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Daher M, Kreichati G, Kharrat K, Maroun R, Aoun M, Chalhoub R, Diebo BG, Daniels AH, Sebaaly A. Dual Versus Single Attending Surgeon Performance of Spinal Deformity Surgery? A Meta-Analysis. World Neurosurg 2024; 188:93-98. [PMID: 38754547 DOI: 10.1016/j.wneu.2024.05.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND The inclusion of 2 surgeons in spinal deformity surgery is considered beneficial by some. In fact, select studies indicate advantages such as reduced operation time and blood loss. Another observed decreased patient morbidity with a dual-surgeon approach, attributed to shorter operative times and reduced intraoperative blood losses. Therefore, this meta-analysis will assess the benefits of a having 2 surgeons compared to 1 surgeon during spine surgeries. METHODS PubMed, Cochrane, and Google Scholar (page 1-20) were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, the rate of transfusion, reoperation, and surgery-related parameters such as operative room time, length of stay (LOS), and estimated blood loss. RESULTS Thirteen studies were included. A greater rate of complications was seen in patients operated upon by 1 surgeon (odds ratio = 0.50; 95% confidence intervals [CI]: 0.25-0.99, P = 0.05). Furthermore, operative room time (mean differences = -82.73; 95% CI: -111.42 to -54.03, P < 0.001) and LOS (mean differences = -0.91; 95% CI: -1.12 to -0.71, P < 0.001) were reduced in the dual surgeon scenario. No statistically significant difference was shown in the remaining analyzed outcomes. CONCLUSIONS The presence of 2 surgeons in the odds ratiowas shown to reduce complications, operative room time, and LOS. More cost-effectiveness studies are needed in order to substantiate the financial advantages associated with the dual-surgeon approach.
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Affiliation(s)
- Mohammad Daher
- Department of Orthopedic Surgery, Brown University, Providence, Rhode Island, USA; Faculty of medicine, Saint Joseph University, Beirut, Lebanon
| | - Gaby Kreichati
- Faculty of medicine, Saint Joseph University, Beirut, Lebanon; Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Khalil Kharrat
- Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon
| | | | - Marven Aoun
- Faculty of medicine, Saint Joseph University, Beirut, Lebanon
| | - Ralph Chalhoub
- Faculty of medicine, Saint Joseph University, Beirut, Lebanon
| | - Bassel G Diebo
- Department of Orthopedic Surgery, Brown University, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopedic Surgery, Brown University, Providence, Rhode Island, USA
| | - Amer Sebaaly
- Faculty of medicine, Saint Joseph University, Beirut, Lebanon; Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon.
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2
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Escandón JM, Mascaro-Pankova A, DellaCroce FJ, Escandón L, Christiano JG, Langstein HN, Ciudad P, Manrique OJ. The Value of a Co-surgeon in Microvascular Breast Reconstruction: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5624. [PMID: 38317657 PMCID: PMC10843485 DOI: 10.1097/gox.0000000000005624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 12/06/2023] [Indexed: 02/07/2024]
Abstract
Using a co-surgeon model has been suggested to improve perioperative outcomes and reduce the risk of complications. Therefore, we evaluated if a co-surgeon model compared with a single microsurgeon model could decrease the surgical time, length of stay, rate of complications, and healthcare-associated costs in adult patients undergoing microvascular breast reconstruction (MBR). A comprehensive search was performed across PubMed MEDLINE, Embase, and Web of Science. Studies evaluating the perioperative outcomes and complications of MBR using a single-surgeon model and co-surgeon model were included. A random-effects model was fitted to the data. Seven retrospective comparative studies were included. Ultimately, 1411 patients (48.23%) underwent MBR using a single-surgeon model, representing 2339 flaps (48.42%). On the other hand, 1514 patients (51.77%) underwent MBR using a co-surgeon model, representing 2492 flaps (51.58%). The surgical time was significantly reduced using a co-surgeon model in all studies compared with a single-surgeon model. The length of stay was reduced using a co-surgeon model compared with a single-surgeon model in all but one study. The log odds ratio (log-OR) of recipient site infection (log-OR = -0.227; P = 0.6509), wound disruption (log-OR = -0.012; P = 0.9735), hematoma (log-OR = 0.061; P = 0.8683), and seroma (log-OR = -0.742; P = 0.1106) did not significantly decrease with the incorporation of a co-surgeon compared with a single-surgeon model. Incorporating a co-surgeon model for MBR has minimal impact on the rates of surgical site complications compared with a single-surgeon model. However, a co-surgeon optimized efficacy and reduced the surgical time and length of stay.
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Affiliation(s)
- Joseph M. Escandón
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, N.Y
| | | | - Frank J. DellaCroce
- Center for Restorative Breast Surgery and the Tulane School of Public Health and Tropical Medicine, New Orleans, La
| | - Lauren Escandón
- Universidad El Bosque, School of Medicine, Bogotá D.C., Colombia
| | - Jose G. Christiano
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, N.Y
| | - Howard N. Langstein
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, N.Y
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Oscar J. Manrique
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, N.Y
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3
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Kuruba V, Cherukuri AMK, Arul S, Alzarooni A, Biju S, Hassan T, Gupta R, Alasaadi S, Sikto JT, Muppuri AC, Siddiqui HF. Specialty Impact on Patient Outcomes: Paving a Way for an Integrated Approach to Spinal Disorders. Cureus 2023; 15:e45962. [PMID: 37900519 PMCID: PMC10600402 DOI: 10.7759/cureus.45962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
Spinal surgical procedures are steadily increasing globally due to broad indications of certain techniques encompassing a wide spectrum of conditions, including degenerative spine disorders, congenital anomalies, spinal metastases, and traumatic spinal fractures. The two specialties, neurosurgery (NS) and orthopedic surgery (OS), both possess the clinical adeptness to perform these procedures. With the advancing focus on comparative effectiveness research, it is vital to compare patient outcomes in spine surgeries performed by orthopedic surgeons and neurosurgeons, given their distinct approaches and training backgrounds to guide hospital programs and physicians to consider surgeon specialty when making informed decisions. Our review of the available literature revealed no significant difference in postoperative outcomes in terms of blood loss, neurological deficit, dural injury, intraoperative complications, and postoperative wound dehiscence in procedures performed by neurosurgeons and orthopedic surgeons. An increase in blood transfusion rates among patients operated by orthopedic surgeons and a longer operative time of procedures performed by neurosurgeons was a consistent finding among several studies. Other findings include a prolonged hospital stay, higher hospital readmission rates, and lower cost of procedures in patients operated on by orthopedic surgeons. A few studies revealed lower sepsis rates unplanned intubation rates and higher incidence of urinary tract infections (UTIs) and pneumonia postoperatively among patient cohorts operated by neurosurgeons. Certain limitations were identified in the studies including the use of large databases with incomplete information related to patient and surgeon demographics. Hence, it is imperative to account for these confounding variables in future studies to alleviate any biases. Nevertheless, it is essential to embrace a multidisciplinary approach integrating the surgical expertise of the two specialties and develop standardized management guidelines and techniques for spinal disorders to mitigate complications and enhance patient outcomes.
