The Impact of Operating Surgeon Experience, Supervised Trainee vs. Trained Surgeon, in Vascular Surgery Procedures: A Systematic Review and Meta-Analysis

The Impact of Surgeon Experience-Consultant Versus Supervised Trainees After Elective Infrarenal EVAR: Short-term to Mid-term Outcomes

INTRODUCTION

Vascular trainees are required to have a comprehensive training program, encompassing the completion of clinical, surgical, and research tasks. To fulfill their surgical abilities and performance, sufficient supervised operating time is mandatory. After open vascular procedures, it has been observed that trainee involvement does not lead to detrimental outcomes. On the contrary, its impact during endovascular procedures, which require distinct technical skills, is scarcely reported. The authors aim to analyze the impact of primary operator experience on the outcomes of elective infrarenal endovascular aneurysm repair (EVAR) performed within a teaching institution over a 14-year period.

METHODS

This is a single-center, retrospective, comparative study. All consecutive patients submitted to elective EVAR (2011-2023) were considered. Two groups were defined: supervised trainee (ST) and consultant (C), according to the experience of the primary operator. The primary outcome was the incidence of 30-day major adverse events (MAEs). The secondary outcomes were contrast usage, operative time, bleeding, length of stay (LOS), return to operating room (OR), and freedom from aortic-related interventions up to 2 years.

RESULTS

Overall, 507 patients were included (62.1% ST vs 32.5% C). Seventy-two MAEs occurred in 8.1%, with no differences across groups (7.0% ST vs 9.9% C, p=0.31, adjusted odds ratio [aOR]=0.94, 95% confidence interval [CI]=0.46-1.91 for ST-performed procedures), even when MAE components were depicted individually. After adjustment for confounders, no significant differences were found in contrast usage ≥120 mL (aOR=0.89, 95% CI=0.50-1.56), operative time ≥160 minutes (aOR=0.73, 95% CI=0.45-0.18), bleeding (aOR=1.13, 95% CI=0.60-2.12), intensive care unit admission (aOR=0.68, 95% CI=0.40-1.17), prolonged LOS (aOR=0.93, 95% CI=0.60-1.43), return to OR (aOR=0.91, 95% CI=0.37-2.20), and mid-term freedom from aortic-related interventions (adjusted hazard ratio [aHR]=1.39, 95% CI=0.69-2.79).

CONCLUSION

In carefully selected cases, elective EVAR performed by supervised trainees seems as safe and effective at mid-term as operations performed by consultants. These findings may have important implications for training programs. Further studies to confirm and clarify our findings are required.

CLINICAL IMPACT

In carefully selected cases, elective EVAR performed by supervised trainees seems safe, when compared to operations performed by consultants. Short-term major adverse events, contrast usage, operative time, bleeding, secondary interventions and length of stay appear similar. Mid-term freedom-from aortic interventions is comparable. These findings may have important implications for vascular training programs.

Operating room organization and surgical performance: a systematic review

BACKGROUND

Organizational factors may influence surgical outcomes, regardless of extensively studied factors such as patient preoperative risk and surgical complexity. This study was designed to explore how operating room organization determines surgical performance and to identify gaps in the literature that necessitate further investigation.

METHODS

We conducted a systematic review according to PRISMA guidelines to identify original studies in Pubmed and Scopus from January 1, 2000 to December 31, 2019. Studies evaluating the association between five determinants (team composition, stability, teamwork, work scheduling, disturbing elements) and three outcomes (operative time, patient safety, costs) were included. Methodology was assessed based on criteria such as multicentric investigation, accurate population description, and study design.

RESULTS

Out of 2625 studies, 76 met inclusion criteria. Of these, 34 (44.7%) investigated surgical team composition, 15 (19.7%) team stability, 11 (14.5%) teamwork, 9 (11.8%) scheduling, and 7 (9.2%) examined the occurrence of disturbing elements in the operating room. The participation of surgical residents appeared to impact patient outcomes. Employing specialized and stable teams in dedicated operating rooms showed improvements in outcomes. Optimization of teamwork reduced operative time, while poor teamwork increased morbidity and costs. Disturbances and communication failures in the operating room negatively affected operative time and surgical safety.

CONCLUSION

While limited, existing scientific evidence suggests that operating room staffing and environment significantly influences patient outcomes. Prioritizing further research on these organizational drivers is key to enhancing surgical performance.

