The Impact of Resident and Fellow Participation in Transsphenoidal Pituitary Surgery

The impact of resident involvement and postgraduate year on head and neck surgery for obstructive sleep apnea

To assess the impact of resident involvement and resident postgraduate year (PGY) on head and neck obstructive sleep apnea (OSA) surgical outcomes. We analyzed head and neck OSA surgeries from 2005-2012 via the National Surgical Quality Improvement Program database. Demographic, preoperative, and postoperative variables were analyzed via multivariate regression to determine the impact of resident involvement and resident PGY on 30-day outcomes. Of 975 surgeries, 234 (24.0%) involved a resident: 120 (51.3%) involved a junior (PGY 1-3) resident and 114 (48.7%) involved a senior (PGY 4-5) resident. Multivariate analysis showed no significant impact on surgical, medical, or overall complication rates with resident involvement (all p > 0.05). Likewise, after separation of involved residents into junior or senior cohorts based on PGY, neither junior nor senior resident involvement significantly increased the odds of medical, surgical, or overall complications compared to operations performed by the attending alone (all p > 0.05). Resident involvement significantly increased readmission rates (6.1% versus 1.4%, p = 0.041) and operation time (92.1 ± 59.9 minutes versus 53.6 ± 42.0 minutes, p < 0.001) when compared to cases without resident involvement. Resident involvement in OSA surgery does not significantly impact rates of surgical medical, or overall complications. However, resident involvement increases 30-day readmission rates and almost doubles operation time, suggesting that resident involvement in head and neck OSA surgery remains relatively safe but further efforts to improve efficiency are likely needed.

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.

Prediction of Readmission and Complications After Pituitary Adenoma Resection via the National Surgical Quality Improvement Program (NSQIP) Database

Introduction Pituitary adenomas are common intracranial tumors (incidence 4:100,000 people) with good surgical outcomes; however, a subset of patients show higher rates of perioperative morbidity. Our goal was to identify risk factors for postoperative complications or readmission after pituitary adenoma resection. Methods We undertook a retrospective cohort study of patients who underwent surgery for pituitary adenoma in 2006-2018 by using the National Surgical Quality Improvement Program database. The main outcome measures were patient complications and the 30-day readmission rate. Results Among the 2,292 patients (mean age 53.3±15.9 years), there were 491 complications in 188 patients (8.2%). Complications and 30-day readmission have remained stable over time rather than declined. Unplanned readmission was seen in 141 patients (6.2%). Multivariable analysis demonstrated that hypertension (OR=1.6; 95% CI= 1.1, 2.1; p=0.005) and high white blood cell count (OR=1.08; 95% CI=1.03, 1.1; p=0.0001) were independent predictors of complications. Return to the operating room (OR=5.9, 95% CI=1.7, 20.2, p=0.0005); complications (OR=4.1, 95% CI=1.6, 10.6, p=0.004); and blood urea nitrogen (OR=1.08, 95% CI=1.02, 1.2, p=0.02) were independent predictors of 30-day readmission. Conclusion Using one of the largest datasets of pituitary adenoma patients, we identified perioperative factors most critical for patient outcome. One strength of this study is adjusting for cofactors that predict outcomes, which has not been done previously. Several patient biomarkers, namely white blood cell count and blood urea nitrogen, may serve as preoperative markers that might identify patients at higher risk. Control of blood pressure and renal disease may be perioperative management strategies that can impact the outcome.

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.

Prevalence of major structures injury in thyroid and neck surgeries: a national perspective

Background

The objectives of the study is to examine the prevalence and burden of major structures injury (pharynx, esophagus, trachea, larynx, lymphatic, vessels & nerves) in patients who underwent thyroid, parathyroid, and neck dissection surgeries in the United States.

Methods

The study is a retrospective cross-sectional analysis utilizing the Nationwide Readmissions Database, 2010-2015. The study population included adults (≥18 years) patients who underwent thyroid, parathyroid, and neck dissection surgeries.