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Affiliation(s)
- Venkataramana Kuruba
- Department of Orthopedic Surgery, All India Institute of Medical Sciences, Vijayawada, IND
| | | | - Subiksha Arul
- Department of Medicine, JONELTA Foundation School of Medicine, University of Perpetual Help System DALTA, Manila, PHL
| | | | - Sheryl Biju
- Department of Medicine, Christian Medical College, Vellore, IND
| | - Taimur Hassan
- Department of Medicine, Texas A&M College of Medicine, College Station, USA
| | - Riya Gupta
- Department of Medicine, Shri Atal Bihari Vajpayee Medical College and Research Institute, Bangalore, IND
| | - Saya Alasaadi
- Department of Medicine, University College of Dublin, Dublin, IRL
| | - Jarin Tasnim Sikto
- Department of Medicine, Jahurul Islam Medical College and Hospital, Bhagalpur, BGD
| | - Arnav C Muppuri
- Department of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Humza F Siddiqui
- Department of Internal Medicine, Jinnah Postgraduate Medical Center, Karachi, PAK
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4
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Menapace B, McCarthy J, Schultz L, Leitsinger N, Jain V, Sturm P. Utilizing two surgeons for neuromuscular scoliosis suggests improved operative efficiency. Spine Deform 2023; 11:985-992. [PMID: 37067777 DOI: 10.1007/s43390-023-00678-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 03/11/2023] [Indexed: 04/18/2023]
Abstract
PURPOSE Neuromuscular scoliosis (NMS) patients tend to have significant comorbidities with complex medical and surgical histories. When undergoing posterior spinal fusion (PSF), NMS risks can be much higher than the idiopathic population. This study aimed to identify the impact of two experienced pediatric cosurgeons (CS) compared to a single spine surgeon (SS) on the intra- and postoperative results of NMS PSF. METHODS A database of NMS patients who had undergone PSF 2016-2021 identified 53 patients, of which 32 were CS, while 21 were SS. Patients' sex, age, weight, diagnosis, curve severity, fusion performed, estimated blood loss (EBL), transfusion rates, hemoglobin, anesthesia and surgical times, length of stay, and complications were collected. RESULTS Patient demographics were similar between groups. Curves were more severe in the CS group (p = 0.013). Intraoperatively, CS patients underwent larger corrections (p = 0.089) but in significantly shorter anesthetic (p = 0.0018) and operative (p = 0.0025) times. Blood loss and transfusions were similar. Postoperatively, intensive-care unit (ICU) admission and length of stay (LOS) were similar, but SS had higher rates of both unplanned ICU admissions (p = 0.36) and 30 day readmissions (p = 0.053). Complications overall were similar between the groups both within 30 days (p = 0.40) and in the short-term period (31-90 days, p = 0.76), though the CS cohort had less Grade 2 immediate postoperative pulmonary complications (p = 0.16). CONCLUSION Utilizing CS for NMS PSF has been found to reduce operative times. Downstream, additional potential impacts trended toward fewer unplanned ICU admissions, less-frequent postoperative pulmonary complications, and reduced 30-day readmission rates.
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Affiliation(s)
- Bryan Menapace
- Department of Orthopaedic Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA.
| | - James McCarthy
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lindsay Schultz
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nichole Leitsinger
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Viral Jain
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Sturm
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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5
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Cuello CC, Flores-Milan G, Pressman E, Krafft PR, Lawing C, Alikhani P. Neuromuscular Scoliosis: A Dual-Surgeon Approach. World Neurosurg 2022; 167:e1045-e1049. [PMID: 36058482 DOI: 10.1016/j.wneu.2022.08.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/29/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Neuromuscular Scoliosis (NMS) causes severe deformity and operative correction for these patients carries high complication rates. We present a retrospective study comparing a series of consecutive patients who underwent posterior fusion via a single-surgeon (SS) approach with a consecutive series of patients treated via a dual-surgeon (DS) approach. METHODS Patients with NMS who underwent posterior fusion via a SS approach from 2019 to 2022 were analyzed and compared to a series of patients with NMS who underwent posterior fusion via a DS approach. RESULTS In the SS group, the average estimated blood loss (EBL) was 675 mL, average length of stay (LOS) was 6.3 days, average operative time (OT) was 6.5 hours, average packed red blood cell transfusion was 1.5 units, with a complication rate of 30%. The DS group had an average EBL of 400 mL, a LOS of 4.8 days, an OT of 4.75 hours, an average packed red blood cell transfusion of 0.8 units, with a complication rate of 20%. The DS approach was significant for a lower EBL, OT (P < 0.001), and LOS (P < 0.03). CONCLUSIONS This study suggests that for patients with NMS the DS approach decreases OT, EBL, complication rates, and LOS. This further supports that this approach may benefit outcomes in NMS patients.
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Affiliation(s)
- César Carballo Cuello
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Gabriel Flores-Milan
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Paul R Krafft
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Cheryl Lawing
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Puya Alikhani
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA.
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6
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Olson SL, Ingram MCE, Graffy PM, Murphy PM, Tian Y, Samis JH, Josefson JL, Rastatter JC, Raval MV. Effect of surgeon volume on pediatric thyroid surgery outcomes: A systematic review. J Pediatr Surg 2022; 57:208-215. [PMID: 34980469 DOI: 10.1016/j.jpedsurg.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 11/26/2021] [Accepted: 12/01/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pediatric thyroidectomy has been identified as a surgical procedure that may benefit from concentrating cases to high-volume surgeons. This systematic review aimed to address the definition of "high-volume surgeon" for pediatric thyroidectomy and to examine the relationship between surgeon volume and outcomes. METHODS PubMed, Embase, Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov, and OpenGrey databases were searched for through February 2020 for studies which reported on pediatric thyroidectomy and specified surgeon volume and surgical outcomes. RESULTS Ten studies, encompassing 6430 patients, were included in the review. Five single-center retrospective studies reported only on high-volume surgeons, one single center retrospective study reported on only low-volume surgeons, and four national database studies (2 cross sectional, 2 retrospective reviews) reported outcomes for both high-volume and low-volume surgeons. Majority of patients underwent total thyroidectomy (54.9%); common indications for surgery were malignancy (41.7%) and hyperthyroidism/thyroiditis (40.5%). Rates of transient hypocalcemia (11.4% - 74.2%), transient recurrent laryngeal nerve injury (0% - 9.7%), and bleeding (0.5% - 4.3%) varied across studies. Definitions for high-volume pediatric thyroid surgeons ranged from ≥9 annual pediatric thyroid operations to >200 annual thyroid operations (with >30 pediatric cases). Four studies reported significantly better outcomes, including lower post-operative complications and shorter length of hospital stay, for patients treated by high-volume surgeons. CONCLUSIONS Despite significant variation in caseloads to define volume, pediatric thyroid patients have generally better outcomes when operated on by higher volume surgeons. Concentration thyroidectomy cases to a smaller cohort of surgeons within pediatric practices may confer improved outcomes. LEVEL OF EVIDENCE Systematic Reviews and Meta-Analyses; Level IV.
