The Influence of Volume and Experience on Individual Surgical Performance: A Systematic Review

Is the annual hospital volume associated with recurrence and chronic postoperative inguinal pain (CPIP) syndrome after inguinal hernia repair in laparo-endoscopic or open mesh technique (Lichtenstein)?

BACKGROUND

In major surgery, several studies have shown a correlation between high annual hospital volume (hospital caseload) and better outcome. Therefore, centralization is recommended. However, in inguinal hernia surgery the data are limited.

METHODS

The study is based on a retrospective analysis of prospective data from the German Herniamed Registry collected between 2009 and 2018. Out of the total of 731,982 patients operated on in 737 institutions, patients who had undergone inguinal hernia repair in Lichtenstein or in laparo-endoscopic (TAPP/TEP) technique were included. Hospitals were divided into three annual caseload categories: Low volume: ≤ 75 cases; middle volume: 76-199 cases; high volume: ≥ 200 cases. The relationship between hospital volume and the outcome parameters was analyzed using multivariable binary logistic models.

RESULTS

222,487 patients were enrolled in analysis, with 70.4% hernias operated on in laparo-endoscopic technique and 29.6% cases in open mesh technique. Overall, the outcome after laparo-endoscopic repair was significantly favorable except for the intraoperative complications (worse) and recurrence rate (no significant difference). Descriptive and multivariable analysis identified a long operating time as the main factor associated with an unfavorable outcome. In low-volume hospitals the risk was higher for intraoperative complications as well as for postoperative complications in both techniques. There was a significantly favorable association between the recurrence rate and hospital volume but only after laparo-endoscopic repair. Patients who were operated on in a low-volume center experienced significantly less pain across all three pain categories, independently of the technique used.

CONCLUSIONS

While hospital volume has a favorable association with most outcome parameters, this varied in accordance with the operative technique used. In contrast to open surgery, laparo-endoscopic surgery in a low-volume hospital (≤ 75) has the disadvantage of a higher recurrence rate. Long operating time is the most detrimental factor, proving that surgeon proficiency is of paramount importance. However, chronic postoperative inguinal pain (CPIP) syndrome is significantly less frequent in patients operated on in low-volume hospitals; this result is difficult to explain but may be due to a closer patient-surgeon relationship in these institutions.

Microvascular Free Flap Practice Management and Career Development

Microvascular free flap surgery has become the gold standard for head and neck reconstruction. There is significant variability in the technical aspects of this type of surgery, but commonalities can be found regarding general workflow and practice setup. This text will highlight several strategies to help the reconstructive head and neck surgeon improve efficiency, outcomes, and surgeon wellness.

Technical skills assessment during simulated cleft lip repair

INTRODUCTION

Cleft lip repair is a challenging procedure with a steep learning curve. A cleft lip simulator can augment the operating experience to shorten the learning curve. This study evaluated the efficacy of a high-fidelity cleft lip simulator using a newly developed cleft lip technical assessment tool.

METHODS

Four plastic surgery residents and 6 fellows performed 3 sequential cleft lip repairs. Three staff surgeons performed 1 cleft lip repair. Each procedure was video recorded and assessed by 3 staff cleft surgeons using a newly developed cleft lip technical assessment scale and a previously developed global rating scale. The reliability (intraclass correlation coefficient [ICC]) of the assessment scores was determined. The first simulation session was compared among participants to determine whether the scales and simulator could distinguish between skill level. Learning curves were determined using successive assessment scores among the trainees.

RESULTS

The average ICC for the cleft lip-specific and global scores were 0.72 (range 0.65-0.82) and 0.70 (range 0.60-0.79), respectively. All scale items demonstrated statistically significant interrater reliability. The staff surgeons significantly outperformed the trainees in the first simulation session for both assessment scores (p < 0.05). The trainees demonstrated improved performance after each session.

CONCLUSIONS

A cleft lip assessment scale was developed and found to be reliable at evaluating technical skill in simulated cleft lip repair. Repeated use of the cleft lip simulator improved performance in simulated cleft lip repair.

Impact of surgical specialization on long-term survival after emergent colon cancer resections

BACKGROUND

The impact of surgical specialization on long-term survival in patients undergoing emergent colon cancer resections remains unclear.

METHOD

A retrospective analysis was conducted on all patients who underwent emergent colon cancer resections at a secondary care hospital between 2010 and 2020. The most senior surgeon performing the procedures was classified as colorectal surgeon (CS) or non-colorectal surgeon (NCS). NCS was further divided into acute care surgeons (ACSs) or general surgeons (GSs). Overall survival (OS) and cancer-free survival (CFS) were compared in patients operated by surgeons with different specializations.

RESULTS

A total of 235 emergent resections were performed during the study period, of which 99 (42%) were performed by CS and 136 (58%) by NCS. In adjusted Cox regression analyses, OS and CFS were similar in patients operated on by CS and NCS (hazard ratio (HR) for OS: 1.02 (0.72-1.496), p = 0.899 and HR for CFS: 0.91 (0.61-1.397), p = 0.660). Similarly, OS and CFS were equivalent in patients operated by ACS and CS (HR for OS: 1.10 (0.75-1.62), p = 0.629 and HR for CFS: 1.24 (0.80-1.92), p = 0.343). However, patients operated by GS had significantly shorter OS and CFS (HR for OS: 1.78 (1.05-3.00), p = 0.031 and HR for CFS: 1.83 (1.02-3.26), p = 0.041) compared with those operated by ACS and CS.

CONCLUSION

Long-term survival after emergent colon cancer resections was similar in patients operated on by CS and NCS, and the subgroup of ACS, indicating equivalent comparable surgical quality. The less favorable poorer survival observed for patients operated on by GS may possibly be due to less frequent exposure to colorectal and emergent surgery.

Assessing Surgical Competency among Fellows in Vitreoretinal Surgery: A Survey of Fellowship Program Directors and Fellows

PURPOSE

We surveyed vitreoretinal (VR) fellowship program directors (PDs) to elucidate how they assess surgical competency among VR fellows. In addition, we also surveyed fellowship program graduates for the years 2022 and 2023 regarding assessment metrics and tools used during VR fellowship training.

DESIGN

Web-based, cross-sectional descriptive study.

SUBJECTS

Fellowship PDs and recent fellowship graduates in the United States and Canada METHODS: The survey, distributed via email, queried participants about several aspects of assessing surgical competency in VR training including surgical numbers, teaching/assessment methods used to assess fellow surgical competency, comfort of fellows for various surgical procedures, appropriate degree of supervision, and criteria for a hypothetical national competence standard. A Likert scale was utilized for questions capturing participants' opinion. Mean response scores were reported.

MAIN OUTCOME MEASURES

Comparison of responses between PDs and fellows.

RESULTS

Forty-two PDs (42.1%) (33 university-based and 9 private institutions) and 40 fellows (16.8%) (28 academic and 12 private institutions) responded to the survey. Fellows expect a higher minimum number of vitrectomies (≥300) by graduation than PDs (≥200). Both PDs and fellows ranked direct observation of fellow (4.95/4.75), discussion with other faculty on fellow surgical performance (3.93/3.60), and outcomes of fellow surgical cases (3.88/3.53) (P > 0.05) respectively, as top 3 teaching tools. Both PDs and fellows expressed high comfort levels with various complex surgeries, such as primary scleral buckle (4.45/4.60), proliferative vitreoretinopathy detachments (4.57/4.45), advanced diabetic retinal detachments (4.57/4.38), and giant retinal tears (4.64/4.50), by the time of graduation. Autonomy was also considered an important indicator of surgical competence by both groups. However, apart from direct surgical experience, fellows rated other educational tools lower than PDs. There was overall agreement between the groups on several aspects of a hypothetical national competence standard.

CONCLUSIONS

This survey identified that the key tools utilized to assess surgical proficiency were direct observation of surgery by attending physician, discussions about fellow performance among faculty, and outcomes of fellow surgical cases. Both groups emphasized that by graduation, fellows should be proficient in several complex VR surgeries. These findings suggest a need for a more systematic approach to assess surgical competency of VR fellows.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Readiness of Graduating General Surgery Residents To Perform Common Pediatric Surgery Procedures

OBJECTIVE

Up to 40% of pediatric surgery procedures occur at adult hospitals. We aim to evaluate how competent graduating general surgery residents are to perform common pediatric surgery procedures.

DESIGN

Pediatric and adult inguinal (IH) and umbilical (UH) hernia operative evaluations were collected. Ratings were analyzed using Bayesian generalized linear mixed models. The primary outcome was graduating residents' estimated probability of being competent to perform an IH or UH repair.

SETTING

This study was conducted using operative assessment data from general surgery programs in the Society for Improving Medical and Professional Learning (SIMPL) collaborative.

PARTICIPANTS

113,621 evaluations (2,924 UH, 5,555 IH) from 7,032 categorical general surgery residents were analyzed from 2015-2023.

RESULTS

Graduating residents had an adjusted probability of being competent to perform an adult IH of 94.3% (Interquartile Range [IQR] 83.4%-98.3%). In contrast, competence probabilities were 79.5% (IQR 52.7%-93.3%) for a <6 month old, 89.6% (IQR 72.1%-96.9%) for a 6 month to 5 year old, and 89.9% (IQR 71.9%-96.9%) for a >5 year old. For UH repairs, competence probabilities were similar for adult (97.6%, IQR 92.4%-99.3%) and pediatric procedures (97.3% for <5 years old [IQR 91.4%-99.2%]; 97.6% for >5 years old [IQR 92.3%-99.3%]).

CONCLUSIONS

Nearly all graduating general surgery residents are competent to perform pediatric UH repairs. However, there is variability in competence of general surgery residents performing pediatric IH repairs, especially in children <6 months old.

Preserving Essential Skills: The Future of Vaginal Hysterectomy Training in Urogynaecology

OBJECTIVES

This study aimed to evaluate the training and self-assessed proficiency of surgeons in the surgical management of pelvic organ prolapse (POP). We focused on the factors that influence decision-making, the surgical techniques employed, the training received, and the management of complications.