Results

A total of 54,443 patients were included. Major structures injury was reported in 221 (0.48%) patients. The injured structures were vascular (0.22%), lymphatic (0.18%), pharynx/esophagus (0.06%), neural (0.03%), and trachea/larynx (0.002%). The risk of injury increased annually during the study period (OR: 1.29, 95% CI: 1.16, 1.44, P<0.001). The risk of injury was highest in patients who underwent thyroidectomy with neck dissection (1.01%) or neck dissection alone (1.81%) (P<0.001 each). The risk was also highest for patients with a head and neck cancer diagnosis (OR: 1.80, 95% CI: 1.24, 2.61, P=0.002). Patients with those injuries had a higher prevalence of blood transfusion (2.82% vs. 0.17%), postoperative fistula (3.10% vs. 0.03%), readmission (28.90% vs. 3.59%), and postoperative mortality (0.87% vs. 0.06%) (P<0.05 each). Management of patients with those injuries was associated with a longer hospital stay by 4.86±0.48 days (P<0.001), and a higher cost by $16,151.00±173.36 (P<0.001).

Conclusions

Injuries of major structures in thyroid and neck surgeries are more prevalent in cancer patients. There has been a recent increase in the risk of such injuries in the United States. Those injuries are associated with significant clinical and economic burden.

Safety of tympanoplasty and ossiculoplasty performed by otorhinolaryngology trainees

OBJECTIVE

This study aimed to examine the impact of trainee involvement in performing tympanoplasty or tympano-ossiculoplasty on outcomes.

METHODS

A retrospective analysis was performed of a prospective database of all patients undergoing tympanoplasty and tympano-ossiculoplasty in a single centre during a three-year period. Patients were divided into three primary surgeon groups: consultants, fellows and residents. The outcomes of operative time, surgical complications, length of hospital stay, and air-bone gap improvement were compared among the groups.

RESULTS

The study included 398 tympanoplasty and tympano-ossiculoplasty surgical procedures, 71 per cent of which were performed by junior trainees (residents). The junior trainee group was associated with a significantly longer surgical time, without adverse impact on outcomes.

CONCLUSION

Trainee participation in tympanoplasty and tympano-ossiculoplasty surgery was associated with longer surgical time, but did not negatively affect the peri-operative course or hearing outcome. Therefore, resident involvement in these types of surgery is safe.

Readmissions after endoscopic skull base surgery: associated risk factors and prevention

BACKGROUND

Unplanned readmissions within 30 days of discharge is a quality measure introduced by the Centers for Medicare Services. This measure has been used to rate hospital quality and also to penalize hospitals for excess readmissions. It has been hypothesized that shorter hospital stays and fewer readmissions are associated with endoscopic skull base procedures. In this study we analyze endoscopic skull base procedures performed at our institution over a 10-year period to identify rates and factors associated with readmissions after endoscopic skull base surgery.

METHODS

A retrospective chart review was performed at a tertiary care academic medical center identifying patients who underwent endoscopic skull base surgery over the past 10 years. Data on patient demographics and tumor variables, as well as patient variables such as body mass index (BMI), revision surgery, history of skull base radiation, medical comorbidities, intraoperative cerebrospinal fluid (CSF) leaks, and postoperative CSF leaks, were recorded.

RESULTS

Eight hundred thirty-three patients were included in our study. Sixty-one patients (7.3%) were readmitted a total of 66 times within 30 days. The most common reasons were as follows: hyponatremia (n = 18); CSF leak (n = 17); epistaxis (n = 3); diabetes insipidus (n = 3); rhinorrhea (n = 3); as well as other reasons. Statistical analysis revealed that the presence of intraoperative CSF leak was the only statistically significant variable associated with increased rate of readmissions within 30 days of discharge (p < 0.001).

CONCLUSION

Presence of intraoperative CSF leak was the only statistically significant variable associated with an increased risk for readmission after surgery. Other tumor and patient variables were not associated with an increased risk of readmission within 30 days.