Short- and midterm outcomes of coronary artery bypass surgery performed by surgeons in training

Performance of left internal thoracic artery-left anterior descending artery anastomosis by residents versus attendings and coronary artery bypass grafting outcomes

OBJECTIVES

Performance of a technically sound left internal thoracic artery to left anterior descending artery (LITA-LAD) anastomosis during coronary artery bypass grafting (CABG) is critically important. We used prospectively collected data from the multicentre, randomized REGROUP (Randomized Endograft Vein Perspective) trial to investigate CABG outcomes based on whether a resident or an attending surgeon performed the LITA-LAD anastomosis.

METHODS

This was a post hoc subanalysis of the REGROUP trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest from 2014 through 2017. The primary end point was major cardiac adverse events, defined as the composite of all-cause deaths, nonfatal myocardial infarctions or repeat revascularizations.

RESULTS

Among 1,084 patients, 344 (31.8%) LITA-LAD anastomoses were performed by residents and 740 (68.2%), by attending surgeons. Residents (compared to attendings) operated on fewer patients with high tercile SYNTAX scores (22.1% vs 37.4%, P < 0.001), performed fewer multiarterial CABGs (5.2% vs 14.6%, P < 0.001) and performed more anastomoses to distal targets with diameters > 2.0 mm (19.0% vs 10.9%, P < 0.001) and non-calcified landing zones (25.1% vs 21.6%, P < 0.001). During a median observation time of 4.7 years (interquartile range 3.84-5.45), major cardiac adverse events occurred in 77 patients (22.4%) in the group treated by residents and 169 patients (22.8%) in the group treated by attendings (unadjusted HR 1.00; 95% confidence interval, 0.76-1.33; P = 0.99). Outcomes persisted on adjusted analyses.

CONCLUSIONS

Based on this REGROUP trial subanalysis, under careful supervision and with appropriate patient selection, LITA-LAD anastomoses performed by the residents yielded clinical outcomes similar to those of the attendings.

Outcomes of cardiac surgical procedures performed by trainees versus consultants: A systematic review with meta-analysis

OBJECTIVES

Cardiac surgery is highly demanding and the ideal teaching method to reach competency is widely debated. Some studies have shown that surgical trainees can safely perform full operations with equivocal outcomes compared with their consultant colleagues while under supervision. We aimed to compare outcomes after cardiac surgery with supervised trainee involvement versus consultant-led procedures.

METHODS

We systematically reviewed databases (PubMed/MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar) and reference lists of relevant articles for studies that compared outcomes of cardiac surgery performed by trainees versus consultants. Primary end points included: operative mortality, coronary events, neurological/renal complications, reoperation, permanent pacemaker implantation, and sternal complications. Secondary outcomes included cardiopulmonary bypass and aortic cross-clamp times and intensive care/in-hospital length of stay. Random effects meta-analysis was performed.

RESULTS

Thirty-three observational studies that reported on a total of 81,616 patients (trainee: 20,154; consultant: 61,462) were included. There was a difference favoring trainees in terms of operative mortality in the main analysis and in an analysis restricted to propensity score-matched samples, whereas other outcomes were not consistently different in both analyses. Overall cardiopulmonary bypass and aortic cross-clamp times were longer in the trainee group but did not translate in longer intensive care unit or hospital stay.

CONCLUSIONS

In the right conditions, good outcomes are possible in cardiac surgery with trainee involvement. Carefully designed training programs ensuring graduated hands-on operative exposure as primary operator with appropriate supervision is fundamental to maintain high-quality training in the development of excellent cardiac surgeons.

The presence of residents during orthopedic operation exerts no negative influence on outcome

BACKGROUND

Operative procedural training is a key component of orthopedic surgery residency. It is unclear how and whether residents participation in orthopedic surgical procedures impacts on post-operative outcomes.

SOURCES OF DATA

A systematic search was performed to identify articles in which the presence of a resident in the operating room was certified, and was compared with interventions without the presence of residents.

AREAS OF AGREEMENT

There is a likely beneficial role of residents in the operating room, and there is only a weak association between the presence of a resident and a worse outcome for orthopedic surgical patients.

AREAS OF CONTROVERSY

Most of the studies were undertaken in USA, and this represents a limit from the point of view of comparison with other academic and clinical realities.