Supportive and collaborative interdependence: Distinguishing residents' contributions within health care teams

INTRODUCTION

Individual assessments disregard team contributions, while team assessments disregard an individual's contributions. Interdependence has been put forth as a conceptual bridge between our educational traditions of assessing individual performance and our imminent challenge of assessing team-based performance without losing sight of the individual. The purpose of this study was to develop a more refined conceptualisation of interdependence to inform the creation of measures that can assess the interdependence of residents within health care teams.

METHODS

Following a constructivist grounded theory approach, we conducted 49 semi-structured interviews with various members of health care teams (e.g. physicians, nurses, pharmacists, social workers and patients) across two different clinical specialties-Emergency Medicine and Paediatrics-at two separate sites. Data collection and analysis occurred iteratively. Constant comparative inductive analysis was used, and coding consisted of three stages: initial, focused and theoretical.

RESULTS

We asked participants to reflect upon interdependence and describe how it exists in their clinical setting. All participants acknowledged the existence of interdependence, but they did not view it as part of a linear spectrum where interdependence becomes independence. Our analysis refined the conceptualisation of interdependence to include two types: supportive and collaborative. Supportive interdependence occurs within health care teams when one member demonstrates insufficient expertise to perform within their scope of practice. Collaborative interdependence, on the other hand, was not triggered by lack of experience/expertise within an individual's scope of practice, but rather recognition that patient care requires contributions from other team members.

CONCLUSION

In order to assess a team's collective performance without losing sight of the individual, we need to capture interdependent performances and characterise the nature of such interdependence. Moving away from a linear trajectory where independence is seen as the end goal can also help support efforts to measure an individual's competence as an interdependent member of a health care team.

Surgical training during the COVID-19 pandemic at a designated 'cold' site: are we meeting the challenge?

INTRODUCTION

There has been a marked reduction in surgical operative training opportunities during the COVID-19 pandemic. This may be improved by the establishment of 'cold' sites for NHS elective surgery. We investigated the training opportunities at a newly designated elective surgery cold site in the West Midlands, UK.

METHODS

An observational retrospective study was undertaken to include all gastrointestinal and urological elective surgery at a single 'cold' site during the first peak of the COVID-19 pandemic. Patient demographics, details of surgery and data relating to surgical training such as primary surgeon and portfolio index procedure were collected. Factors affecting the likelihood of trainees being the primary surgeon were analysed using logistic regression models.

RESULTS

There were 880 patients, with a median (interquartile range) age of 62 (48-74). Some 658 (74.8%) procedures were defined as 'index procedures' for specialty training year 4 (ST4) level: 409/509 (80.4%) for urology, 155/235 (66%) for colorectal and 94/136 (69.1%) for upper gastrointestinal (GI). Only 253/880 (28.8%) procedures were performed by a trainee as the primary surgeon: 201/509 (39.4%) for urology, 21/235 (8.9%) for colorectal and 31/136 (22.8%) for upper GI. The likelihood of a trainee being the primary surgeon was reduced for major surgery (p<0.001) and for GI surgery when compared with urology (p<0.001).

CONCLUSIONS

Surgical training was facilitated at an elective surgery 'cold' site during the COVID-19 pandemic, but at lower levels than anticipated. Type of surgery influenced trainee participation. Surgical training should be incorporated into 'cold' site elective surgical services if trainees are to be prepared for the future.

Expert consensus on the establishment and maintenance of native arteriovenous fistula

Vascular access is the lifeline of hemodialysis patients. There are great differences in the establishment and use of vascular access in different countries and regions around the world. We believe that on the basis of good evaluation and planning, it is recommended that hemodialysis patients choose native arteriovenous fistula first. In view of the new progress of vascular access views domestic and international at home and abroad in recent years, we organized experts to recommend the establishment and maintenance of arteriovenous fistula (AVF) for the Chinese population, including preoperative evaluation and planning of the establishment of AVF, AVF surgery, perioperative drug intervention measures and postoperative maintenance, and put forward suggestions for future research directions. The recommendations in this consensus are general and clinicians need to make treatment decisions based on the actual situation.

Weekend Carotid Endarterectomies are Not Associated with a Greater Risk of Stroke and/or Death in Australia and New Zealand

BACKGROUND

Data from multiple surgical studies and settings have reported an increase in adverse events in patients admitted or treated on weekends. The aim of this study was to investigate short-term outcomes for patients undergoing carotid endarterectomy (CEA) in Australia and New Zealand based on the day of surgery.

