative visual acuity (VA) and unplanned return to operating room were extracted from the EHR.

Main Outcome Measures

Postoperative VA and reoperation rate within 90 days.

Results

This study analyzed 14 537 cataract surgery cases over 32 months. Data were extracted from the EHR using an automated approach to assess surgical outcomes for resident and attending surgeons. Of 337 resident surgeries with both preoperative and postoperative VA data, 248 cases (74%) had better postoperative VA, and 170 cases (51%) had more than 2 lines improvement. There was no statistical difference in the proportion of cases with better postoperative VA or more than 2 lines improvement between resident and attending cases. Attending surgeons had a statistically greater proportion of cases with postoperative VA better than 20/40, but this finding has to be considered in the context that, on average, resident cases started out with poorer baseline VA.A multivariable regression model of VA outcomes vs. resident/attending status that controlled for preoperative VA, patient age, American Society of Anesthesiologists (ASA) score, and estimated income found that resident status, preoperative VA, patient age, ASA score, and estimated income were all significant predictors of VA. The rate of unplanned return to the operating room within 90 days of cataract surgery was not statistically different between resident (1.8%) and attending (1.2%) surgeons.

Conclusions

This study demonstrates that EHR data can be used to evaluate and monitor surgical outcomes in an ongoing way. Analysis of EHR-extracted cataract outcome data showed that preoperative VA, ASA classification, and attending/resident status were important in predicting postoperative VA outcomes. These findings suggest that the utilization of EHR data could enable continuous assessment of surgical outcomes and inform interventions to improve resident training. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Artificial intelligence and simulation in urology

INTRODUCTION AND OBJECTIVE

Artificial intelligence (AI) is in full development and its implementation in medicine has led to an improvement in clinical and surgical practice. One of its multiple applications is surgical training, with the creation of programs that allow avoiding complications and risks for the patient. The aim of this article is to analyze the advantages of AI applied to surgical training in urology.

MATERIAL AND METHODS

A literary research is carried out to identify articles published in English regarding AI applied to medicine, especially in surgery and the acquisition of surgical skills.

RESULTS

Surgical training has evolved over time thanks to AI. A model for surgical learning where skills are acquired in a progressive way while avoiding complications to the patient, has been created. The use of simulators allows a progressive learning, providing trainees with procedures that increase in number and complexity. On the other hand, AI is used in imaging tests for surgical or treatment planning.

CONCLUSION

Currently, the use of AI in daily clinical practice has led to progress in medicine, specifically in surgical training.

Artificial intelligence and simulation in urology

INTRODUCTION AND OBJECTIVE

Artificial intelligence (AI) is in full development and its implementation in medicine has led to an improvement in clinical and surgical practice. One of its multiple applications is surgical training, with the creation of programs that allow avoiding complications and risks for the patient. The aim of this article is to analyze the advantages of AI applied to surgical training in urology.

MATERIAL AND METHODS

A literary research is carried out to identify articles published in English regarding AI applied to medicine, especially in surgery and the acquisition of surgical skills.

RESULTS

Surgical training has evolved over time thanks to AI. A model for surgical learning where skills are acquired in a progressive way while avoiding complications to the patient, has been created. The use of simulators allows a progressive learning, providing trainees with procedures that increase in number and complexity. On the other hand, AI is used in imaging tests for surgical or treatment planning.

CONCLUSION

Currently, the use of AI in daily clinical practice has led to progress in medicine, specifically in surgical training.

Assessing the Phacoemulsification Learning Curve Utilizing Duration of Each Step

PURPOSE

To assess the phacoemulsification learning curve for ophthalmology residents using duration for each step.

SETTING

Single tertiary, training site hospital.

DESIGN

Cross sectional study examining duration of cataract surgery steps as a function of categorized experience levels.

METHODS

Emory Ophthalmology PGY-3 and PGY-4 residents operating at Grady Memorial Hospital between April 2017 and February 2018 were eligible to participate. Duration in seconds for each step of surgery was calculated for incisions, continuous curvilinear capsulorrhexis (CCC), hydrodissection, nucleus disassembly, quadrant removal, cortical cleanup, intra-ocular lens insertion, closure, and this outcome was analyzed as a function of different experience levels.