DESIGN

A cross-sectional survey.

SETTING

An electronic questionnaire.

POPULATION

European Urogynaecological Association (EUGA) and International Urogynecological Association (IUGA) members.

METHODS

A total of 33 questions evaluating surgeon preference regarding vaginal surgeries.

MAIN OUTCOME MEASURES

Demographics, surgical selection, proficiency and technique, and training methods.

RESULTS

There were 471 respondents, of which 273 (58%) dedicated more than 50% of their week to urogynaecology. 250 (53%) had completed a fellowship, with 215 (86%) of those fellowships being in urogynaecology and pelvic floor reconstruction. A preference for hysterectomy in cases of uterine descent was noted by 297 (63%) respondents, influenced mainly by patient preference, age, and prolapse anatomical score. A total of 443 (94%) were proficient in vaginal hysterectomy, with two-thirds performing 30 or fewer procedures annually; 212 (45%) reporting a decrease in the number of procedures over the last decade. Additionally, 373 (79%) respondents believed that 10-30 cases were needed to achieve and maintain proficiency.

CONCLUSION

Vaginal hysterectomy remains a key component in uterine prolapse repair. However, with the rise of uterine-sparing prolapse repairs, the decision-making process may be influenced by multiple factors, including surgical training. Emphasis should be placed on training and maintaining proficiency in both traditional and novel techniques.

Unusual presentation of a giant recurrent inguinal hernia: a case report

The recurrence rate of inguinal hernia is 1-10%, most often in the inguinal region, and seldom in different locations. A 72-year-old man with a large soft swelling in the right ventrolateral abdominal region without swelling in the scrotum, operated on right inguinal hernia at pediatric age. Clinical findings revealed a giant right ventrolateral hernia and abdominal CT showed weakness of the abdominal wall with a 25 cm long hernial sac with an apex under the right costal arch and a base at the deep inguinal opening, that was diagnosed as a recurrent inguinal hernia with unusual presentation. Hernioplasty without opening the hernial sac was performed in an atypical manner. The patient was discharged from the hospital without pain or discomfort at the follow-up. The common presentation of recurrent inguinal hernia is inguinal-scrotal but an unusual presentation should be reconsidered with a proper diagnosis and adequate surgical treatment.

Vascular Closure Device vs Open Decannulation for Femoral Venoarterial Extracorporeal Membrane Oxygenation

BACKGROUND

Traditional decannulation of femoral venoarterial (VA) extracorporeal membrane oxygenation (ECMO) involves femoral cutdown. Percutaneous methods have been developed, but data supporting their use are limited. This study sought to compare the MANTA (Teleflex) vascular closure device with open decannulation.

METHODS

The study investigators retrospectively reviewed patients decannulated from femoral VA ECMO from January 2018 to January 2023 at our institution (University of Maryland Medical Center, Baltimore, MD). Patients were excluded if cannulation was not percutaneous or if percutaneous decannulation was performed without MANTA use. The primary outcome was lower extremity complications. Closure of the distal perfusion site was compared between superficial femoral artery (SFA) manual pressure and percutaneous closure with MYNX (Cordis) or Angioseal (Terumo Medical Corporation).

RESULTS

A total of 160 patients underwent open decannulation, and 94 patients (30 at bedside) underwent MANTA decannulation. Both groups had 6-day median ECMO support duration. The intraoperative revision rate between MANTA and open decannulation was similar (9 [9.6%] vs 26 [16.4%]; P = .13). Four revisions for MANTA were technical failures in early surgeon experience. In a multivariable model, there was a 46% relative reduction in lower extremity complications with MANTA decannulation compared with open decannulation (26.1% vs 39.6%; odds ratio, 0.54; 95% CI, 0.28-1.00). There was no significant difference in SFA complications between manual pressure and percutaneous closure (14.4% vs 10.7%; odds ratio, 0.71; 95% CI, 0.29-1.76).

CONCLUSIONS

There is a significant reduction in lower extremity complications with MANTA decannulation compared with open decannulation from femoral VA ECMO, thus allowing for safe bedside decannulation. Percutaneous SFA closure has outcomes equivalent to those of manual pressure.

Anorectal Malformation Patients in Australia and Europe: Different Location, Same Problem? A Retrospective Comparative Registry-Based Study

Anorectal malformations (ARM) encompass a spectrum of rare congenital defects of the rectum and anus, requiring specialized reconstructive surgery. To improve epidemiological and clinical research in rare diseases such as ARM, collaborative efforts and patient registries are key. This retrospective study pools clinical data over a 30-year period from two ARM patient registries (The Royal Children's Hospital (RCH) in Melbourne, Australia, and the ARM-Network Consortium in Europe). It aims to draw comparisons on demographics, management, and outcomes between ARM patients in Australia and Europe. A total of 2947 ARM patients were included in the analyses. The RCH cohort had more complex ARM types (including rectal atresia and recto-vaginal fistula) and more associated anomalies, specifically skeletal, cardiac, and/or trachea-esophageal, than ARM-Net patients. Other patient characteristics were similar. Treatments clearly differed between the groups. European surgeons favoured the PSARP approach for both less complex and more complex ARM types, where Australian surgeons opted more often for cutback surgery in less complex, and laparoscopic assistance in more complex types. Complications were differently distributed, with less complications after LAARP and more after PSARP at RCH, compared to ARM-Net. While RCH patients more often required a redo, ARM-Net patients more commonly underwent anal dilatations. Anorectal malformation patients in Australia and Europe had minor differences in disease characteristics, and both operative and medical approaches differed. Joint efforts such as the present study emphasize the importance of collaboration to elucidate areas of improvement where surgeons may learn from each other across the world, ultimately improving patient outcomes. TYPE OF STUDY: Original Research. LEVEL OF EVIDENCE: III.

Effect of Surgeons' Years of Experience on Outcomes of Acute Type A Aortic Dissection

Background The effect of surgeons' years of experience on the outcomes of acute type A aortic dissection (ATAAD) repair has not yet been studied. This study aimed to evaluate the association between the surgeon's years in practice and the outcomes of ATAAD repair. Methods Surgical records of ATAAD repairs performed at Saga University Hospital between 2004 and 2020 were reviewed. Surgeons were divided into two groups based on their surgical experience: late-career surgeons (LCSs) and early-career surgeons (ECSs) with ≥16 years and <16 of practice, respectively. The surgeons were designated as the primary surgeons or first assistants and grouped as follows: LCS-LCS, LCS-ECS, ECS-LCS, and ECS-ECS. Results During the study period, 25 primary surgeons performed 203 ATAAD repairs with 31 different first assistants: LCS-LCS, 50 repairs; LCS-ECS, 82 repairs; ECS-LCS, 55 repairs; and ECS-ECS, 16 repairs. The mean years in practice as a primary surgeon was 19.8 ± 3.3 for LCSs and 13.0 ± 1.8 for ECSs (p < 0.01). The unadjusted in-hospital mortality rates were 10.0%, 12.2%, 5.5%, and 6.3% for the LCS-LCS, LCS-ECS, ECS-LCS, and ECS-ECS groups, respectively (p = 0.63). Multivariable regression analysis showed that the surgeon's years of experience in practice were not a risk factor for in-hospital mortality. Furthermore, the long-term survival rate did not differ between the groups (p = 0.62). Conclusions The surgeons' years in practice had no effect on the outcomes of ATAAD repair. These investigations could aid in on-call coverage for ATAAD in medium-sized centers.

A Conceptual Model of Individual Clinical Readiness

INTRODUCTION

Force readiness is a priority among senior leaders across all branches of the Department of Defense. Units that do not achieve readiness benchmarks are considered non-deployable until the unit achieves the requisite benchmarks. Because military units are made up of individuals, the unit cannot be ready if the individuals within the unit are not ready. For medical personnel, this refers to one's ability to competently provide patient care in a deployed setting or their individual clinical readiness (ICR). A review of the literature found no conceptual model of ICR. Other potential concepts, such as individual medical readiness, were identified but used inconsistently. Therefore, the purpose of this article is to define ICR and propose a conceptual model to inform future efforts to achieve ICR and facilitate future study of the concept.

MATERIALS AND METHODS

Model development occurred using a 3-step theoretical model synthesis process. The process included specification of key concepts, identification of related factors and relationships, and organizing them into an integrated network of ideas.

RESULTS

ICR is the clinically oriented service members' (COSM) ability to meet the demands of the militarily relevant, assigned clinical mission. ICR leads to one's "individual clinical performance," a key concept distinct from ICR. To understand ICR, one must account for "individual characteristics," as well as one's "education," "training," and "exposure." ICR and individual clinical performance are influenced by the "quality of exposure" and the "patient care environment." One's "individual clinical performance" also reciprocally influences the patient care environment, as well as the "team's clinical performance." These factors (individual clinical performance, team clinical performance, and the patient care environment) influence "patient outcomes." In the proposed model, patient outcomes are an indirect result of ICR and its antecedents (personal characteristics, education, training, and exposure); one's individual clinical performance may not be consistent with their ICR. Patient outcomes are also influenced by the "patient environment" (external to the health care environment) and "patient characteristics"; these elements of the model do not influence ICR or individual clinical performance.

CONCLUSION

Force readiness is a Department of Defense priority. In order for military units to be deployment ready, so too must their personnel be deployment ready. For COSMs, this includes one's ability to competently provide patient care in a deployed setting or their ICR. This article defines ICR, as well as identifies another key concept and other factors associated with ICR. The proposed model is a tool for military medical leaders to communicate with and influence non-medical military leaders in the Department of Defense. Future research is needed to further refine the proposed model, determine the strength of the proposed relationships, and identify interventions to improve ICR.