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Affiliation(s)
- Sydney L Olson
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Martha-Conley E Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Peter M Graffy
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Peggy M Murphy
- Pritzker Research Library, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Yao Tian
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Jill H Samis
- Division of Pediatric Endocrinology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Jami L Josefson
- Division of Pediatric Endocrinology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Jeffery C Rastatter
- Department of Otorhinolaryngology-Head & Neck Surgery, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.
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7
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Iyer RR, Vitale MG, Fano AN, Matsumoto H, Sucato DJ, Samdani AF, Smith JS, Gupta MC, Kelly MP, Kim HJ, Sciubba DM, Cho SK, Polly DW, Boachie-Adjei O, Angevine PD, Lewis SJ, Lenke LG. Establishing consensus: determinants of high-risk and preventative strategies for neurological events in complex spinal deformity surgery. Spine Deform 2022; 10:733-744. [PMID: 35199320 DOI: 10.1007/s43390-022-00482-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/22/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE To establish expert consensus on various parameters that constitute elevated risk during spinal deformity surgery and potential preventative strategies that may minimize the risk of intraoperative neuromonitoring (IONM) events and postoperative neurological deficits. METHODS Through a series of surveys and a final virtual consensus meeting, the Delphi method was utilized to establish consensus among a group of expert spinal deformity surgeons. During iterative rounds of voting, participants were asked to express their agreement (strongly agree, agree, disagree, strongly disagree) to include items in a final set of guidelines. Consensus was defined as ≥ 80% agreement among participants. Near-consensus was ≥ 60% but < 80% agreement, equipoise was ≥ 20% but < 60%, and consensus to exclude was < 20%. RESULTS Fifteen of the 15 (100%) invited expert spinal deformity surgeons agreed to participate. There was consensus to include 22 determinants of high-risk (8 patient factors, 8 curve and spinal cord factors, and 6 surgical factors) and 21 preventative strategies (4 preoperative, 14 intraoperative, and 3 postoperative) in the final set of best practice guidelines. CONCLUSION A resource highlighting several salient clinical factors found in high-risk spinal deformity patients as well as strategies to prevent neurological events was successfully created through expert consensus. This is intended to serve as a reference for surgeons and other clinicians involved in the care of spinal deformity patients. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Rajiv R Iyer
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA
| | - Michael G Vitale
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA.,Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Adam N Fano
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA
| | - Hiroko Matsumoto
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA. .,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA.
| | - Daniel J Sucato
- Department of Orthopaedic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael P Kelly
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Long Island Jewish Medical Center, North Shore University Hospital of Northwell Health, New York, NY, USA
| | - Samuel K Cho
- Department of Orthopedic Surgery, Mount Sinai Medical Center, New York, NY, USA
| | - David W Polly
- Department of Orthopedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Peter D Angevine
- The Daniel and Jane Och Spine Hospital at New York-Presbyterian/Allen, New York, NY, USA.,Division of Spinal Surgery, Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Stephen J Lewis
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - Lawrence G Lenke
- The Daniel and Jane Och Spine Hospital at New York-Presbyterian/Allen, New York, NY, USA.,Division of Spinal Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
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8
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Lubelski D, Alomari S, Pennington Z, Lo L, Witham T, Theodore N, Sciubba DM, Bydon A. Single-Surgeon Versus Dual-Surgeon Strategy in Spinal Tumor Surgery: A Single Institution Experience. Clin Spine Surg 2022; 35:E566-E570. [PMID: 35276721 DOI: 10.1097/bsd.0000000000001302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The objective of this study is to compare the outcomes of spinal tumor surgery between dual-surgeon and single-surgeon approach. SUMMARY OF BACKGROUND DATA Perioperative adverse outcomes may be improved with 2 attending surgeons in spinal deformity cases. It is unclear if this advantage may be seen in spinal oncology operations. METHODS A retrospective chart review identified 24 patients who underwent spinal tumor surgery by two attending surgeons between January 1, 2016, and April 30, 2020 at a single tertiary care institution. 1:1 matching was then performed to identify 24 patients who underwent spinal tumor operations of similar complexity by a single attending surgeon. Postoperative outcomes were collected. RESULTS Cases in the dual-surgeon group had significantly lower total operative time (601 vs. 683 minutes), reduced estimated blood loss (956 vs. 1780 ml), and were less likely to have an intraoperative blood transfusion (41.7% vs. 75.0%). The incidence of cerebrospinal fluid leak and wound infection did not significantly differ between groups, nor were there differences in total length of hospital stay, discharge disposition, 6-month emergency room visit, readmission, and reoperation rates. CONCLUSION Dual-surgeon strategy in spinal tumors surgery may lead to decreased operative time and estimated blood loss. These benefits may have clinical and cost implications, but should be weighed against the impact of resident and fellow training. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
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9
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Lee NJ, Fields M, Boddapati V, Mathew J, Hong D, Sardar ZM, Selber PR, Roye B, Vitale MG, Lenke LG. Spinal Deformity Surgery in Pediatric Patients With Cerebral Palsy: A National-Level Analysis of Inpatient and Postdischarge Outcomes. Global Spine J 2022; 12:610-619. [PMID: 32964747 PMCID: PMC9109575 DOI: 10.1177/2192568220960075] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To provide a national-level assessment of the short-term outcomes after spinal deformity surgery in pediatric patients with cerebral palsy. METHODS A national, prospectively collected database was queried to identify pediatric (≤18 years) patients with cerebral palsy, who underwent spinal fusion surgery from 2012 to 2017. Separate multivariate analyses were performed for the primary outcomes of interest including extended length of stay (>75th percentile, >8 days), and readmissions within 90 days after the index admission. RESULTS A total of 2856 patients were reviewed. The mean age ± standard deviation was 12.8 ± 2.9 years, and 49.4% of patients were female. The majority of patients underwent a posterior spinal fusion (97.0%) involving ≥8 levels (79.9%) at a teaching hospital (96.6%). Top medical complications (24.5%) included acute respiratory failure requiring mechanical ventilation (11.4%), paralytic ileus (8.2%), and urinary tract infections (4.6%). Top surgical complications (40.7%) included blood transfusion (35.6%), wound complication (4.9%), and mechanical complication (2.7%). The hospital cost for patients with a length of hospital stay >8 days ($113 669) was nearly double than that of those with a shorter length of stay ($68 411). The 90-day readmission rate was 17.6% (mean days to readmission: 30.2). The most common reason for readmission included wound dehiscence (21.1%), surgical site infection (19.1%), other infection (18.9%), dehydration (16.9%), feeding issues (14.5%), and acute respiratory failure (13.1%). Notable independent predictors for 90-day readmissions included preexisting pulmonary disease (odds ratio [OR] 1.5), obesity (OR 3.4), cachexia (OR 27), nonteaching hospital (OR 3.5), inpatient return to operating room (OR 1.9), and length of stay >8 days (OR 1.5). CONCLUSIONS Efforts focused on optimizing the perioperative pulmonary, hematological, and nutritional status as well as reducing wound complications appear to be the most important for improving clinical outcomes.