RESULTS

528 surgeries were included out of 549 total surgeries recorded. Six categories of experience levels were established A-F, increasing by increments of 50. There was an overall downward trend across various steps across the eight case categories, and several adjacent categories demonstrate statistically significant differences. The three most time-intensive steps early in training were nucleus disassembly (336.5 ± 16.5 secs), quadrant removal (275.1 ± 18.0 secs) and cortical cleanup (244.2 ± 24.6 secs). There was a sustained drop in mean duration for all steps through at least Category D, with most steps showing a drop through Category F.

CONCLUSIONS

There is a benefit to a higher case load, well above the ACGME-mandated 86 cases. Improvements in efficiency were observed after 250 cases with nuclear disassembly and CCC demonstrating a significant decrease in operative time.

Surgical Outcomes among Focused versus Diversified Cataract Surgeons

PURPOSE

Narrowly focused surgical practice has become increasingly common in ophthalmology and may have an effect on surgical outcomes. Previous research evaluating the influence of surgical focus on cataract surgical outcomes has been lacking. This study aimed to evaluate whether surgeons' exclusive surgical focus on cataract surgery influences the risk of cataract surgical adverse events.

DESIGN

Population-based cohort study.

PARTICIPANTS

All patients 66 years of age or older undergoing cataract surgery in Ontario, Canada, between January 1, 2002, and December 31, 2013.

METHODS

Outcomes of isolated cataract surgery performed by exclusive cataract surgeons (no other types of surgery performed), moderately diversified cataract surgeons (1%-50% noncataract procedures), and highly diversified cataract surgeons (>50% noncataract procedures) were evaluated using linked healthcare databases and controlling for patient-, surgeon-, and institution-level covariates. Surgeon-level covariates included both surgeon experience and surgical volume.

MAIN OUTCOME MEASURES

Composite outcome incorporating 4 adverse events: posterior capsule rupture, dropped lens fragments, retinal detachment, and suspected endophthalmitis.

RESULTS

The study included 1 101 864 cataract operations. Patients had a median age of 76 years, and 60.2% were female. Patients treated by the 3 groups of surgeons were similar at baseline. Adverse events occurred in 0.73%, 0.78%, and 2.31% of cases performed by exclusive cataract surgeons, moderately diversified surgeons, and highly diversified surgeons, respectively. The risk of cataract surgical adverse events for patients operated on by moderately diversified surgeons was not different than for patients operated on by exclusive cataract surgeons (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.00-1.18). Patients operated on by highly diversified surgeons had a higher risk of adverse events than patients operated on by exclusive cataract surgeons (OR, 1.52; 95% CI, 1.09-2.14). This resulted in an absolute risk difference of 0.016 (95% CI, 0.012-0.020) and a number needed to harm of 64 (95% CI, 50-87).

CONCLUSIONS

Exclusive surgical focus did not affect the safety of cataract surgery when compared with moderate levels of surgical diversification. The risk of cataract surgical adverse events was higher among surgeons whose practice was dedicated mainly to noncataract surgery.

Utilization of Flexible-Wearable Sensors to Describe the Kinematics of Surgical Proficiency

BACKGROUND

Traditional assessment (e.g., checklists, videotaping) for surgical proficiency may lead to subjectivity and does not predict performance in the clinical setting. Hand motion analysis is evolving as an objective tool for grading technical dexterity; however, most devices accompany with technical limitations or discomfort. We purpose the use of flexible wearable sensors to evaluate the kinematics of surgical proficiency.

METHODS

Surgeons were recruited and performed a vascular anastomosis task in a single institution. A modified objective structured assessment of technical skills (mOSATS) was used for technical qualification. Flexible wearable sensors (BioStamp RCTM, mc10 Inc., Lexington, MA) were placed on the dorsum of the dominant hand (DH) and nondominant hand (nDH) to measure kinematic parameters: path length (T_path), mean (V_mean) and peak (V_peak) velocity, number of hand movements (N_move), ratio of DH to nDH movements (rMov), and time of task (tTask) and further compared with the mOSATS score.

