Does resident participation influence otolaryngology-head and neck surgery morbidity and mortality?

Does length of time between cases affect resident operative time for tonsillectomy and adenoidectomy?

OBJECTIVE

To evaluate the effect of prolonged time intervals between tonsillectomy and adenoidectomy (TA) on resident operative time and complications.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary academic hospital.

METHODS

This retrospective study covers a five-year period from 2015 to 2020. Time intervals between isolated pediatric TA cases performed by eight otolaryngology residents were reviewed to assess effect on operative time (defined as prolonged if ≥ 30 min and non-prolonged if < 30 min). Intervals including a procedure involving either a tonsillectomy or adenoidectomy that was a non-isolated TA were excluded.

RESULTS

A total of 309 isolated TAs were identified with 67.3% of procedures performed under 30 min. The mean surgical time interval between procedures was 5.83 ± 10.02 days (range 0.02-69.82). Most TAs were performed on patients aged 7 years or younger. Surgical time interval between TA was not a significant factor in determining prolonged operative time on univariable logistic regression, OR 1.01 (CI: 0.98 to 1.03) (p = 0.63). Patient age at surgery, adenoid grade, tonsil size and total number of TAs performed to date were significant factors in determining prolonged operative time in both univariable and multivariable logistic regression models. Prolonged operative time did not have a significant effect on readmission, reoperation, or post-operative bleeding.

CONCLUSION

Extended time interval (up to 3 months) between routine TA does not affect operative time. Expansion of our methodology to more complex cases would be beneficial in designing resident training curriculum.

Evaluating resident involvement and the 'July effect' in parotidectomy

OBJECTIVE

This study aimed to evaluate the effect of resident involvement and the 'July effect' on peri-operative complications after parotidectomy.

METHOD

The American College of Surgeons National Surgical Quality Improvement Program database was queried for parotidectomy procedures with resident involvement between 2005 and 2014.

RESULTS

There were 11 733 cases were identified, of which 932 involved resident participation (7.9 per cent). Resident involvement resulted in a significantly lower reoperation rate (adjusted odds ratio, 0.18; 95 per cent confidence interval, 0.05-0.73; p = 0.02) and readmission rate (adjusted odds ratios 0.30; 95 per cent confidence interval, 0.11-0.80; p = 0.02). However, resident involvement was associated with a mean 24 minutes longer adjusted operative time and 23.5 per cent longer adjusted total hospital length of stay (respective p < 0.01). No significant difference in surgical or medical complication rates or mortality was found when comparing cases among academic quarters.

CONCLUSION

Resident participation is associated with significantly decreased reoperation and readmission rates as well as longer mean operative times and total length of stay. Resident transitions during July are not associated with increased risk of adverse peri-operative outcomes after parotidectomy.

Association Between Surgical Trainee Daytime Sleepiness and Intraoperative Technical Skill When Performing Septoplasty

Importance

Daytime sleepiness in surgical trainees can impair intraoperative technical skill and thus affect their learning and pose a risk to patient safety.

Objective

To determine the association between daytime sleepiness of surgeons in residency and fellowship training and their intraoperative technical skill during septoplasty.

Design, Setting, and Participants

This prospective cohort study included 19 surgical trainees in otolaryngology-head and neck surgery programs at 2 academic institutions (Johns Hopkins University School of Medicine and MedStar Georgetown University Hospital). The physicians were recruited from June 13, 2016, to April 20, 2018. The analysis includes data that were captured between June 27, 2016, and April 20, 2018.

Main Outcomes and Measures

Attending physician and surgical trainee self-rated intraoperative technical skill using the Septoplasty Global Assessment Tool (SGAT) and visual analog scales. Daytime sleepiness reported by surgical trainees was measured using the Epworth Sleepiness Scale (ESS).