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Affiliation(s)
- Nathan J. Lee
- Columbia University Medical Center,
The Och Spine Hospital at New York-Presbyterian, New York, NY, USA,Nathan J. Lee, Department of Orthopaedics,
Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY
10032, USA.
| | - Michael Fields
- Columbia University Medical Center,
The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Venkat Boddapati
- Columbia University Medical Center,
The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Justin Mathew
- Columbia University Medical Center,
The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Daniel Hong
- Columbia University Medical Center,
The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Zeeshan M. Sardar
- Columbia University Medical Center,
The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Paulo R. Selber
- Columbia University Medical Center,
The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Benjamin Roye
- Columbia University Medical Center,
The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Michael G. Vitale
- Columbia University Medical Center,
The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Lawrence G. Lenke
- Columbia University Medical Center,
The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
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The Effect of Surgeon Experience on Outcomes Following Growth Friendly Instrumentation for Early Onset Scoliosis. J Pediatr Orthop 2022; 42:e132-e137. [PMID: 34759190 DOI: 10.1097/bpo.0000000000002000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to utilize a multicenter, multisurgeon cohort to assess the effect of surgeon experience on outcomes of growth friendly instrumentation (GFI) in early onset scoliosis (EOS). We hypothesized that unplanned return to the operating room (UPROR), estimated blood loss (EBL), and surgical time would be greater amongst early career surgeons (ECSs) when compared with advanced career surgeons (ACSs). METHODS An international pediatric spine database was queried for patients ages 2 to 10 years treated by posterior distraction-based GFI with at least of 2-year follow up. Two groups were created for analysis based on surgeon experience: ECSs (with ≤10 y of experience) and ACSs (with >10 y of experience). The primary outcome was UPROR. Additional outcomes included: operating room time, EBL, neurological deficits, infection rate, hardware failure, and the Early Onset Scoliosis Questionnaire (EOSQ-24). Subgroup analysis was performed for further assessment based on procedure type, superior anchor type, etiology, and curve severity. RESULTS A total of 960 patients met inclusion criteria including 243 (25.3%) treated by ECS. Etiology, sex, superior anchor, and EOSQ-24 scores were similar between groups (P>0.05). There were no clinically significant differences in patient age or preoperative major coronal curve. UPROR (35.8% vs. 32.7%, P=0.532), infection (17.0% vs. 15.6%, P=0.698), operating room time (235 vs. 231 min, P=0.755), and EBL (151 vs. 155 mL, P=0.833) were comparable between ECS and ACS groups. The frequency of having at least 1 complication was relatively high but comparable among groups (60.7% vs. 62.6%, P=0.709). EOSQ-24 subdomain scores were similar between groups at 2-year follow-up (P>0.05). Subgroup analysis revealed that ECS had increased surgical time compared with ACS in severe curves >90 degrees (270 vs. 229 min, P=0.05). CONCLUSIONS This study represents the first multicenter assessment of surgeon experience on outcomes in EOS. Overall, surgeon experience did not significantly influence UPROR, complication rates, EBL, or surgical time associated with GFI in this cohort of EOS patients. LEVEL OF EVIDENCE Level III.
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Changoor S, Faloon M, Dunn C, Sahai N, Coban D, Saela S, Sinha K, Hwang K, Emami A. Two Attending Surgeons Improve Outcomes of Single Level Anterior Cervical Discectomy and Fusion. J Long Term Eff Med Implants 2022; 32:1-7. [DOI: 10.1615/jlongtermeffmedimplants.2022040313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Bixby EC, Skaggs K, Marciano GF, Simhon ME, Menger RP, Anderson RCE, Vitale MG. Resection of congenital hemivertebra in pediatric scoliosis: the experience of a two-specialty surgical team. J Neurosurg Pediatr 2021; 28:250-259. [PMID: 34214975 DOI: 10.3171/2020.12.peds20783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Institutions investigating value and quality emphasize utilization of two attending surgeons with different areas of technical expertise to treat complex surgical cases and to minimize complications. Here, the authors chronicle the 12-year experience of using a two-attending surgeon, two-specialty model to perform hemivertebra resection in the pediatric population. METHODS Retrospective cohort data from 2008 to 2019 were obtained from the NewYork-Presbyterian Morgan Stanley Children's Hospital operative database. This database included all consecutive pediatric patients < 21 years old who underwent hemivertebra resection performed with the two-attending surgeon (neurosurgeon and orthopedic surgeon) model. Demographic information was extracted. Intraoperative complications, including durotomy and direct neurological injury, were queried from the clinical records. Intraoperative neuromonitoring data were evaluated. Postoperative complications were queried, and length of follow-up was determined from the clinical records. RESULTS From 2008 to 2019, 22 patients with a median (range) age of 9.1 (2.0-19.3) years underwent hemivertebra resection with the two-attending surgeon, two-specialty model. The median (range) number of levels fused was 2 (0-16). The mean (range) operative time was 5 hours and 14 minutes (2 hours and 59 minutes to 8 hours and 30 minutes), and the median (range) estimated blood loss was 325 (80-2700) ml. Navigation was used in 14% (n = 3) of patients. Neither Gardner-Wells tongs nor halo traction was used in any operation. Neuromonitoring signals significantly decreased or were lost in 14% (n = 3) of patients. At a mean ± SD (range) follow-up of 4.6 ± 3.4 (1.0-11.6) years, 31% (n = 7) of patients had a postoperative complication, including 2 instances of proximal junctional kyphosis, 2 instances of distal junctional kyphosis, 2 wound complications, 1 instance of pseudoarthrosis with hardware failure, and 1 instance of screw pullout. The return to the operating room (OR) rate was 27% (n = 6), which included patients with the abovementioned wound complications, distal junctional kyphosis, pseudoarthrosis, and screw pullout, as well as a patient who required spinal fusion after loss of motor evoked potentials during index surgery. CONCLUSIONS Twenty-two patients underwent hemivertebra resection with a two-attending surgeon, two-specialty model over a 12-year period at a specialized children's hospital, with a 14% rate of change in neuromonitoring, 32% rate of nonneurological complications, and a 27% rate of unplanned return to the OR.