RESULTS

Participants were categorized as experts (n = 12) and novices (n = 8) based on a cutoff mean mOSATS score. Significant differences for tTask (P = 0.02), rMov (P = 0.07), DH T_path (P = 0.04), V_mean (P = 0.07), V_peak (P = 0.04), and nDH N_move (P = 0.02) were in favor of the experts. Overall, mOSATS had significant correlation with tTask (r = -0.69, P = 0.001), N_move of DH (r = -0.44, P = 0.047) and nDH (r = -0.66, P = 0.001), and rMov (r = 0.52, P = 0.017).

CONCLUSIONS

Hand motion analysis evaluated by flexible wearable sensors is feasible and informative. Experts utilize coordinated two-handed motion, whereas novices perform one-handed tasks in a hastily jerky manner. These tendencies create opportunity for improvement in surgical proficiency among trainees.

Current methods for assessing technical skill in cataract surgery

Surgery is a major source of errors in patient care. Preventing complications from surgical errors in the operating room is estimated to lead to reduction of up to 41 846 readmissions and save $620.3 million per year. It is now established that poor technical skill is associated with an increased risk of severe adverse events postoperatively and traditional models to train surgeons are being challenged by rapid advances in technology, an intensified patient-safety culture, and a need for value-driven health systems. This review discusses the current methods available for evaluating technical skills in cataract surgery and the recent technological advancements that have enabled capture and analysis of large amounts of complex surgical data for more automated objective skills assessment.

Quantifying the educational benefit of additional cataract surgery cases in ophthalmology residency

PURPOSE

To quantify the resident learning curve for cataract surgery using operative time as an indicator of surgical competency, to identify the case threshold at which marginal additional educational benefit became equivocal, and to characterize heterogeneity in residents' pathways to surgical competency.

SETTING

Academic medical center.

DESIGN

Large-scale retrospective consecutive case series.

METHODS

All cataract surgery cases performed by resident physicians as primary surgeon at Massachusetts Eye and Ear from July 1, 2010, through June 30, 2015, were reviewed. Data were abstracted from Accreditation Council for Graduate Medical Education case logs and operative time measurements. A linear mixed-methods analysis was conducted to model changes in residents' cataract surgery operative times as a function of sequential case number, with resident identity included as a random effect in the model to normalize between-resident variability.

RESULTS

A total of 2096 cases were analyzed. A marked progressive decrease in operative time was noted for resident cases 1 to 39 (mean change -0.17 minutes per additional case, 95% CI, -0.21 to -0.12; P < .001). A modest, steady reduction in operative time was subsequently noted for case numbers 40 to 149 (mean change -0.05 minutes per additional case, 95% CI, -0.07 to -0.04; P < .001). No statistically significant improvement was found in operative times beyond the 150th case.

CONCLUSIONS

Residents derived educational benefit from performing a greater number of cataract procedures than current minimum requirements. However, cases far in excess of this threshold might have diminishing educational return in residency. Educational resources currently used for these cases might be more appropriately devoted to other training priorities.

Incidence of Intraoperative and Early Postoperative Adverse Events in a Large Cohort of Consecutive Refractive Lens Exchange Procedures

PURPOSE

To evaluate the incidence of adverse events (AEs) in patients who underwent refractive lens exchange.

DESIGN

Retrospective case series.

METHODS

Setting: Private refractive surgery clinics. Patients/Study Population: Patients who underwent refractive lens exchange between July 1, 2014, and June 30, 2016. Intervention/Observation Procedures: All AEs recorded in the electronic medical record were extracted and retrospectively reviewed. The total incidence of AEs and serious AEs was calculated. Loss of 2 or more lines of corrected distance visual acuity (CDVA) was calculated for the entire cohort of patients that attended a minimum of 3 months follow-up.

MAIN OUTCOME MEASURES

AEs.