Supporting early-career military general surgeons: an Eastern Association for the Surgery of Trauma Military Committee position paper

Early-career surgeons must be exposed to a sufficient number of surgical cases of varying complexity in a mentored environment to allow them to solidify, sustain and build on the skills gained in training. Decreased operative volumes at military treatment facilities and assignments that do not include strong mentoring environments can place military surgeons at a disadvantage relative to their civilian counterparts during this critical time following training. The challenge of lower operative volumes in the current interwar lull has been exacerbated by the decline in beneficiary care conducted within the Military Healthcare System. These challenges must be addressed by ensuring early-career surgeons maintain exposure to a large volume of complex surgical procedures and deliberate mentoring from senior surgeons. The purpose of this position statement is to provide actionable methods to support early-career military surgeons to effectively transition from training to independent practice.

An initial exploration of factors that may impact radiographer performance in reporting mammograms

OBJECTIVES

In the United Kingdom, radiographers with a qualification in image interpretation have interpreted mammograms since 1995. These radiographers work under the title of radiography advanced practitioners (RAP) or Consultant Radiographer. This study extends upon what has been very recently published by exploring further clinical, non-clinical and experiential factors that may impact the reporting performance of RAPs.

METHODS

Fifteen RAPs interpreted an image test set of 60 2D mammograms of known truth using the Detected-X software platform. Unknown to the reader, twenty cases contained a malignancy. Sensitivity, specificity, lesion sensitivity, receiver operating characteristic (ROC) and jack-knife free response operating characteristic (AFROC) values were established for each RAP. Specific features that had significant impact on accuracy were identified using Student's-T and Mann Whitney tests.

RESULTS

RAPs with more than 10 years' experience in image interpretation, compared to those with less than 10 years' experience, demonstrated lower specificity (51.3% vs 84.8%, p = 0.0264), ROC (0.83 vs 0.91, p = 0.0264) and AFROC (0.75 vs 0.87, p = 0.0037) values. Further, higher sensitivity values of 90.7% were seen in those RAPs who had an eye test in the last year compared to those who had not, 82% (p = 0.021). Other changes are presented in the paper.

CONCLUSION

These data reveal previously unidentified factors that impact the diagnostic efficacy of RAPs when interpreting mammographic images. Highlighting such findings will empower screening authorities to better examine ways of standardising performance and offer a baseline for performance benchmarks.

IMPLICATIONS FOR PRACTICE

This study for the first time performs an initial exploration of the factors that may be associated with RAP performance when interpreting screening mammograms.

Evaluating Performance and Autonomy Levels of Previous Preliminary Surgery Interns

INTRODUCTION

Surgery residents who complete a nondesignated preliminary year have an additional year of training compared to those who begin as categorical residents. While this additional year is sometimes perceived negatively, these more experienced residents may outperform traditional categorical (TC) residents in their first year of training.

METHODS

Operative assessment ratings were recorded for first year categorical general surgery residents in the United States between 2015 and 2023 using the Society for Improving Medical and Professional Learning assessment platform. Residents were categorized based on the completion of a nondesignated preliminary year ("Previous Prelim" [PP]) or not ("Traditional Categorical"). Ratings were analyzed using generalized mixed effects models. Performance and autonomy outcomes were dichotomized: "less experience" or "more experience" and "no autonomy" or "some autonomy", respectively. Fixed effects included academic month and case complexity, while random effects included resident, faculty, program, and procedure.

RESULTS

A total of 34,353 evaluations from 86 general surgery programs were collected. Of these, 829 were evaluations from PP residents. Faculty ratings of PP versus TC revealed no differences in adjusted probabilities of achieving a "more experience" rating (82% versus 76%, P = 0.26) but a higher adjusted probability of achieving a "some autonomy" rating (88% versus 80%, P = 0.04) for PP compared to TC. Analysis of resident self-reported ratings revealed higher adjusted probabilities of a "more experience" rating (77% versus 50%, P = 0.01) and "some autonomy" rating (87% versus 73%; P = 0.02) for PP compared to TC.

CONCLUSIONS

First year general surgery residents who previously completed a preliminary year have similar operative performance faculty ratings when compared to their peers.

Adoption and Effect of Sealants for Occlusal Noncavitated Caries in a Large Dental Network in the USA

INTRODUCTION

Dental sealants applied to occlusal pit-and-fissure surfaces have been shown to prevent caries and arrest occlusal noncavitated carious lesions (NCCLs). The American Dental Association (ADA) recommends that oral healthcare providers apply sealants on occlusal NCCLs. Though the evidence is clear that sealants are effective, few studies have examined the adoption of the ADA guideline by dentists and the duration of protection provided by sealants in a large real-world setting.

METHODS

This study used observational electronic health record (EHR) data from a network of dental clinics to follow teeth over a 2 year time period from when they were diagnosed as having an occlusal NCCL until either they were treated with a restoration or the time period ended with no restoration. The objectives of the study were to determine: (1) the degree to which dentists adopted the guideline, (2) whether the duration of protection was different for teeth that received a sealant from teeth that did not receive a sealant, and (3) whether dentists' experience placing sealants was associated with the duration of protection.

RESULTS

Overall, there were 7,299 teeth in the sample. Of those, dentists restored 591 teeth and applied sealants on 164. The sealant application rate for eligible teeth was 2.2%. Sealant application was associated with provider, with 1.9% of providers placing more than half of the sealants. By the end of the observation period, the proportion of teeth progressing to restorations was 8.2% for teeth that had not received a sealant and 3.0% for teeth that had received one (RR = 0.37; 95% CI: 0.16-0.88; p = 0.02). Multilevel survival analysis showed that teeth that had not received a sealant were restored sooner than teeth that had received a sealant (aHR = 0.11; 95% CI: 0.03-0.36; p < 0.01). Overall, teeth that received a sealant had an 89% reduced hazard of restoration within 2 years compared with teeth that did not receive sealants.

CONCLUSION

This study found that by arresting decay, the presence of sealants led to fewer restorations and delayed restorations compared with teeth not receiving a sealant or restoration in the 2 years following diagnosis of occlusal NCCL in clinical settings.

Laparoscopy experience in East, Central, and Southern Africa: insights from operative case volume analysis

BACKGROUND

With the primary objective of addressing the disparity in global surgical care access, the College of Surgeons of East, Central, and Southern Africa (COSECSA) trains surgeons. While sufficient operative experience is crucial for surgical training, the extent of utilization of minimally invasive techniques during COSECSA training remains understudied.

METHODS

We conducted an extensive review of COSECSA general surgery trainees' operative case logs from January 1, 2015, to December 31, 2020, focusing on the utilization of minimally invasive surgical procedures. Our primary objective was to determine the prevalence of laparoscopic procedures and compare this to open procedures. We analyzed the distribution of laparoscopic cases across common indications such as cholecystectomy, appendicitis, and hernia operations. Additionally, we examined the impact of trainee autonomy, country development index, and hospital type on laparoscopy utilization.

RESULTS

Among 68,659 total cases, only 616 (0.9%) were laparoscopic procedures. Notably, 34 cases were conducted during trainee external rotations in countries like the United Kingdom, Germany, and India. Gallbladder and appendix pathologies were most frequent among the 582 recorded laparoscopic cases performed in Africa. Laparoscopic cholecystectomy accounted for 29% (276 of 975 cases), laparoscopic appendectomy for 3% (76 of 2548 cases), and laparoscopic hernia repairs for 0.5% (26 of 5620 cases). Trainees self-reported lower autonomy for laparoscopic (22.5%) than open cases (61.5%). Laparoscopy usage was more prevalent in upper-middle-income (2.7%) and lower-middle-income countries (0.8%) compared with lower-income countries (0.5%) (p < 0.001). Private (1.6%) and faith-based hospitals (1.5%) showed greater laparoscopy utilization than public hospitals (0.5%) (p < 0.001).

CONCLUSIONS

The study highlights the relatively low utilization of minimally invasive techniques in surgical training within the ECSA region. Laparoscopic cases remain a minority, with variations observed based on specific diagnoses. The findings suggest a need to enhance exposure to minimally invasive procedures to ensure well-rounded training and proficiency in these techniques.

Does resident involvement in tonsillectomy affect outcomes?

OBJECTIVE

Tonsillectomy is essentially a solo surgery with a well-described complication profile. It may serve as a good benchmark to evaluate the resident-as-surgeon. This study examined complications such as post-tonsillectomy bleeding in children undergoing tonsillectomy by attending surgeons (AS) or pediatric otolaryngologist-supervised residents.

METHODS

Charts were reviewed of all children aged 12 and under who had tonsillectomy +/- adenoidectomy at a children's hospital between Jan 2019 and Dec 2020. Patient age, gender, BMI, indication for surgery, surgical technique, presence of a resident surgeon, primary bleeding, secondary bleeding, treatment of bleeding, other Emergency Room (ER) visits, and clinic phone calls were recorded. Binary logistic regression was performed.

RESULTS

2051 total children (1092 (53.2 %) males and 956 (46.6 %) females) with a mean age of 6.1 years (95 % CI 6.0-6.2) were included. 1910 (93.0 %) underwent surgery for tonsillar obstruction. 1557 (75.9 %) underwent monopolar cautery tonsillectomy. 661 (32.2 %) had a resident surgeon. 274 (13.4 %) had a related ER visit within 15 days. 18 (0.9 %) had a primary bleed and 155 (7.6 %) had a secondary bleed. Binary logistic regression showed that significant predictors of postoperative ER visits were patient age (OR = 1.101, 95 % CI = 1.050-1.154, p < .001) and resident involvement (OR = 0.585, 95 % CI = 0.429-,797, p < .001). Only age was associated with overall postoperative bleeding incidence (OR = 1.131, 95 % CI = 1.068-1.197, p < .001), as well as secondary bleeding (OR = 1.128, 95 % CI = 1.063-1.197, p < .001). There were no significant predictors of primary bleeding.

CONCLUSION

Resident involvement in pediatric tonsillectomy is associated with decreased postoperative ER utilization and does not appear to increase common postoperative complications including bleeding and dehydration.

Surgeon Skill and Perioperative Outcomes in Robot-Assisted Partial Nephrectomy

Importance

Technical skill in complex surgical procedures may affect clinical outcomes, and there is growing interest in understanding the clinical implications of surgeon proficiency levels.