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Affiliation(s)
- Elise C Bixby
- 1Department of Orthopedics, Columbia University Irving Medical Center, New York, New York
| | - Kira Skaggs
- 1Department of Orthopedics, Columbia University Irving Medical Center, New York, New York
| | - Gerard F Marciano
- 1Department of Orthopedics, Columbia University Irving Medical Center, New York, New York
| | - Matthew E Simhon
- 1Department of Orthopedics, Columbia University Irving Medical Center, New York, New York
| | | | | | - Michael G Vitale
- 1Department of Orthopedics, Columbia University Irving Medical Center, New York, New York
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Chan CYW, Chiu CK, Ch'ng PY, Lee SY, Chung WH, Hasan MS, Kwan MK. Dual attending surgeon strategy learning curve in single-staged posterior spinal fusion (PSF) surgery for 415 idiopathic scoliosis (IS) cases. Spine J 2021; 21:1049-1058. [PMID: 33610804 DOI: 10.1016/j.spinee.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 02/07/2021] [Accepted: 02/13/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The implementation of a dual attending surgeon strategy had improved perioperative outcomes of idiopathic scoliosis (IS) patients. Nevertheless, the learning curve of a dual attending surgeon practice in single-staged posterior spinal fusion (PSF) surgery has not been established. OBJECTIVE To evaluate the surgical learning curve of a dual attending surgeon strategy in IS patients. STUDY DESIGN Retrospective study. PATIENT SAMPLE 415 IS patients (Cobb angle <90°) who underwent PSF using a dual attending surgeon strategy OUTCOME MEASURES: Primary outcomes included operative time, total blood loss, allogenic blood transfusion requirement, length of hospital stay and perioperative complication rate. METHODS Regression analysis using Locally Weighted Scatterplot Smoothing (LOWESS) method was applied to create the best-fit-curve between case number versus operative time and total blood loss in identifying cut-off points for the learning curve. RESULTS The mean Cobb angle was 60.8±10.8°. Mean operative time was 134.4±32.1 minutes and mean total blood loss was 886.0±450.6 mL. The mean length of hospital stay was 3.0±1.6 days. The learning curves of a dual attending surgeon strategy in this study were established at the 115th case (operative time) and 196th case (total blood loss) respectively (p<.001). In comparison of cases before and after the cut-off points, mean operative time reduced significantly from 147.2±36.5 minutes to 129.5±28.9 minutes and mean total blood loss reduced significantly from 1015.1±506.6 mL to 770.4±357.3 mL (p<.001). No allogenic blood transfusion was required and there were 7 perioperative complications (n=7/415, 1.7%) recorded. CONCLUSION The learning curve of a dual surgeon strategy in single-staged PSF surgery based on operative time and total blood loss were established at 115th case and 196th case respectively (p<.001).
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Affiliation(s)
- Chris Yin Wei Chan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Chee Kidd Chiu
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Pei Ying Ch'ng
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sin Ying Lee
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Weng Hong Chung
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohd Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mun Keong Kwan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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McDonald TC, Gnam AL, Brooks JT, Sukkarieh H, Replogle WH, Wright PB. The value-added benefit of utilizing two attending surgeons for patients with scoliosis secondary to cerebral palsy. Spine Deform 2021; 9:1145-1150. [PMID: 33587269 DOI: 10.1007/s43390-021-00301-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 01/28/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The use of two attending surgeons during posterior spinal fusion (PSF) for cerebral palsy (CP) patients has been shown to improve perioperative outcomes. This study aims to determine if the use of two surgeons is associated with an increase in the number of subsequent surgeries that can be performed in the same operating room (OR) during business hours. METHODS Patients with scoliosis and CP treated with PSF with minimum 90-day follow-up were included. Patients were grouped based on whether one or two attending surgeons performed the case. The primary outcome was the number of surgeries that followed in the same OR before 5 PM. Secondary outcomes included operative time, estimated blood loss (EBL), length of stay, rate of surgical site infection, and rate of unplanned return to the operating room. RESULTS Thirty-six patients were included (10 with 1 surgeon and 26 with 2 surgeons). The two surgeon group had a significant increase in the average number of surgeries subsequently performed in the same OR during business hours (1.1 vs. 0.3, p = 0.01), as well as shorter mean operative time (159 vs. 307 min, p = 0.007) and EBL (554 vs. 840 cc, p = 0.01; 26 vs. 39%EBV, p = 0.03). CONCLUSION The use of two attending surgeons was associated with a significant increase in the number of cases subsequently performed in the same OR during business hours, and significant decreases in operative time and EBL. Hospitals should consider the patient care and potential system-level improvements when considering implementation of two surgeon teams for PSF in CP patients. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Tyler C McDonald
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA.
| | - Ashley L Gnam
- School of Medicine, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Jaysson T Brooks
- Department of Orthopaedic Surgery and Rehabilitation, The University of Mississippi Medical Center, Jackson, MS, USA
- Children's of Mississippi, Jackson, MS, USA
| | - Hamdi Sukkarieh
- Department of Orthopaedic Surgery and Rehabilitation, The University of Mississippi Medical Center, Jackson, MS, USA
- Children's of Mississippi, Jackson, MS, USA
| | - William H Replogle
- School of Nursing, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Patrick B Wright
- Department of Orthopaedic Surgery and Rehabilitation, The University of Mississippi Medical Center, Jackson, MS, USA
- Children's of Mississippi, Jackson, MS, USA
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Lak AM, Abunimer AM, Goedmakers CMW, Aglio LS, Smith TR, Makhni M, Mekary RA, Zaidi HA. Single- versus Dual-Attending Surgeon Approach for Spine Deformity: A Systematic Review and Meta-Analysis. Oper Neurosurg (Hagerstown) 2021; 20:233-241. [PMID: 33372960 DOI: 10.1093/ons/opaa393] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/13/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Surgical management of spine deformity is associated with significant morbidity. Recent literature has inconsistently demonstrated better outcomes after utilizing 2 attending surgeons for spine deformity. OBJECTIVE To conduct a systematic review and meta-analysis on studies reporting outcomes following single- vs dual-attending surgeons for spine deformity. METHODS MEDLINE, Embase, Web of science, and Cochrane databases were last searched on July 16, 2020. A total of 1013 records were identified excluding duplicates. After screening, 10 studies (4 cohort, 6 case series) were included in the meta-analysis. Random-effect models were used to pool the effect estimates by study design. When feasible, further subgroup analysis by deformity type was conducted. RESULTS A total of 953 patients were analyzed. Pooled results from propensity score-matched cohort studies revealed that the single-surgeon approach was unfavorably associated with a nonstatistically significant higher blood loss (mean difference = 421.0 mL; 95% CI: -28.2, 870.2), a statistically significant higher operative time (mean difference = 94.3 min; 95% CI: 54.9, 133), length of stay (mean difference = 0.84 d; 95% CI: 0.46, 1.22), and an increased risk of complications (Mantel-Haenszel risk ratio = 2.93; 95% CI: 1.12, 7.66). Data from pooled case series demonstrated similar results for all outcomes. Moreover, these results did not differ significantly between deformity types (adolescent idiopathic scoliosis and adult spinal deformity). CONCLUSION Dual-attending surgeon approach appeared to be associated with reduced operative time, shorter hospital stays, and reduced risk of complications. These findings may potentially improve outcomes in surgical treatment of spine deformity.