RESULTS

The total number of patients included was 10,206 (18,689 eyes). A multifocal intraocular lens (IOL) was implanted in 84.3% of eyes; 15.7% of eyes received a monofocal IOL. A total of 1164 AEs were recorded (1112 eyes of 1039 patients, incidence 6.0% of eyes, 1:17 eyes). The most common AE was posterior capsular opacification (PCO; 748 eyes, incidence 4.0%). Of all AEs, 171 events (occurring in 165 eyes of 151 patients, incidence 0.9%, 1:113 eyes) were classified as serious, potentially sight threatening. Loss of 2 or more lines of CDVA was 0.56% when excluding eyes where the loss of CDVA was due to PCO; the majority of these were due to macular causes.

CONCLUSION

The incidence of sight-threatening AEs and significant loss of CDVA in elective refractive lens exchange surgery was low. Other than PCO, postoperative macular issues were the most common cause of vision loss in this cohort.

Association of Cataract Surgical Outcomes With Late Surgeon Career Stages: A Population-Based Cohort Study

Importance

Evidence suggests that the quality of some aspects of care provided by physicians may decrease during their late career stage. However, to our knowledge, data regarding the association of advancing surgeon career phase with cataract surgical outcomes have been lacking.

Objective

To investigate whether an increase in cataract surgical adverse events occurs during later surgeon career stages.

Design, Setting, and Participants

This population-based study of 499 650 cataract operations performed in Ontario, Canada, between January 1, 2009, and December 31, 2013, investigated the association between late surgeon career stage and the risk of surgical adverse events. Linked health care databases were used to study cataract surgical complications while controlling for patient-, surgeon-, and institution-level covariates. All ophthalmologists who performed cataract surgery in Ontario within the study period were included in the analysis.

Exposures

Isolated cataract surgery performed by surgeons at early, mid, and late career stages.

Main Outcomes and Measures

Four serious adverse events were evaluated: dropped lens fragments, posterior capsule rupture, suspected endophthalmitis, and retinal detachment.

Results

Of 416 502 participants, 244 670 (58.7%) were women, 90 429 (21.7%) were age 66 to 70 years, 111 530 (26.8%) were age 71 to 75 years, 90 809 (21.8%) were age 76 to 80 years, and 123 734 (29.7%) were 81 years or older. Late-career surgeons performed 143 108 of 499 650 cataract operations (28.6%) during the study period. Late surgeon career stage was not associated with an increased overall risk of surgical adverse events (odds ratio [OR] vs midcareer, 1.06; 95% CI, 0.85-1.32). In a sensitivity analysis with surgeon volume removed from the model, late career stage was still not associated with overall adverse surgical events (OR, 1.10; 95% CI, 0.88-1.38). Among individual complications, late surgeon career stage was associated with an increased risk of dropped lens fragment (OR, 2.30; 95% CI, 1.50-3.54) and suspected endophthalmitis (OR, 1.41; 95% CI, 1.01-1.98). These corresponded with small absolute risk differences of 0.11% (95% CI, 0.085%-0.130%) and 0.045% (95% CI, 0.028%-0.063%) for dropped lens fragment and suspected endophthalmitis, respectively.

Conclusions and Relevance

These findings suggest that later-career surgeons are performing a substantial proportion of cataract operations with overall low surgical adverse event rates. Future studies might extend evaluations to the frequency of secondary surgical interventions as additional measures of surgical care quality.

Preoperative Vision and Surgeon Volume as Predictors of Visual Outcomes after Cataract Surgery

PURPOSE

To evaluate the relationship between preoperative vision and surgeon volume with visual outcomes after cataract surgery.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients aged ≥18 years old enrolled in the Kaiser Permanente Southern California Health Plan who underwent cataract surgery by nontrainee surgeons.

METHODS

Patients who underwent cataract surgery between January 1, 2013 and December 31, 2015, were included. A multivariate analysis using Generalized Additive Mixed Models was performed to determine the relationship between surgeon volume and postoperative visual acuity after controlling for patient age, preoperative visual acuity, history of diabetes, and history of diabetic retinopathy. Modeling was done for the relationship between preoperative vision and visual outcomes while controlling for surgeon volume, patient age, history of diabetes, and history of diabetic retinopathy.