Objectives

To determine whether surgeon scores representing technical skills of robot-assisted kidney surgery are associated with patient outcomes.

Design, Setting, and Participants

This quality improvement study included 10 urological surgeons participating in a surgical collaborative in Michigan from July 2021 to September 2022. Each surgeon submitted up to 7 videos of themselves performing robot-assisted partial nephrectomy. Videos were segmented into 6 key steps, yielding 127 video clips for analysis. Each video clip was deidentified and distributed to at least 3 of the 24 blinded peer surgeons from the collaborative who also perform robot-assisted partial nephrectomy. Reviewers rated technical skill and provided written feedback. Statistical analysis was performed from May 2023 to January 2024.

Main Outcomes and Measures

Reviewers scored each video clip using a validated instrument to assess technical skill for partial nephrectomy on a scale of 1 to 5 (higher scores indicating greater skill). For all submitting surgeons, outcomes from a clinical registry were assessed for length of stay (LOS) greater than 3 days, estimated blood loss (EBL) greater than 500 mL, warm ischemia time (WIT) greater than 30 minutes, positive surgical margin (PSM), 30-day emergency department (ED) visits, and 30-day readmission.

Results

Among the 27 unique surgeons who participated in this study as reviewers and/or individuals performing the procedures, 3 (11%) were female, and the median age was 47 (IQR, 39-52) years. Risk-adjusted outcomes were associated with scores representing surgeon skills. The overall performance score ranged from 3.5 to 4.7 points with a mean (SD) of 4.1 (0.4) points. Greater skill was correlated with significantly lower rates of LOS greater than 3 days (-6.8% [95% CI, -8.3% to -5.2%]), EBL greater than 500 mL (-2.6% [95% CI, -3.0% to -2.1%]), PSM (-8.2% [95% CI, -9.2% to -7.2%]), ED visits (-3.9% [95% CI, -5.0% to -2.8%]), and readmissions (-5.7% [95% CI, -6.9% to -4.6%]) (P < .001 for all). Higher overall score was also associated with higher partial nephrectomy volume (β coefficient, 11.4 [95% CI, 10.0-12.7]; P < .001).

Conclusions and Relevance

In this quality improvement study on video-based evaluation of robot-assisted partial nephrectomy, higher technical skill was associated with lower rates of adverse clinical outcomes. These findings suggest that video-based evaluation plays a role in assessing surgical skill and can be used in quality improvement initiatives to improve patient care.

Does a junior doctor focused 'Bootcamp' improve the confidence and preparedness of newly appointed ENT registrars to perform their job roles?

BACKGROUND

To assess changes in confidence and preparedness after conducting a 2-day induction bootcamp for novice Ear Nose and Throat (ENT) first year specialty trainee registrars (ST3s) in the United Kingdom (UK). The bootcamp covered common ENT presentations on the ward, and in the elective and emergency settings.

METHODS

A total of 32 trainees (ST3 or research fellow) voluntarily registered via an online application form to the Southern ST3 accelerated learning course bootcamp through ENT UK. ENT UK is a membership body that supports ENT trainees throughout their careers. They completed a two-day bootcamp that was hosted at St Mary's Hospital, London and 10 skills sessions were delivered by either a senior ENT registrar or an ENT consultant. A pre-session questionnaire was distributed to all participants and a post-session questionnaire was provided that assessed the changes in confidence and preparedness of the participants, if any. The responses were scored by a 10-point Likert scale. Only participants who fully completed the pre and post questionnaire were included, which was 29 in total.

RESULTS

Participants self-reported a significant increase in confidence (p < 0.001) and preparedness (p < 0.001) following the bootcamp course. The greatest improvements in comparison to all other stations were self-preparedness in the rigid bronchoscopy station and self-confidence in the sphenopalatine artery (SPA) ligation station.

CONCLUSION

The use of a two-day bootcamp improved confidence and preparedness of managing common ENT presentations in the ward, elective and emergency settings for ENT ST3s. It provides a useful adjunct in the acquisition of technical and non-technical skills alongside the traditional surgical apprenticeship. In the future, more work is required to assess the impact of bootcamps on patient outcomes and long-term benefits on trainees' skill retention and clinical proficiency.

Optimising head and neck cancer patient management: the crucial contributions of multidisciplinary tumour board decision-making

Introduction

Squamous cell carcinoma (SCC) of the head and neck is a great burden globally, which is being tackled through treatment options of surgery, radiation therapy, chemotherapy, or a combination of these, to avoid disease-related mortality. Multidisciplinary tumour boards play a pivotal role in customising and deciding management plan based on clinical aspects. The objective of the study is to determine the concordance of opinion between the treatment plan of a primary physician and board members.

Material and methods

This is a retrospective cross-sectional study that includes 137 head and neck carcinoma cases. They were discussed in the multidisciplinary tumour board meeting and were reviewed; all demographics were analysed including the tumour staging and the decisions of the primary physician was compared with those of the board. To check the concordance between primary surgeon plans or after board discussion Kappa agreement test was used.

Results

Total of 137 patients were included in the study out of which 63 cases were pre-treatment and 74 cases were post-treatment, i.e., surgically treated cases, with the distribution being 46% and 54%, respectively. Most cases, totaling 120, were SCC, accounting for 80% of the total cases. Among the pre-treatment cases, T4a and N0 were the most common categories, with 29 and 40 cases, respectively. Similarly, in post-treatment cases, the majority fell into the T4a and N1 categories, with 29 and 38 cases, respectively. When comparing the primary surgeon's plan with the tumour board meeting decision, the agreement showed a value of 0.273, indicating a slight level of agreement between the two entities.

Conclusion

Our data indicates that the multidisciplinary head and neck tumour board may have influenced the treatment plans of the primary surgeon, in approximately one in two patients (43.06%).

Analysis of the Accuracy of CAM-type Deformity Resection on a Low-cost Arthroscopic Simulator in a Training Scenario

Objective To evaluate surgeons' performance in resecting CAM-type deformities using a realistic arthroscopic surgery simulator. Methods An arthroscopic simulator was created using low-cost materials with the help of a GTMax Core A1 3D printer and the programs Invesalius and Meshmixer 2017, which were used to develop femoral head parts in ABS material, with the presence of a CAM-type deformity, to mimic a femoroacetabular impact situation. After the operations were performed by 16 surgeons, the femurs were compared to a previous model with deformity and another without, using Cloudcompare, and parameters such as the volumetric difference between the operated femurs, with and without deformity, the minimum and maximum distance between them, the percentage of the deformity resected, the estimated time for total resection of the deformity, as well as a qualitative analysis based on the images and graphs provided by the program representing the areas of the parts resected, were evaluated at the end. Results The average resection speed was 34.66 mm 3 /min (SD = 46 mm 3 /min, max = 147.33; min = -2.66). The average resection rate was 26.2% (SD = 34.7%, max = 111; min = -2). Qualitative analysis showed hyporesection of deformities and sometimes hyperresection of nondeformed areas. The simulator was highly rated by the surgeons, with a tactile sensation very similar to real surgery, according to them. Conclusion Arthroscopic simulators have proved very useful in training less experienced surgeons.

Surgeon Experience Matters: An Exact Matched Analysis of TLIF Outcomes Demonstrates No Difference in Surgical Outcomes Between Experienced Neurosurgeons and Orthopedic Surgeons

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare surgical and medical complications profile between neurosurgeons and orthopedic surgeons after transforaminal lumbar interbody fusion (TLIF) procedures.

BACKGROUND

Studies comparing the impact of spine surgeon specialty (neurosurgery vs. orthopedic spine) on TLIF outcomes have been inconclusive and failed to control for operative learning curves and surgical maturity. Orthopedic spine surgeons perform fewer spine procedures in residency, although these differences may be attenuated by mandatory fellowship before starting practice. Any observed differences are likely attenuated with increasing surgeon experience.

MATERIALS AND METHODS

Using an all-payer claims database, PearlDiver Mariner, 120 million patient records were analyzed between 2010 and 2022, to identify individuals with lumbar stenosis or spondylolisthesis who underwent index one- to three-level TLIF procedures. International Classification of Diseases-Ninth Edition (ICD-9), International Classification of Diseases-10th Edition (ICD-10) and Current Procedural Terminology (CPT) codes were used to query the database. Only Neurosurgeons and Orthopedic spine surgeons who had performed at least 250 procedures were included in the study. Patients undergoing surgery for tumor, trauma, or infection were excluded. 1:1 exact matching was performed using demographic factors, medical comorbidities, and surgical factors which were significantly associated with all-cause surgical or medical complications in a linear regression model.

RESULTS

1:1 exact matching created two equal groups of 18,195 patients without baseline differences who underwent TLIF procedures by neurosurgeons or orthopedic surgeons. There was no difference in all-cause surgical complications between neurosurgeons and orthopedic spine surgeons (relative risk=1.008, 95% CI: 0.850-1.195, P =0.965). All-cause medical complication rate was higher in the neurosurgery cohort (relative risk=1.144, 95% CI: 1.042-1.258, P =0.005).

CONCLUSION

The results of this study suggest that after accounting for surgical maturity, neurosurgeons and orthopedic spine surgeons have similar surgical outcomes. However, neurosurgeons have higher all-cause medical complication rates compared with orthopedic spine surgeons. Further research is warranted to validate this relationship in other spine procedures and for other outcomes.

Effect of gender discordance on surgical outcomes in predominantly female patient surgeries in NYS

BACKGROUND

Preliminary evidence demonstrates female surgeons have improved post-operative outcomes compared to male colleagues despite underrepresentation in surgery. This study explores the effect of patient-surgeon gender discordance on outcomes in three specialties with high female patient populations: bariatric, foregut, colorectal.

METHODS

This is a retrospective study using the New York State (NYS) SPARCS database and first study evaluating outcomes based on surgeon/patient concordance in NYS. Bariatric, foregut, and colorectal surgery cases from 2013 to 2017 were identified.