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Affiliation(s)
- Asad M Lak
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Abdullah M Abunimer
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Caroline M W Goedmakers
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Linda S Aglio
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesia, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Melvin Makhni
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,MCPHS University, Boston, Massachusetts
| | - Hasan A Zaidi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Nahm NJ, Ludwig M, Thompson R, Rogers KJ, Imerci A, Dabney KW, Miller F, Sees JP. Single-event multilevel surgery in cerebral palsy: Value added by a co-surgeon. Medicine (Baltimore) 2021; 100:e26294. [PMID: 34128865 PMCID: PMC8213317 DOI: 10.1097/md.0000000000026294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT The aim of this study was to compare outcomes for single-event multilevel surgery (SEMLS) in cerebral palsy (CP) performed by 1 or 2 attending surgeons.A retrospective review of patients with CP undergoing SEMLS was performed. Patients undergoing SEMLS performed by a single senior surgeon were compared with patients undergoing SEMLS by the same senior surgeon and a consistent second attending surgeon. Due to heterogeneity of the type and quantity of SEMLS procedures included in this study, a scoring system was utilized to stratify patients to low and high surgical burden. The SEMLS events scoring less than 18 points were categorized as low burden surgery and SEMLS scoring 18 or more points were categorized as high burden surgery. Operative time, estimated blood loss, hospital length of stay, and operating room (OR) utilization costs were compared.In low burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 8 patients had SEMLS performed by 2 surgeons. In high burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 12 patients had SEMLS performed by 2 surgeons. For high burden SEMLS, operative time was decreased by a mean of 69 minutes in cases performed by 2 co-surgeons (P = 0.03). Decreased operative time was associated with an estimated savings of $2484 per SEMLS case. In low burden SEMLS, a trend toward decreased operative time was associated for cases performed by 2 co-surgeons (182 vs 221 minutes, P = 0.11). Decreased operative time was associated with an estimated savings of $1404 per low burden SEMLS case. No difference was found for estimated blood loss or hospital length of stay between groups in high and low burden SEMLS.Employing 2 attending surgeons in SEMLS decreased operative time and OR utilization cost, particularly in patients with a high surgical burden. These findings support the practice of utilizing 2 attending surgeons for SEMLS in patients with CP.Level of Evidence: Level III.
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Affiliation(s)
- Nickolas J. Nahm
- Department of Orthopaedic Surgery, University of Nebraska, Omaha, NE
| | | | - Rachel Thompson
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA,Orthopaedic Institute for Children, Los Angeles, CA
| | - Kenneth J. Rogers
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Ahmet Imerci
- Department of Orthopaedics and Traumatology, Mugla Sitki Kocman University, Merkez, Mugla, Turkey
| | - Kirk W. Dabney
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Freeman Miller
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Julieanne P. Sees
- National Academy of Medicine Fellowship, American Osteopathic Association, Chicago, IL, USA
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17
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Chan CYW, Lee SY, Ch'ng PY, Chung WH, Chiu CK, Hasan MS, Kwan MK. Learning Curve for a Dual Attending Surgeon Strategy in Posterior Spinal Fusion (PSF): An Analysis of 105 Severe Adolescent Idiopathic Scoliosis Patients (Cobb Angle ≥90°). Spine (Phila Pa 1976) 2021; 46:E663-E670. [PMID: 33306608 DOI: 10.1097/brs.0000000000003866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To assess the learning curve of a dual attending surgeon strategy in severe adolescent idiopathic scoliosis patients. SUMMARY OF BACKGROUND DATA The advantages of a dual attending surgeon strategy in improving the perioperative outcome in scoliosis surgery had been reported. However, the learning curve of this strategy in severe scoliosis had not been widely studied. METHODS A total of 105 patients with adolescent idiopathic scoliosis with Cobb angle of 90° or greater, who underwent posterior spinal fusion using a dual attending surgeon strategy were recruited. Primary outcomes were operative time, total blood loss, allogeneic blood transfusion requirement, length of hospital stay from time of operation and perioperative complications. Cases were sorted chronologically into group 1: cases 1 to 35, group 2: cases 36 to 70, and group 3: case 71 to 105. Mean operative time (≤193.3 min), total blood loss (≤1612.2 mL), combination of both and allogeneic blood transfusion were the selected criteria for receiver operating characteristic analysis of the learning curve. RESULTS The mean Cobb angle was 104.5° ± 12.3°. The operative time, total blood loss, and allogeneic blood transfusion requirement reduced significantly for group 1 (220.6 ± 54.8 min; 2011.3 ± 881.8 mL; 12 cases) versus group 2 (183.6 ± 36.7 min; 1481.6 ± 1035.5 mL; 3 cases) and group 1 versus group 3 (175.6 ± 38.4 min; 1343.7 ± 477.8 mL; 3 cases) (P < 0.05). There were six perioperative complications. Fifty-seven cases were required to achieve the preset criteria (mean operative time and mean total blood loss) (area under the curve 0.740; P < 0.001; sensitivity 0.675; specificity 0.662). CONCLUSION There was significant improvement in operative time and total blood loss when comparing group 1 versus group 2 and group 1 versus group 3. The cut-off point for the learning curve was 57 cases when the preset criteria were fulfilled (≤193.3 min operative time and ≤1612.2 mL of total blood loss).Level of Evidence: 4.