METHODS

This is a retrospective observational cohort study. Analysis of 7,857 CEAs recorded for more than 4 years in the Australasian Vascular Audit database was performed. Multivariate logistic regression was used to compare the following outcomes between CEAs performed during the week and on the weekend: (1) in-hospital stroke and/or death; (2) other postoperative complications; and (3) shorter (2 days or less) length of stay (LOS).

RESULTS

A total of 7,857 CEAs were recorded, with significantly more procedures performed during the week (n = 7,333, P < 0.001). There was no statistically significant difference in the frequency of stroke and/or death or other complications between CEAs performed during the week or on the weekend (P = 0.294 and P = 0.806, respectively). However, there was a significant difference in LOS for procedures performed during the weekend, with more of these patients being discharged within 2 days compared with procedures performed during the week (56.8% vs. 51.5%; P = 0.003). Multivariable logistic regression found no effect of day of the week on the odds of postoperative stroke and/or death (P = 0.685). Day of surgery was also not associated with greater odds of other complications (P = 0.925). However, CEAs performed by nonconsultants had significantly lower adjusted odds of other complications (3.1% vs. 4.1%; P = 0.033). The adjusted odds of having a shorter LOS were significantly greater for operations taking place on the weekend (P = 0.003).

CONCLUSIONS

In Australia and New Zealand, there appears to be no disadvantage to performing CEA on the weekend, in terms of stroke and/or death. Level of experience of the primary operator does not affect rates of stroke and/or death after CEA. Weekend CEA is associated with a shorter hospital LOS.

Shunt intention during carotid endarterectomy in the early symptomatic period and perioperative stroke risk

OBJECTIVE

Whether recent stroke mandates planned shunting during carotid endarterectomy (CEA) is controversial. Our goal was to determine associations of various shunting practices with postoperative outcomes of CEAs performed after acute stroke.

METHODS

The Vascular Quality Initiative database (2010-2018) was queried for CEAs performed within 14 days of an ipsilateral stroke. Surgeons who prospectively planned to shunt either shunted routinely per their usual practice or shunted selectively for preoperative indications. Surgeons who prospectively planned not to shunt either shunted selectively for intraoperative indications or did not shunt. Univariable and multivariable analyses compared shunting approaches.

RESULTS

There were 5683 CEAs performed after acute ipsilateral stroke. Surgeons planned to shunt in 56.1% of cases. Patients whose surgeons planned to shunt vs planned not to shunt were more likely to have severe contralateral stenosis (8.8% vs 6.9%; P = .008), to receive general anesthesia (97.5% vs 89.1%; P < .001), and to undergo conventional CEA (94% vs 81.8%; P < .001). Unadjusted outcomes were similar between the cohorts for operative duration (124.3 ± 48.1 minutes vs 123.6 ± 47 minutes; P = .572) and 30-day stroke (3.4% vs 3%; P = .457), myocardial infarction (1.1% vs 0.8%; P = .16), and mortality (1.6% vs 1.3%; P = .28). On multivariable analysis, planning to shunt vs planning not to shunt was associated with similar risk of 30-day stroke (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.82-1.67; P = .402). On subgroup analysis, in 38.4% patients, no shunt was placed, whereas the remainder received routine shunts (44.4%), preoperatively indicated shunts (11.6%), and intraoperatively indicated shunts (5.5%). Compared with no shunting, shunting by surgeons who routinely shunt was associated with a similar stroke risk (OR, 1.39; 95% CI, 0.91-2.13; P = .129), but shunting by surgeons who selectively shunt on the basis of preoperative indications (OR, 2.11; 95% CI, 1.22-3.63; P = .007) or intraoperative indications (OR, 3.34; 95% CI, 1.86-6.01; P < .001) was associated with increased stroke risk. Prior coronary revascularization independently predicted increased intraoperatively indicated shunting (OR, 1.37; 95% CI, 1.05-1.8; P = .022).

CONCLUSIONS

In CEAs performed after acute ipsilateral stroke, there is no difference in postoperative stroke risk when surgeons prospectively plan to shunt or not to shunt. Shunting is often not necessary; however, when shunting is performed, routine shunters achieve better outcomes.