RESULTS

Bariatric: female patients (FP) with CC had lower 30-day readmissions but higher complications compared with DC. Male patients (MP) with CC trended towards higher 30-day readmissions but lower complications compared with DC. FP received significantly better influence from CC in 30-day readmission, but disadvantages in complications. There was no significant difference in LOS or ED visits between CC and DC groups for either FP or MP. Foregut: FP with CC had lower LOS, 30-day readmissions, and 30-day ED visits compared with DC. MP showed opposite trends between CC and DC, although non-significant. The benefit from concordance was pronounced in FP compared to MP in LOS, 30-day readmissions, and 30-day ED visit. Concordance vs discordance did not significantly affect complications within either FP or MP group. Colorectal: the difference between CC and DC was not significant within FP or MP groups in any outcomes. When comparing the difference of 30-day readmissions in CC vs DC between FP and MP, there is a significant difference.

CONCLUSION(S)

Overall, our results show DC between patient and surgeon has significant effect on patient outcomes. A negative effect is seen for female patients in certain specialties, most pronounced in foregut surgery. This emphasizes need for surgeons to be conscious of care provided to opposite gender patients and underscores increasing female surgeons in high FP fields.

Millions Saved in Head and Neck Free Flap Reconstruction at a High-Volume Center: A Cost Analysis

Background: Within a resource-limited healthcare system, an emphasis on financial accountability is imperative. Over the past decade at our institution, there have been many operational changes employed to improve patient care during oncologic head and neck resections with free flap (HNFF) reconstruction. The objective of this study is to assess whether these changes are associated with cost savings. Methods: A retrospective cohort study that included consecutive patients treated from January 2007 to February 2020 was performed. The perspective of the third payer party was used and direct costs were considered. The peri-operative period was defined as the day of surgery and subsequent admission. Total peri-operative cost was defined as staffing, material, reconstructive surgeon, anesthetist, and admission costs. Costs are represented in Canadian Dollars ($CAD) adjusted for inflation. Results: There were 590 consecutive cases. Average age was 61 with a male proportion of 69% (n = 409). Tumor type, need for tracheostomy, neck dissection, anatomic region resected, 30-day re-operation, and re-admission did not change significantly over the study period (P > 0.05). The mean total operative time per case decreased by 4.1 h over the study period. The median length of stay per patient decreased by 4.5 days. The total peri-operative cost per patient during the study period decreased by $19,928. Net cost savings to the third-party payer over the study period was $8,142,962. Conclusion: A culture of improvement-focused teamwork allowed for several advances over the study period. These were associated with improved patient care, operative efficiency, and significant cost savings of HNFF reconstruction.

Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews and meta-analyses

OBJECTIVES

This study aims to examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons and whether surgery or the drug intervention was favoured.

DESIGN

Systematic review of systematic reviews (umbrella review).

DATA SOURCES

Cochrane Database of Systematic Reviews.

ELIGIBILITY CRITERIA

Systematic reviews attempt to compare surgical to drug interventions.

DATA EXTRACTION

We extracted whether the review found any randomised controlled trials (RCTs) for eligible comparisons. Individual trial results were extracted directly from the systematic review.

SYNTHESIS

The outcomes of each meta-analysis were resynthesised into random-effects meta-analyses. Egger's test and excess significance were assessed.

RESULTS

Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% CIs, the surgical intervention was favoured in 38/103 (37%), and the drugs were favoured in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority in our reanalysis (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favour of surgery and 2 (9%) were in favour of drugs. There was no evidence of excess significance.

CONCLUSIONS

Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomised evidence is rare. More randomised trials comparing surgery to drug interventions are needed.

Pancreatojejunostomy: standing on the shoulders of giants. A single centre retrospective analysis

Gaining experience in pancreatic surgery could be demanding especially when minimally invasive approach is used. Pancreatojejunostomy (PJ) is one of the most critical steps during pancreatoduodenectomy (PD). Our aim was to investigate the impact of a surgeon's experience in performing PJ, especially in a subgroup of patients undergoing laparoscopic PD (LPD). Data of consecutive patients undergoing PD from 2017 to 2022 were prospectively collected and retrospectively analyzed. Patients were divided into two groups: M group included patients in which PJ was performed by an experienced surgeon, D group included those receiving PJ by a less experienced one. The groups were compared in terms of postoperative outcomes. 187 patients were selected (157 in group M and 30 in group D). The cohorts differed in terms of median age (68 vs 74 years, p = 0.016), and previous abdominal surgery (41.4% vs 66.7%, p = 0.011), while no difference was found regarding risk of postoperative pancreatic fistula (POPF). The groups did not differ in terms of surgical outcomes. POPF rate was 15.9% and 10% in the M and D group (p = 0.578), respectively. Among patients undergoing laparoscopic PJ POPF rate was 16.0% and 17.7% in the M and D group (p = 0.867), respectively, without difference. No difference was found in terms of POPF in patients undergoing PD independently from the surgeon who performed the PJ, even during LPD. Moderate/high FRS, BMI > 30 kg/m2 and male sex, but not the surgeon who performed the PJ anastomosis, were independent predictors of POPF.

Operative Case Volumes and Variation for General Surgery Training in East, Central, and Southern Africa

BACKGROUND

Operative experience is a necessary part of surgical training. The College of Surgeons of East, Central, and Southern Africa (COSECSA), which oversees general surgery training programs in the region, has implemented guidelines for the minimum necessary case volumes upon completion of two (Membership) and five (Fellowship) years of surgical training. We aimed to review trainee experience to determine whether guidelines are being met and examine the variation of cases between countries.

METHODS

Operative procedures were categorized from a cohort of COSECSA general surgery trainees and compared to the guideline minimum case volumes for Membership and Fellowship levels. The primary and secondary outcomes were total observed case volumes and cases within defined categories. Variations by country and development indices were explored.

RESULTS

One hundred ninety-four trainees performed 69,283 unique procedures related to general surgery training. The review included 70 accredited hospitals and sixteen countries within Africa. Eighty percent of MCS trainees met the guideline minimum of 200 overall cases; however, numerous trainees did not meet the guideline minimum for each procedure. All FCS trainees met the volume target for total cases and orthopedics; however, many did not meet the guideline minimums for other categories, especially breast, head and neck, urology, and vascular surgery. The operative experience of trainees varied significantly by location and national income level.

CONCLUSIONS

Surgical trainees in East, Central, and Southern Africa have diverse operative training experience. Most trainees fulfill the overall case volume requirements; however, further exploration of how to meet the demands of specific categories and procedures is necessary.

Elective Recurrent Inguinal Hernia Repair: Value of an Abdominal Wall Surgery Unit

BACKGROUND

The aim of this study was to analyze the impact of an abdominal wall surgery unit on postoperative complications (within 90 days postoperatively), hernia recurrence and chronic postoperative inguinal pain after elective recurrent inguinal hernia repair.

METHODS

We conducted a retrospective cohort study of all adult patients who underwent elective recurrent inguinal hernia repair between January 2010 and October 2021. Short- and long-term outcomes were compared between the group of patients operated on in the abdominal wall surgery unit and the group of patients operated on by other units not specialized in abdominal wall surgery. A logistic regression model was performed for hernia recurrence.

RESULTS

A total of 250 patients underwent elective surgery for recurrent inguinal hernia during the study period. The patients in the abdominal wall surgery group were younger (P ≤ 0.001) and had fewer comorbidities (P ≤ 0.001). There were no differences between the groups in terms of complications. The patients in the abdominal wall surgery group presented fewer recurrences (15% vs. 3%; P = 0.001). Surgery performed by the abdominal wall surgery unit was related to fewer recurrences in the multivariate analysis (HR = 0.123; 95% CI = 0.21-0.725; P = 0.021).

CONCLUSIONS

Specialization in abdominal wall surgery seems to have a positive impact in terms of recurrence in recurrent inguinal hernia repair. The influence of comorbidities or type of surgery (i.e., outpatient surgery) require further study.

Identifying Factors of Operative Efficiency in Head and Neck Free Flap Reconstruction

Importance

Head and neck oncological resection and reconstruction is a complex process that requires multidisciplinary collaboration and prolonged operative time. Numerous factors are associated with operative time, including a surgeon's experience, team familiarity, and the use of new technologies. It is paramount to evaluate the contribution of these factors and modalities on operative time to facilitate broad adoption of the most effective modalities and reduce complications associated with prolonged operative time.

Objective

To examine the association of head and neck cancer resection and reconstruction interventions with operative time.

Design, Setting, and Participants

This large cohort study included all patients who underwent head and neck oncologic resection and free flap-based reconstruction in Calgary (Alberta, Canada) between January 1, 2007, and March 31, 2020. Data were analyzed between November 2021 and May2022.

Interventions

The interventions that were implemented in the program were classified into team-based strategies and the introduction of new technology. Team-based strategies included introducing a standardized operative team, treatment centralization in a single institution, and introducing a microsurgery fellowship program. New technologies included use of venous coupler anastomosis and virtual surgical planning.

Main Outcomes and Measures

The primary outcome was mean operative time difference before and after the implementation of each modality. Secondary outcomes included returns to the operating room within 30 days, reasons for reoperation, returns to the emergency department or readmissions to hospital within 30 days, and 2-year and 5-year disease-specific survival. Multivariate regression analyses were performed to examine the association of each modality with operative time.

Results

A total of 578 patients (179 women [30.9%]; mean [SD] age, 60.8 [12.9] years) undergoing 590 procedures met inclusion criteria. During the study period, operative time progressively decreased and reached a 32% reduction during the final years of the study. A significant reduction was observed in mean operative time following the introduction of each intervention. However, a multivariate analysis revealed that team-based strategies, including the use of a standardized nursing team, treatment centralization, and a fellowship program, were significantly associated with a reduction in operative time.

Conclusions

The results of this cohort study suggest that among patients with head and neck cancer, use of team-based strategies was associated with significant decreases in operative time without an increase in complications.