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Affiliation(s)
- Chris Yin Wei Chan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sin Ying Lee
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Pei Ying Ch'ng
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Weng Hong Chung
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chee Kidd Chiu
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohd Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mun Keong Kwan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Ellis R, Hardie JA, Summerton DJ, Brennan PA. Dual surgeon operating to improve patient safety. Br J Oral Maxillofac Surg 2021; 59:752-756. [PMID: 34272111 PMCID: PMC8276090 DOI: 10.1016/j.bjoms.2021.02.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 11/20/2022]
Abstract
The COVID-19 pandemic resulted in an unprecedented reduction in the delivery of surgical services worldwide, especially in non-urgent, non-cancer procedures. A prolonged period without operating (or ‘layoff period’) can result in surgeons experiencing skill fade (both technical and non-technical) and a loss of confidence. While senior surgeons in the UK may be General Medical Council (GMC) validated and capable of performing a procedure, a loss of ‘currency’ may increase the risk of error and intraoperative patient harm, particularly if unexpected or adverse events are encountered. Dual surgeon operating may mitigate risks to patient safety as surgeons regain currency while returning to non-urgent operating and may also be beneficial after the greatly reduced activity observed during the COVID-19 pandemic for low-volume complex operations. In addition, it could be a useful tool for annual appraisal, sharing updated surgical techniques and helping team cohesion. This paper explores lessons from aviation, a leading industry in human factors principles, for regaining surgical skills currency. We discuss real and perceived barriers to dual surgeon operating including finance, training, substantial patient waiting lists, and intraoperative power dynamics.
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Affiliation(s)
- R Ellis
- Intercollegiate Committee for Basic Surgical Examinations, United Kingdom; Urology Department, Nottingham University Hospitals, Nottingham, United Kingdom.
| | - J A Hardie
- Trauma & Orthopaedic Department, Frimley Park Hospital, Camberley GU16 7UJ, United Kingdom
| | - D J Summerton
- Department of Urology, University Hospitals of Leicester NHS Trust, Leicester LE5 4PW, United Kingdom
| | - P A Brennan
- Intercollegiate Committee for Basic Surgical Examinations, United Kingdom; Maxillofacial Unit, Queen Alexandra Hospital, Portsmouth PO6 3LY, United Kingdom
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Rossi T, Romano MR, Iannetta D, Romano V, Gualdi L, D'Agostino I, Ripandelli G. Cataract surgery practice patterns worldwide: a survey. BMJ Open Ophthalmol 2021; 6:e000464. [PMID: 33501377 PMCID: PMC7812090 DOI: 10.1136/bmjophth-2020-000464] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 11/15/2020] [Accepted: 12/03/2020] [Indexed: 11/24/2022] Open
Abstract
Objective To report the results of a global survey on cataract practice patterns related to preoperative, intraoperative and postoperative care, surgical setting and personnel allocation. Methods and analysis An online 28 questions survey was sent to 240 ophthalmologists asking to describe prevailing trends in their institutions across 38 countries and 5 continents. Questions inquired country, institution, surgical volume and setting, anaesthesia, preoperative and intraoperative examination and postsurgical care. Statistical analysis used crosstabs lambda statistics for non-parametric nominal variables. P value less than 0.05 was considered statistically significant. Results 209/240 (87%) ophthalmologists responded: 38% representing public hospitals, 36% private practices and 26% academic sites; overall surgical volume was between 241 700 and 410 500 cataracts per year. There was a significant correlation between type of institution and surgical volume. Complete results available in online (https://freeonlinesurveys.com/r/W6BcLLxy). Conclusion Cataract surgery related patterns of perioperative care showed significant difference among respondents, regardless to type of institution, surgical volume and country. Many evidence-based procedures are unevenly practiced around the world and some widespread and expensive habits lack solid scientific evidence while consuming enormous amount of resources both monetary and human. There is a need to reach consensus and share evidence-based practice patterns.
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Affiliation(s)
- Tommaso Rossi
- Ophthalmology, Ospedale Policlinico San Martino Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia, Genova, Italy
| | - Mario R Romano
- Department of Health Sciences, Humanitas University, Milan, Italy
| | - Danilo Iannetta
- Ophthalmology, Arcispedale Santa Maria Nuova di Reggio Emilia, Reggio Emilia, Italy
| | - Vito Romano
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | | | - Isabella D'Agostino
- Ophthalmology, Ospedale Policlinico San Martino Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia, Genova, Italy
| | - Guido Ripandelli
- IRCSS Fondazione G B Bietti per lo Studio e la Ricerca in Oftalmologia ONLUS, Roma, Italy
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20
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Comparison of a dual-surgeon versus single-surgeon approach for scoliosis surgery: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:740-748. [PMID: 33439334 DOI: 10.1007/s00586-021-06717-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 12/09/2020] [Accepted: 01/01/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Corrective surgery for scoliosis is a complex and challenging prospect for experienced spine surgeons due to the prolonged duration of surgery and the significant level of technical skill and expertise required. Traditionally, shorter operative time and lower blood loss have correlated well with improved outcomes and as such, efforts have been made to affect these metrics including the use of two attending surgeons for major cases in preference to one. This systematic review and meta-analysis assessed the available literature to further clarify the potential benefit that adopting a dual-surgeon approach offers over single-surgeon operations. METHODS A systematic review and meta-analysis assessed the effect of dual-surgeon operating compared to single-surgeon with respect to a number of indicators including blood loss, operative duration and length of hospital stay. In addition, we evaluated whether blood transfusion or complication rates differed between the two groups. RESULT Seven studies met our inclusion criteria. Mean difference indicated shorter duration of surgery (- 90.5 min, 95% CI [- 103.3, - 77.6]) and a lower blood loss (- 379.1, 95% CI [- 572.2, - 230.9]) in the dual-surgeon group compared to the single-surgeon group. Six studies reported mean length of stay and also favoured the dual-surgeon group. CONCLUSION This review observed that there are no randomised control trials evaluating dual-surgeon versus single-surgeon operating for scoliosis. We provide aggregated data and analysis of available literature, suggesting that outcomes in complex scoliosis surgery may be improved by adopting a dual-surgeon approach. LEVEL OF EVIDENCE III.