MAIN OUTCOME MEASURE

Absolute letter change and percentage of patients to achieve ≥5 Early Treatment Diabetic Retinopathy Study (ETDRS) letter gain postoperatively.

RESULTS

There were 103 920 cataract surgeries performed by 136 surgeons included in this analysis. Patients whose surgeons performed <91.0 surgeries/year (95% confidence interval [CI], 61.1-139; P < 0.05) gained fewer letters postoperatively than the overall average, whereas those whose surgeons performed >91 but <227 surgeries/year (95% CI, 169-∞; P < 0.05) gained more letters than average. Although statistically significant, the difference between the lowest and highest performing surgeons was approximately 1.25 letters. Surgeons who performed <110 surgeries/year (95% CI, 81.7-149; P < 0.05) had fewer patients who gained ≥5 letters. Surgeons who performed >110 but <293 surgeries/year (95% CI, 232-∞; P < 0.05) were approximately 15% more likely to have patients who gained ≥5 letters. Patients with preoperative vision <74.7 letters (95% CI, 74.7-74.8; P < 0.05) and <75.8 letters (95% CI, 75.8-75.9; P < 0.05) gained more letters and were more likely to gain ≥5 letters postoperatively, respectively.

CONCLUSIONS

Patients whose vision is approximately 20/32 or worse are more likely to have significant visual gains after cataract surgery. Although statistically significant differences exist in postoperative vision based on surgeon volume, these do not appear to be clinically meaningful. Overall, visual outcomes are functionally comparable across a wide range of surgeon volumes.

Surgical teaching does not increase the risk of intraoperative adverse events

INTRODUCTION

Training and teaching are cornerstones in developing surgical skills. The present study aimed to compare intraoperative outcomes of colonic resections among fellows, consultants, and supervised trainees.

METHODS

Data of consecutive colonic resections including demographics, surgical details, and intraoperative outcomes were recorded in a prospectively maintained institutional database. All procedures were standardized and divided in three groups according to the main surgeons experience (fellow or consultant) and whether the procedure was taught. After weighting by inverse treatment probability, intraoperative adverse events including reactive conversion, blood loss, and operating time were compared between these three groups.

RESULTS

Six hundred sixty-four colectomies were analyzed between January 2014 and October 2017. Among them, 289 (43.5%) were taught. After weighted propensity score analysis, there was no difference between the three groups (fellow taken as reference), for intraoperative adverse event rate (odd ratio (OR) consultant 1.448 (IQR 0.728-2.878), p = 0.282; OR teaching 0.689 (IQR 0.295-1.609), p = 0.381), operating time (beta coefficient 0.76 (- 21.91-23.42), p = 0.947; beta coefficient - 10.79 (- 28.34-6.75), p = 0.919), conversion rates (OR 0.748 (0.329-1.515), p = 0.412; OR 1.025 (0.537-1.954), p = 0.940), pre-emptive conversion (OR 1.994 (0.198-20.032), p = 0.552; OR 0.659 (0.145-2.991), p = 0.583), intraoperative blood loss (beta coefficient 21.19 (- 25.87-68.25), p = 0.368; beta coefficient - 12.34 (- 56.13-31.44), p = 0.573), intraoperative transfusion (OR 1.962 (0.813-4.735), p = 0.127; OR 0.670 (0.260-1.727), p = 0.397), and rates of unusual bleeding (OR 1.273 (0.698-2.321), p = 0.422; OR 0.572 (0.290-1.126), p = 0.099). Time to preemptive conversion was shorter when procedures were performed by consultants (beta coefficient - 25.51 (- 47.71 to - 3.31), p = 0.025), while no difference was found for the teaching group (beta coefficient 4.48 (- 30.95-40.62), p = 0.788).

CONCLUSION

Within a standardized teaching environment, colonic resections were safely performed regardless of the surgical setting in the present cohort. Teaching does not increase intraoperative adverse events.