Outcomes of Incidental Durotomy Repair in Thoracolumbar Spine Surgery: An Institutional Experience With Orthopedic Residents

Background The occurrence of incidental durotomies (IDs) following spinal operations is a widely recognized issue. Complications such as poor outcomes, extended hospitalization, prolonged immobilization, infections, and revision surgeries are all potential consequences of inadequate durotomy management during the initial surgery. This study aims to describe the outcomes of ID repair in thoracolumbar spine surgery in terms of the Oswestry Disability Index (ODI) score and visual analog scale (VAS) when performed with the active involvement of orthopedic residents in the surgical procedure. Methodology Between April 2021 and April 2023, a hospital-based observational study was conducted among 110 patients hospitalized in the orthopedic ward at R.L. Jalappa Hospital and Research Center in Kolar, Karnataka, who required IDs due to an accidental dural tear or a postoperative CSF fluid leak following thoracolumbar spine procedures. Patients with a previous history of thoracolumbar spine surgery, vertebral tumors, spinal metastasis, infections, e.g., spondylodiscitis, or Pott's spine were excluded. The ODI score and VAS score were calculated on the postoperative day, one month, and three months following surgery. Results The mean age of the study participants was 62.81 + 10.49 years, with a male preponderance of 67.2% among the study participants. The mean BMI of study participants was 23.77 kg/m2. Approximately 24.5% of participants had a prior history of spinal surgery. Among 110 patients, 32 had postoperative complications. Six patients reported experiencing urinary retention, followed by five with CSF leakage and one with a postural headache (five cases). Based on the ODI score, mild disability was seen in 32.7% of the study samples at three months of follow-up. Based on the VAS score, moderate pain was seen among all the study samples at three months of follow-up. The ANOVA test revealed statistically significant differences in ODI and VAS score reductions between the immediate postoperative period and the one-month and three-month follow-up periods (p = 0.001 and p = 0.0247, respectively). Conclusion Less than one-third of the samples had postoperative complications. At three months, ODI scores showed mild disability in one-third of the study samples. At three months, all study samples had moderate VAS pain. The improvement in ODI and VAS scores from the day after surgery through the one-month and three-month follow-up periods was statistically significant.

Influence of Surgeon Experience on Surgical Outcome of Maxillomandibular Advancement for Obstructive Sleep Apnea

The primary aim of this study was to assess the association between clinical efficacy outcomes (i.e., polysomnography (PSG) results) of maxillomandibular advancement (MMA) and surgeons' experience. The second aim was to assess the association between the occurrence of postoperative complications of MMA and surgeons' experiences. Patients treated with MMA for moderate to severe obstructive sleep apnea (OSA) were enrolled in this retrospective study. The patient population was divided into two groups based on two different surgeons performing MMA. The associations between surgeons' experience on the one hand and PSG results and postoperative complications on the other hand were investigated. A total of 75 patients were included. There was no significant difference in baseline characteristics between the two groups. The reductions in apnea-hypopnea index and oxygen desaturation index were both significantly greater in group-B than group-A (p = 0.015 and 0.002, respectively). The overall success rate after MMA was 64.0%. There was a negative correlation between surgeon experience and surgical success (odds ratio: 0.963 [0.93, 1.00], p = 0.031). No significant association was found between surgeon experience and surgical cure. Additionally, there was no significant association between surgeon experience and the occurrence of postoperative complications. Within the limitations of this study, it is concluded that surgeon experience may have little to no influence on the clinical efficacy and safety of MMA surgery in OSA patients.

Navigation Improves Tumor Ablation Performance: Results From a Novel Liver Tumor Simulator Study

BACKGROUND

The efficacy of microwave ablation in treating hepatic tumors requires advanced ultrasound skills. Failure of proper technique has the potential for either under- or over-treatment and possible harm to the patient. Emprint SX™ navigation provides surgeons with intra-operative, real-time navigation through augmented reality localization of the ablation antenna and the expected ablation zone. We hypothesize that incorporating this technology leads to improved targeting and optimizes ablation coverage. This study utilizes a simulated model to evaluate ablation outcomes using Emprint SX™ navigation vs standard ultrasound.

METHODS

Surgical residents and faculty were recruited from a single institution. Using a novel tumor ablation simulator, participants performed ablations via 2 modes: standard ultrasound guidance (STD) and Emprint SX™ navigation (NAV). Primary outcome was the percentage of under-ablation. Secondary outcomes included percentage of over-ablation, time to complete trial, and number of attempts to position antenna.

RESULTS

281 trials were performed by fifteen participants, with 47% female and 60% novice ablationists. Under-ablation volume decreased by a mean of 16.3% (SEM ±12.9, P < .001) with NAV compared to STD. Over-ablation volume decreased by a mean of 14.0% (±8.2, P < .001). NAV time was faster by a mean of 32 seconds (±24.9, P < .001) and involved fewer antenna placement attempts by a mean of 1.3 (±1.0, P < .001). For novice ablationists, all outcomes were improved with NAV and novices saw larger improvements compared to experienced ablationists (P = .018).

DISCUSSION

In a simulated model, NAV improves ablation efficacy and efficiency, with novices gaining the greatest benefit over standard ultrasound.

A learning curve in 3D virtual surgical planned orthognathic surgery

OBJECTIVES

To assess the surgical accuracy of 3D virtual surgical planned orthognathic surgery and the influence of posterior impaction and magnitude of the planned movements on a possible learning curve.

MATERIALS AND METHODS

This prospective cohort study included subjects who underwent bimaxillary surgery between 2016 and 2020 at the Department of Oral and Maxillofacial Surgery of the Radboud University Medical Center, Nijmegen. 3D virtual surgical planning (VSP) was performed with CBCT data and digitalized dentition data. By using voxel-based matching with pre- and postoperative CBCT data the maxillary movements were quantified in six degrees of freedom. The primary outcome variable, surgical accuracy, was defined as the difference between the planned and achieved maxillary movement.

RESULTS

Based on 124 subjects, the surgical accuracy increased annually from 2016 to 2020 in terms of vertical translations (0.82 ± 0.28 mm; p = 0.038) and yaw rotations (0.68 ± 0.22°; p = 0.028). An increase in surgical accuracy was observed when combining all six degrees of freedom (p = 0.021) and specifically between 2016 and 2020 (p = 0.004). An unfavorable learning curve was seen with posterior impaction and with a greater magnitude of movements.

CONCLUSION

The present study demonstrated a significant increase in surgical accuracy annually and therefore supports the presence of a learning curve.

CLINICAL RELEVANCE

Cases with planned maxillary posterior impaction and/or a great magnitude of jaw movements should be transferred from the 3D VSP with extra care to obtain a satisfactory surgical accuracy.

Short-term outcome of diverting loop ileostomy reversals performed by residents: a retrospective cohort prognostic factor study

AIM

The reversal of diverting loop ileostomy (DLI) is one of surgical trainees' first procedures. Complications of DLI reversal can cause life-threatening complications and increase patient morbidity. This study compared DLI reversals performed by surgical trainees with those by attending surgeons.

METHOD

This retrospective cohort study was performed at a single primary care center on 300 patients undergoing DLI reversal. The primary outcome was morbidity, according to the Clavien-Dindo classification (CDC), with special attention paid to the surgeon's level of training. The secondary endpoint was postoperative intestinal motility dysfunction.

RESULTS

Surgical trainees had significantly longer operation times (p < 0.001) than attending surgeons. Univariate analyses revealed no influence on the level of training for postoperative morbidity. First bowel movement later than 3 days after surgery was a significant risk factor for CDC [Formula: see text] 3 (OR, 4.348; 96% CI, 1670-11.321; p = 0.003). Independent risk factors for surgical site infections (SSIs) were an elevated BMI (OR, 1.162; 95% CI, 1.043-1.1294; p = 0.007) and a delayed bowel movement (OR, 3.973; 95% CI, 1.300-12.138; p = 0.015). For postoperative intestinal motility dysfunction, an independent risk factor was a primary malignant disease (OR, 1.980; 95% CI, 1.120-3.500; p = 0.019), and side-to-side stapled anastomosis was a protective factor (OR, 0.337; 95% CI 0.155-0.733; p = 0.006).

CONCLUSION

Even though surgical trainees needed significantly more time to perform the surgery, the level of surgical training was not a risk factor for increased postoperative morbidity. Instead, delayed first bowel movement was predictive of SSI.

Between-Hospital and Between-Physician Variation in Outcomes and Costs in High- and Low-Complex Surgery: A Nationwide Multilevel Analysis

OBJECTIVES

Clinicians and policy makers are increasingly exploring strategies to reduce unwarranted variation in outcomes and costs. Adequately accounting for case mix and better insight into the levels at which variation exists is crucial for such strategies. This nationwide study investigates variation in surgical outcomes and costs at the level of hospitals and individual physicians and evaluates whether these can be reliably compared on performance.

METHODS

Variation was analyzed using 92 330 patient records collected from 62 Dutch hospitals who underwent surgery for colorectal cancer (n = 6640), urinary bladder cancer (n = 14 030), myocardial infarction (n = 31 870), or knee osteoarthritis (n = 39 790) in the period 2018 to 2019. Multilevel regression modeling with and without case-mix adjustment was used to partition variation in between-hospital and between-physician components for in-hospital mortality, intensive care unit admission, length of stay, 30-day readmission, 30-day reintervention, and in-hospital costs. Reliability was calculated for each treatment-outcome combination at both levels.

RESULTS

Across outcomes, hospital-level variation relative to total variation ranged between ≤ 1% and 15%, and given the high caseloads, this typically yielded high reliability (> 0.9). In contrast, physician-level variation components were typically ≤ 1%, with limited opportunities to make reliable comparisons. The impact of case-mix adjustment was limited, but nonnegligible.

CONCLUSIONS

It is not typically possible to make reliable comparisons among physicians due to limited partitioned variation and low caseloads. Nevertheless, for hospitals, the opposite often holds. Although variation-reduction efforts directed at hospitals are thus more likely to be successful, this should be approached cautiously, partly because level-specific variation and the impact of case mix vary considerably across treatments and outcomes.