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Improving Safety and Efficacy in the Surgical Management of Low-tone Neuromuscular Scoliosis: Integrated Approach With a 2-attending Surgeon Operative Team and Modified Anesthesia Protocol. J Pediatr Orthop 2021; 41:e1-e6. [PMID: 32804863 DOI: 10.1097/bpo.0000000000001658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Substantially increased operative time and amount of bleeding may complicate the course of surgical treatment in neuromuscular scoliosis. A well-organized team approach is required to reduce morbidity. The aim of this study is to review our early, short-term surgical outcomes with our new integrated approach that includes a 2-attending surgeon team and modifications in the anesthesia protocol in low-tone neuromuscular scoliosis and compare with a matched cohort of our historic patients. METHODS We retrospectively reviewed our patients with (1) neuromuscular scoliosis with collapsing spine deformity, (2) low-tone neuromuscular etiology, (3) multilevel posterior column osteotomies with posterior all pedicle screw spinal fusion, and (4) more than 1-year follow-up. Patients were grouped into 2: group 1 consisted of patients managed with the integrated surgical team approach, group 2 included the matched historic patients. RESULTS There were 16 patients in group 1 and 17 patients in group 2. There was no significant difference between the groups regarding age, sex, body mass index, number of levels fused, major coronal deformity magnitude, pelvic obliquity, number of posterior column osteotomies, or amount of deformity correction. However, significantly shorter operative time (241 vs. 297 min, P=0.006), less intraoperative bleeding (1082 vs. 1852 mL, P=0.001), less intraoperative blood transfusion (2.1 vs. 3.1 U, P=0.028), less postoperative intensive care unit admission (23% vs. 100%, P=0.001), and shorter hospital stay (4.7 vs. 5.9 d, P=0.013) were observed in group 1. CONCLUSIONS Our results indicate that spinal deformity surgery in patients with underlying low-tone neuromuscular disease may not be as intimidating as previously thought. Our surgical team approach integrating a 2-attending surgeon operative team, a new anesthetic protocol that includes a modification of perioperative blood management is effective in reducing operative times, blood loss, transfusion rates, intensive care unit admission, and length of hospital stay. LEVELS OF EVIDENCE Level III-retrospective comparative study.
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Cheng I, Stienen MN, Medress ZA, Varshneya K, Ho AL, Ratliff JK, Veeravagu A. Single- versus dual-attending strategy for spinal deformity surgery: 2-year experience and systematic review of the literature. J Neurosurg Spine 2020; 33:560-571. [PMID: 32650315 DOI: 10.3171/2020.3.spine2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 03/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Adult spinal deformity (ASD) surgery is complex and associated with high morbidity and complication rates. There is growing evidence in the literature for the beneficial effects of an approach to surgery in which two attending physicians rather than a single attending physician perform surgery for and oversee the surgical care of a single patient in a dual-attending care model. The authors developed a dual-attending care collaboration in August 2017 in which a neurosurgeon and an orthopedic surgeon mutually operated on patients with ASD. METHODS The authors recorded data for 2 years of experience with ASD patients operated on by dual attending surgeons. Analyses included estimated blood loss (EBL), transfusions, length of stay (LOS), discharge disposition, complication rates, emergency room visits and readmissions, subjective health status improvement, and disability (Oswestry Disability Index [ODI] score) and pain (visual analog scale [VAS] score) at last follow-up. In addition, the pertinent literature for dual-attending spinal deformity correction was systematically reviewed. RESULTS The study group comprised 19 of 254 (7.5%) consecutively operated patients who underwent thoracolumbar fusion during the period from January 2017 to June 2019 (68.4% female; mean patient age 65.1 years, ODI score 44.5, VAS pain score 6.8). The study patients were matched by age, sex, anesthesia risk, BMI, smoking status, ODI score, VAS pain score, prior spine surgeries, and basic operative characteristics (type of interbody implants, instrumented segments, pelvic fixation) to 19 control patients (all p > 0.05). There was a trend toward less EBL (mean 763 vs 1524 ml, p = 0.059), fewer intraoperative red blood cell transfusions (mean 0.5 vs 2.3, p = 0.079), and fewer 90-day readmissions (0% vs 15.8%, p = 0.071) in the dual-attending group. LOS and discharge disposition were similar, as were the rates of any < 30-day postsurgery complications, < 90-day postsurgery emergency room visits, and reoperations, and ODI and VAS pain scores at last follow-up (all p > 0.05). At last follow-up, 94.7% vs 68.4% of patients in the dual- versus single-attending group stated their health status had improved (p = 0.036). In the authors' literature search of prior articles on spinal deformity correction, 5 of 8 (62.5%) articles reported lower EBL and 6 of 8 (75%) articles reported significantly lower operation duration in dual-attending cases. The literature contained differing results with regard to complication- or reoperation-sparing effects associated with dual-attending cases. Similar clinical outcomes of dual- versus single-attending cases were reported. CONCLUSIONS Establishing a dual-attending care management platform for ASD correction was feasible at the authors' institution. Results of the use of a dual-attending strategy at the authors' institution were favorable. Positive safety and outcome profiles were found in articles on this topic identified by a systematic literature review.
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Affiliation(s)
| | - Martin N Stienen
- 2Neurosurgery, Stanford University Hospitals and Clinics, Stanford, California
- 3Department of Neurosurgery, University Hospital Zurich; and
- 4Clinical Neuroscience Center, University of Zurich, Switzerland
| | - Zachary A Medress
- 2Neurosurgery, Stanford University Hospitals and Clinics, Stanford, California
| | - Kunal Varshneya
- 2Neurosurgery, Stanford University Hospitals and Clinics, Stanford, California
| | - Allen L Ho
- 2Neurosurgery, Stanford University Hospitals and Clinics, Stanford, California
| | - John K Ratliff
- 2Neurosurgery, Stanford University Hospitals and Clinics, Stanford, California
| | - Anand Veeravagu
- 2Neurosurgery, Stanford University Hospitals and Clinics, Stanford, California
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Abstract
PURPOSE Cerebral palsy (CP) is a disorder arising from a non-progressive lesion in the developing immature brain with an encephalopathy, that results in various levels of motor and sensory dysfunction. Motor disability of these children can be assessed by the Gross Motor Function Classification System in five levels, and depending on their motor functional capability, the most severely affected children fall into levels IV and V. Children in groups IV and V present a full spectrum of musculoskeletal deformities, among which, scoliosis is the most frequently found spinal deformity that most often requires surgical treatment. However, these are procedures that are usually technically demanding, requiring experienced surgical teams and a multidisciplinary approach. METHODS In order to overcome some of the technical pitfalls that may complicate these complex surgical procedures, the authors have gathered together different tips and tricks that may help surgeons performing surgical correction of spinal deformities in CP children. CONCLUSION Although for these children surgery is a major undertaking, with the multidisciplinary approach and advances of technology, anaesthesia and optimization of pre- and postoperative care, complications are manageable in most cases, improving not only the outcome of surgery but also the patient's quality of life and satisfaction of parents and caretakers.
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Affiliation(s)
- Jorge Mineiro
- Department of Orthopaedics and Traumatology, Orthopaedic Spine Unit, Hospital CUF Descobertas, Lisbon, Portugal,Paediatric Spine Unit, Hospital Dª Estefania, Lisbon, Portugal,Correspondence should be sent to Jorge Mineiro, Orthopaedic Department - Spine Unit, Hospital CUF Descobertas, Rua Mário Botas, Parque das Nações, 1998-018 Lisboa, Portugal. E-mail:
| | - Muharrem Yazici
- Department of Orthopaedics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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