Results

Of 19 surgical trainees, 17 resident physicians (9 female [53%]) and 2 facial plastic surgery fellowship physicians (1 female and 1 male) performed a median of 3.00 septoplasty procedures (range, 1-9 procedures) under supervision by an attending physician. Of the 19 surgical trainees, 10 (53%) were aged 25 to 30 years and 9 (47%) were 31 years or older. The mean ESS score overall was 6.74 (95% CI, 5.96-7.52), and this score did not differ between female and male trainees. The mean ESS score was 7.57 (95% CI, 6.58-8.56) in trainees aged 25 to 30 years and 5.44 (95% CI, 4.32-6.57) in trainees aged 31 years or older. In regression models adjusted for sex, age, postgraduate year, and technical complexity of the procedure, there was a statistically significant inverse association between ESS scores and attending physician-rated technical skill for both SGAT (-0.41; 95% CI, -0.55 to -0.27; P < .001) and the visual analog scale (-0.75; 95% CI, -1.40 to -0.07; P = .03). The association between ESS scores and technical skill was not statistically significant for trainee self-rated SGAT (0.04; 95% CI, -0.17 to 0.24; P = .73) and the self-rated visual analog scale (0.19; 95% CI, -0.79 to 1.2; P = .70).

Conclusions and Relevance

The findings suggest that daytime sleepiness of surgical trainees is inversely associated with attending physician-rated intraoperative technical skill when performing septoplasty. Thus, surgical trainees' ability to learn technical skill in the operating room may be influenced by their daytime sleepiness.

Level of Evidence

NA.

Long-term Trends in Head and Neck Surgery Outcomes

OBJECTIVE

The aim of the present study is to address the paucity of data on long-term trends in postoperative complication rates in head and neck surgery. Specifically, this study assesses trends in morbidity and mortality following head and neck surgery over a 20-year period from 1995 to 2015 and identifies risk factors for the development of complications.

STUDY DESIGN

Retrospective cross-sectional analysis of Veterans Affairs Surgical Quality Improvement Program database from 1995 to 2015.

SETTING

Veterans Affairs medical centers across the United States.

SUBJECTS AND METHODS

Using the Veterans Affairs Surgical Quality Improvement Program database, we selected 44,161 patients undergoing head and neck procedures from 1995 to 2015. Trends in 30-day morbidity and mortality were assessed, and univariate and multivariate analyses of risk factors for complications were performed.

RESULTS

From 1995-2000 to 2011-2015, overall complication rates decreased >45% (from 10.9% to 5.9%), and 30-day postsurgical mortality decreased nearly 70% (from 1.3% to 0.4%). Postoperative hospital stays also significantly declined. Major procedures, such as free flap cases and total laryngectomies, had less change in complication rate as compared with less invasive procedures.

CONCLUSION

Substantial improvement in postoperative morbidity and mortality has taken place in head and neck surgery over the past decades. Static complication rates in some procedures may reflect that the improvement of surgical techniques allow for the treatment of sicker patients. The trends seen in this study speak to the importance of probing further why high rates of complications are still seen in certain procedures and ensuring that effective treatment is balanced with limiting morbidity and mortality.

Resident and fellow participation in Thyroid and Parathyroid surgery: an ACS-NSQIP clinical outcomes analysis

BACKGROUND

The effect of decreased overall hours of training in surgical specialties is still being examined. Of particular interest is the safety of patients undergoing surgeries with trainee surgeons. The aim of this study was to identify if there were significant differences in outcomes of patients undergoing commonly performed thyroid and parathyroid surgeries when trainees were involved.

MATERIALS AND METHODS

Postoperative complication rates, length of stay (LOS), and total operation time (OT) data were gathered from the American College of Surgeons National Surgical Quality Improvement Project database. The cases were identified by CPT code and were divided based on the training level of the participating resident surgeon: Junior (postgraduate year [PGY] 1-2), senior (PGY 3-5), fellow (PGY >5), as well as an attending-only group where no resident was present. We compared the clinical outcomes, LOS, and OT in each trainee group to the attending-only group as the reference.

RESULTS

A total of 84,711 cases were identified of which 45.33% involved trainee participation. Odds ratios (ORs) and 95% confidence interval for overall, neurologic, and bleeding complications were calculated. No difference in the odds of overall patient complications or neurologic complications was observed. A decrease in the odds of bleedings complications when a junior or senior trainee was present was observed. Overall complications in operations including a junior trainee (PGY 1-2) had an OR of 1.04 (0.85, 1.29), a senior trainee (PGY 3-5) had an OR of 1.00 (0.89, 1.13), and a fellow had an OR of 0.98 (0.74, 1.31). Mean OT was found to be significantly different between attending only and junior and senior trainees. There was no significant difference in OT between fellows and attending only. LOS did not meaningfully differ across groups.

CONCLUSIONS

In three commonly performed thyroid and parathyroid operations, there is not an increased overall or neurologic complication odds when a surgical trainee is involved; there are decreased odds of a bleeding complication.