"Happy to close?" The relationship between surgical experience and incisional hernia rates following abdominal wall closure in colorectal surgery

AIM

Incisional hernia (IH) is a common complication of colorectal surgery, affecting up to 30% of patients at 2 years. Given the associated morbidity and high recurrence rates after attempted repair of IH, emphasis should be placed on prevention. There is an association between surgeon volume and outcomes in hernia surgery, yet there is little evidence regarding impact of the seniority of the surgeon performing abdominal wall closure on IH rate. The aim of our study was to assess the rates of IH at 1 year following abdominal wall closure between junior and senior surgeons in patients undergoing elective colorectal surgery.

METHODS

This was an exploratory analysis of patients who underwent elective surgery for colorectal cancer between 2014-2018 as part of the Hughes Abdominal Repair Trial (HART), a prospective, multicentre randomised control trial comparing abdominal wall closure methods. Grade of surgeon performing abdominal closure was categorised into "trainee" and "consultant" and compared to IH rate at one year.

RESULTS

A total of 663 patients were included in this retrospective analysis of patients in the HART trial. The rate of IH in patients closed by trainees was 20%, compared to 12% in those closed by consultants (p = <0.001). When comparing closure methods, IH rates were significantly higher in the Hughes closure arm between trainees and consultants (20% vs. 12%, p = 0.032), but not high enough in the mass closure arm to reach statistical significance (21% vs. 13%, p = 0.058). On multivariate analysis, age (p = 0.036, OR: 1.02, 95% CI: 1.00-1.04), Male sex (p = 0.049, OR: 1.61, 95% CI: 1.00-2.59) and closure by a trainee (p = 0.006, OR: 1.85, 95% CI: 1.20-2.85) were identified as risk factors for developing IH.

CONCLUSION

Patients who undergo abdominal wall closure by a surgeon in training have an increased risk of developing IH when compared to those closed by a consultant. Further work is needed to determine the impact of supervised and unsupervised trainees on IH rates, but abdominal wall closure should be regarded as a training opportunity in its own right.

Learning curve in flexible ureteroscopy for renal stones: A propensity score-matched study

OBJECTIVE

To assess the learning curve and evaluate the impact of surgical experience related to the outcomes of flexible ureteroscopy (fURS) for upper urinary tract stones.

METHOD

We evaluated retrospectively lithiasis fURS performed in our institution between January 2004 and December 2020. Patients were divided into two groups by the number of procedures performed by surgeon. Group 1 (G1) included the first 50 procedures, and group 2 (G2) the next cases. These groups were matched on baseline characteristics by a propensity score. Stones free rate (SFR) and complication rate (CR) were compared. Learning curves were realized using logistic curve with 95% confidence interval.

RESULTS

After criteria exclusion and propensity score matching, 1548 procedures were analyzed (1:1, G1 and G2, n=774 procedures). A total of 29 surgeons were evaluated. The overall SFR was 68.4% without statistical difference between the two groups (G1=67.9% vs. G2=68.8%, P=0.72). The surgeon's experience was not associated with SFR (OR=1.15, 95% CI: 0.90-1.47), except in subgroup stones>2cm (OR=2.89, 95% CI: 1.29-6.46). The overall CR was 12.5%, mainly Clavien-Dindo grade I-II complications (96.2%). Surgical experience was not associated with CR (OR=1.06, 95% CI: 0.77-1.45). The overall logistic curves for probability of stone clearance and complication tended to be a flat slope.

CONCLUSION

Impact of surgical experience on fURS for UUTS was not associated with SFR and CR. However, for stones larger than 2cm, surgeon's experience tended to be associated with SFR, but without impact on overall complications.

LEVEL OF EVIDENCE: 3

Increased Surgeon-specific Experience and Volume is Correlated With Improved Clinical Outcomes in Lumbar Fusion Patients

STUDY DESIGN

The present study design was that of a single center, retrospective cohort study to evaluate the influence of surgeon-specific factors on patient functional outcomes at 6 months following lumbar fusion. Retrospective review of a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis identified the present study population.

OBJECTIVE

This study seeks to evaluate surgeon-specific variable effects on patient-reported outcomes such as Oswestry Disability Index (ODI) and the effect of North American Spine Society (NASS) concordance on outcomes in the setting of variable surgeon characteristics.

SUMMARY OF BACKGROUND DATA

Lumbar fusion is one of the fastest growing procedures performed in the United States. Although the impact of surgeon-specific factors on patient-reported outcomes has been contested, studies examining these effects are limited.

METHODS

This is a single center, retrospective cohort study analyzing a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis by 1 of 5 neurosurgery fellowship trained spine surgeons. The primary outcome was improvement of ODI at 6 months postoperative follow-up compared with preoperative ODI.

RESULTS

A total of 307 patients were identified for analysis. Overall, 62% of the study population achieved minimum clinically important difference (MCID) in ODI score at 6 months. Years in practice and volume of lumbar fusions were statistically significant independent predictors of MCID ODI on multivariable logistic regression ( P =0.0340 and P =0.0343, respectively). Concordance with evidence-based criteria conferred a 3.16 (95% CI: 1.03, 9.65) times greater odds of achieving MCID.

CONCLUSION

This study demonstrates that traditional surgeon-specific variables predicting surgical morbidity such as experience and procedural volume are also predictors of achieving MCID 6 months postoperatively from lumbar fusion. Independent of surgeon factors, however, adhering to evidence-based guidelines can lead to improved outcomes.

Continued Performance Improvement-What Practicing Surgeons Can Learn From Athletes

This Viewpoint describes how surgeons can optimize performance with methods for continuous performance improvement used by athletes.

Effect of annualized surgeon volume on major surgical complications for abdominal and laparoscopic radical hysterectomy for cervical cancer in China, 2004-2016: a retrospective cohort study

BACKGROUND

Previous studies have suggested that higher surgeon volume leads to improved perioperative outcomes for oncologic surgery; however, the effect of surgeon volumes on surgical outcomes might differ according to the surgical approach used. This paper attempts to evaluate the effect of surgeon volume on complications or cervical cancer in an abdominal radical hysterectomy (ARH) cohort and laparoscopic radical hysterectomy (LRH) cohort.

METHODS

We conducted a population-based retrospective study using the Major Surgical Complications of Cervical Cancer in China (MSCCCC) database to analyse patients who underwent radical hysterectomy (RH) from 2004 to 2016 at 42 hospitals. We estimated the annualized surgeon volumes in the ARH cohort and in the LRH cohort separately. The effect of the surgeon volume of ARH or LRH on surgical complications was examined using multivariable logistic regression models.

RESULTS

In total, 22,684 patients who underwent RH for cervical cancer were identified. In the abdominal surgery cohort, the mean surgeon case volume increased from 2004 to 2013 (3.5 to 8.7 cases) and then decreased from 2013 to 2016 (8.7 to 4.9 cases). The mean surgeon case volume number of surgeons performing LRH increased from 1 to 12.1 cases between 2004 and 2016 (P < 0.01). In the abdominal surgery cohort, patients treated by intermediate-volume surgeons were more likely to experience postoperative complications (OR = 1.55, 95% CI = 1.11-2.15) than those treated by high-volume surgeons. In the laparoscopic surgery cohort, surgeon volume did not appear to influence the incidence of intraoperative or postoperative complications (P = 0.46; P = 0.13).

CONCLUSIONS

The performance of ARH by intermediate-volume surgeons is associated with an increased risk of postoperative complications. However, surgeon volume may have no effect on intraoperative or postoperative complications after LRH.

Relationship between surgical volume and outcomes in elective and acute cholecystectomy: nationwide, observational study

BACKGROUND

High surgical volumes are attributed to improved quality of care, especially for extensive procedures. However, it remains unknown whether high-volume surgeons and hospitals have better results in gallstone surgery. The aim of this study was to investigate whether operative volume affects outcomes in cholecystectomies.

METHODS

A registry-based cohort study was performed, based on the Swedish Registry of Gallstone Surgery. Cholecystectomies from 2006 to 2019 were included. Annual volumes for the surgeon and hospital were retrieved. All procedures were categorized into volume-based quartiles, with the highest group as reference. Low volume was defined as fewer than 20 operations per surgeon per year and fewer than 211 cholecystectomies per hospital per year. Differences in outcomes were analysed separately for elective and acute procedures.

RESULTS

The analysis included 154 934 cholecystectomies. Of these, 101 221 (65.3 per cent) were elective and 53 713 (34.7 per cent) were acute procedures. Surgeons with low volumes had longer operating times (P < 0.001) and higher conversion rates in elective (OR 1.35; P = 0.023) and acute (OR 2.41; P < 0.001) operations. Low-volume surgeons also caused more bile duct injuries (OR 1.41; P = 0.033) and surgical complications (OR 1.15; P = 0.033) in elective surgery, but the results were not statistically significant for acute procedures. Low-volume hospitals had more bile duct injuries in both elective (OR 1.75; P = 0.002) and acute (OR 1.96; P = 0.003) operations, and a higher mortality rate after acute surgery (OR 2.53; P = 0.007).

CONCLUSION

This study has demonstrated that operative volumes influence outcomes in cholecystectomy. The results indicate that gallstone surgery should be performed by procedure-dedicated surgeons at hospitals with high volumes of this type of benign surgery.

Surgical resident experience with common bile duct exploration and assessment of performance and autonomy with formative feedback

BACKGROUND

Common bile duct exploration (CBDE) is safe and effective for managing choledocholithiasis, but most US general surgeons have limited experience with CBDE and are uncomfortable performing this procedure in practice. Surgical trainee exposure to CBDE is limited, and their learning curve for achieving autonomous, practice-ready performance has not been previously described. This study tests the hypothesis that receipt of one or more prior CBDE operative performance assessments, combined with formative feedback, is associated with greater resident operative performance and autonomy.

METHODS

Resident and attending assessments of resident operative performance and autonomy were obtained for 189 laparoscopic or open CBDEs performed at 28 institutions. Performance and autonomy were graded along validated ordinal scales. Cases in which the resident had one or more prior CBDE case evaluations (n = 48) were compared with cases in which the resident had no prior evaluations (n = 141).

RESULTS

Compared with cases in which the resident had no prior CBDE case evaluations, cases with a prior evaluation had greater proportions of practice-ready or exceptional performance ratings according to both residents (27% vs. 11%, p = .009) and attendings (58% vs. 19%, p < .001) and had greater proportions of passive help or supervision only autonomy ratings according to both residents (17% vs. 4%, p = .009) and attendings (69% vs. 32%, p < .01).

CONCLUSIONS

Residents with at least one prior CBDE evaluation and formative feedback demonstrated better operative performance and received greater autonomy than residents without prior evaluations, underscoring the propensity of feedback to help residents achieve autonomous, practice-ready performance for rare operations.

Characteristics of exceptionally good Doctors-A survey of public adults

Background

Systematic reviews have found that doctors can have a substantial effect on patients' physical health, beyond what can be explained by known factors. In a previous qualitative study, 13 medical doctors were interviewed on their experiences of exceptionally good doctors, and all had met at least one such doctor.

Objective

To determine how common it is for exceptionally good doctors to be encountered by patients and what are the characteristics of exceptionally good doctors.

Design

Mixed methods cross-sectional survey of 580 Amazon Mechanical Turk participants. Questions included doctor and participant demographics, and 34 Likert questions on characteristics of exceptionally good and average doctors. Free-text questions allowed participants to describe exceptional doctors, record their experience, and provide survey feedback. Stratified sampling ensured gender parity and 33% of participants aged ≥55 years. Analysis included descriptive statistics, statistical modelling of associations between Likert scale scores and patient demographics, and factor analysis.

Results

Of 580 responses, 505 (86%) were included in the analysis. Factor analysis confirmed internal validity. Most respondents (86%) had met at least two exceptionally good doctors, of whom 55% were specialists. 58% of respondents regarded doctors as exceptional based on an overall impression with multiple reasons. Doctors were most commonly considered exceptional based on one or more of their personality, diagnostic, or intervention ability. Respondents who reported the doctors "willingly listened to them to the end" scored their doctors higher on 33 of 34 Likert questions, except for popularity. They also rated average doctors lower throughout.

Conclusions

Exceptionally good doctors appear to be commonly encountered by the adult public. Listening to patients willingly to the end is a highly rated and influential characteristic, suggesting that listening could be targeted for quality improvement.

Difficulty score for the treatment of isolated gingival recessions with the coronally advanced flap: a preliminary reliability study

OBJECTIVES

The treatment of gingival recessions (GRs) is operator-sensitive and dependent upon several local anatomical factors. The aim of this study was to introduce a difficulty score for the treatment of localized GRs with the coronally advanced flap (CAF) and to test its consistency among different operators.

MATERIALS AND METHODS

A rubric (difficulty score) consisting of the assessment and grading of 8 anatomical parameters (anatomical papilla, apical and lateral keratinized tissue width, apical and lateral frenum, vestibulum depth, scar tissue, and mucosal invagination) is described based on the available evidence and the authors' experience. Inter-examiner agreement, with the score, was tested on 32 localized GRs among four different experienced practitioners.

RESULTS

Minor discrepancies were observed in the total scores between the reviewers (intraclass correlation coefficient [ICC] 0.95). A good reproducibility, with ICCs ranging from 0.56 to 0.98, was found for the individual parameters. All models showed high absolute variance contribution conveying true differences among the cases, and small examiner variance, demonstrating minor systematic variability among the four reviewers and reproducible evaluations.

CONCLUSIONS

The proposed difficulty score for the treatment of GRs with CAF was reproducible among different operators. Clinical interventional studies are the next step to validate the clinical magnitude of the present score.

CLINICAL RELEVANCE

A novel tool for evaluating the difficulty of the treatment of isolated gingival recession using CAF was described. Clinicians can benefit from this score when assessing the expected level of complexity of the surgical case.

Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews

Objectives

To examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons, and whether surgery or the drug intervention was favored.

Design

Systematic review of systematic reviews (umbrella review).

Data sources

Cochrane Database of Systematic Reviews (CDSR).

Eligibility criteria and synthesis of results

Using the search term "surg*" in CDSR, we retrieved systematic reviews of surgical interventions. Abstracts were subsequently screened to find systematic reviews that aimed to compare surgical to drug interventions; and then, among them, those that included any randomized controlled trials (RCTs) for such comparisons. Trial results data were extracted manually and synthesized into random-effects meta-analyses.

Results

Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs with data) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% confidence intervals, the surgical intervention was favored in 38/103 (37%), and the drugs were favored in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favor of surgery, and 2 (9%) were in favor of drugs.

Conclusions

Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomized evidence is rare. More randomized trials comparing surgery to drug interventions are needed.

Protocol registration

https://osf.io/p9x3j.

Association of Hospital Bed Turnover With Patient Outcomes in Digestive Surgery

To determine the influence of hospital bed turnover rate (BTR) on the occurrence of complications following minor or major digestive surgery.

Background

Performance improvement in surgery aims at increasing productivity while preventing complications. It is unknown whether this relationship can be influenced by the complexity of surgery.

Methods

A nationwide retrospective cohort study was conducted, based on generalized estimating equation modeling to determine the effect of hospital BTR on surgical outcomes, adjusting for patient mix and clustering within 631 public and private French hospitals. All patients who underwent minor or major digestive surgery between January 1, 2013 and December 31, 2018 were included. Hospital BTR was defined as the annual number of stays per bed for digestive surgery and categorized into tertiles. The primary endpoint was a composite measurement of events occurring within 30 days after surgery: inpatient death, extended intensive care unit (ICU) admission, and reoperation.

Results

Rate of adverse events was 2.51% in low BTR hospitals versus 2.25% in high BTR hospitals for minor surgery, and 16.79% versus 16.83% for major surgery. Patients who underwent minor surgery in high BTR hospitals experienced lower complications (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.81-0.97; P = 0.009), mortality (OR, 0.87; 95% CI, 0.78-0.98, P = 0.02), ICU admission (OR, 0.83; 95% CI, 0.70-0.99; P = 0.03), and reoperation (OR, 0.91; 95% CI, 0.85-0.97; P = 0.002) compared to those in low BTR hospitals. Such differences were not consistently observed among patients admitted for major surgery.

Conclusions

High turnover of patients in beds is beneficial for minor procedures, but questionable for major surgeries.

Urology Residents' Perspectives on the In-House On-Call Systems: A Study in an Accredited Academic Center

INTRODUCTION

Medical education and training are crucial in maintaining patients' safety and improving patient care quality. Multiple studies have evaluated the effects of restrictive policies on the resident's quality of life and education. Due to the compiling data and the fact that these trials evaluated programs with a substantial number of residents, it remains uncertain whether these conclusions can be extended to urology programs with a small number of residents. Multiple on-call systems have been adopted in residency programs across the world. This study evaluated the residents' quality of life, clinical experience, and education upon transitioning from 24-hour to 12-hour in-house on-call systems.

METHODS AND MATERIALS

In this observational and questionnaire-based study, the effect of the transition from 24-hour to 12-hour in-house on-call systems was compared in terms of the resident's quality of life and education, surgical case volume, and working hours' rules compliance. Quality of life and education: We adopted a validated survey based on a 5-point Likert scale to assess the residents' perception of the transition to a 12-hour on-call system on their quality of life and education. Surgical case volume: We extracted the number of cases the residents operated on from the operating theater database at our institution. Working hours: compliance and violations: The weekly working hours, compliance, and violations per ACGME-I rules were collected from the MedHub platform.

RESULTS

Quality of life and education: Residents rated the 12-hour on-call system superior in terms of quality of life, education, and surgical case volume. Surgical case volume: There was a 45% increment in the surgical case volume (p = 0.04) with the 12-hour on-call system. Working hours: compliance and violations There was no significant difference in the mean weekly working hours (p = 0.1). However, the total number of duty hours violations decreased in the 12-hour on-call system.

CONCLUSION

The 12-hour system is a better alternative to the 24-hour system in terms of the resident's quality of life, education, surgical case volume, and compliance with duty hour rules.

Safety and Cost Savings Associated with Reduced Inpatient Hospitalization for Microvascular Decompression

OBJECTIVES

Microvascular decompression (MVD) has grown as a first-line surgical intervention for severe facial pain from trigeminal neuralgia and/or hemifacial spasm. We sought to examine the safety and cost-benefits of discharging patients with MVD within 1 day of admission.

METHODS

We retrospectively reviewed patients undergoing MVD at our institution from 2008 to 2020. Patients were sorted by 1 day, 2 days, or >2 days until discharge and by year from 2008 to 2013, 2014 to 2018, or 2019 to 2020. Patient presenting characteristics, intraoperative measures, and complications were documented. Statistical differences were calculated by one-way analysis of variance and χ2 analyses.

RESULTS

Our cohort included 976 patients undergoing MVD, with 231 (23.6%) between 2008 and 2013, 517 (52.9%) between 2014 and 2018, and 228 (23.3%) between 2019 and 2020. Over time, postoperative admission rates to the critical care unit, total inpatient hospital admission times, and Barrow Neurological Institute scores at first follow-up decreased. Postoperative complications, including cerebrospinal fluid leak, decreased significantly. In addition, patients discharged within 1 day of admission incurred a total hospital cost of $26,689, which was $3588 lower than patients discharged within more than 1 day of admission, P < 0.0001. Discharging carefully selected patients who are appropriate for discharge within 1 day of admission could translate to a potential cost-savings of $255,346 per year in our clinical practice.

CONCLUSIONS

In our experience, MVDs are a safe, elective intervention. Our findings suggest that postoperative day 1 discharge in patients with an uncomplicated postoperative course may be safe while improving hospital resource use.