GROWING POINT

The data provide support for continued and perhaps increased involvement of resident in orthopedic surgery.

AREAS OF RESEARCH

To clarify the role of residents on clinically relevant outcomes in orthopedic patients, appropriately powered randomized control trials should be planned.

Has Publishing Surgeon-Specific Outcomes Had an Impact on Training in Cardiac Surgery?

BACKGROUND

Surgeon-specific outcome data are now published for most surgical specialties in the United Kingdom. There are concerns that this initiative has had a negative impact on training. The primary objective of this study was to assess whether training activity has changed since the publication of surgeon-specific outcomes in cardiac surgery.

METHODS

Prospectively collected data for cardiac surgical procedures performed at a single center from 2004 to 2016 were analyzed. The cohort was split into two halves according to operation date. Multivariable logistic regression was used to assess whether training activity had increased from the first to the second part of the study and to identify whether trainee first operator was associated with adverse outcomes.

RESULTS

A total of 14,054 cardiac surgical procedures were included, of which 1,777 (12.6%) had a trainee as first operator. Despite an increase in the risk profile of patients undergoing surgical procedures, the proportion of cases performed by trainees increased from 11.7% (786 of 6,708) in the first half of the study to 13.5% (991 of 7,346) in the second half of the study (p = 0.002). This effect remained after adjustment for confounding variables. Trainee first operator was not significantly associated with an increased risk of any adverse short-term outcome.

CONCLUSIONS

Since surgeon-specific outcome publication began in United Kingdom, cardiac surgical training activity has significantly increased at the study center despite an increase in the risk profile of patients. This study demonstrates that it is possible to maintain or even increase training activity with good outcomes in the era of surgeon-specific outcome publication.

Single crossclamp: Safe training tool for coronary artery bypass grafting

OBJECTIVE

The single-crossclamp technique for coronary artery bypass grafting is recognized to reduce manipulation of the ascending aorta, and thereby improve neurological outcomes. However, there is a perceived disadvantage of long cardiopulmonary bypass and crossclamp times. Our objective was to evaluate outcomes with this technique and determine whether it is safe for training.

METHODS

Patients undergoing coronary artery bypass between October 2005 and February 2014 with use of the single-crossclamp method were divided into 2 groups: a consultant group (n = 1024), and a trainee group (n = 504), depending on the primary surgeon. Their outcomes were compared.

RESULTS

The consultants operated on more nonelective patients who had a higher risk profile (mean additive EuroSCORE I 4.05 vs. 3.80, p = 0.085; logistic EuroSCORE I 4.36 vs. 3.64, p = 0.002). There were 9 (0.9%) deaths in the consultant group and 5 (1%) in the trainee group. The mean number of grafts in the consultant group was greater, but the crossclamp time was similar and cardiopulmonary bypass time was shorter. There were 4 (0.4%) cerebrovascular events in the consultant group and 3 (0.6%) in the trainee group. Postoperative stay was shorter in the trainee group (7.19 vs. 7.97 days, p = 0.033). Other complication rates were similar.

CONCLUSIONS

The technique has excellent outcomes, especially neurological, and is safe for training junior surgeons.

Training the novice to become cardiac surgeon: does the "early learning curve" training compromise surgical outcomes?

OBJECTIVE

It is unclear whether novice trainees can be taught safely to perform adult cardiac surgery without any impact on early or late outcomes.

METHODS

All patients (n = 1305) data were obtained from an externally validated, mandatory institutional database (2003-2010). 'Novice' is defined as a trainee who required substantial assistance or supervision to perform part or whole of the specified procedure (Intercollegiate Surgical Curriculum Programme UK, Competency Level ≤2). Outcome measures were in-hospital mortality, composite score of in-hospital mortality-morbidities, mid-term survival and revascularisation rate after CABG. Follow-up up to 7 years (median 3.2 years) was determined.

RESULTS

Some 39 % (n = 510) of the cases involved novice (28 %-part, 11 %-whole procedure), 12 % (n = 157) competent trainees and 49 % (n = 638) consultant. Median EuroSCORE was higher in consultant group (p < 0.001). Without risk adjustment, composite outcome score and mid-term mortality were higher in consultant group (p = 0.03). With adjustment using EuroSCORE and propensity scores, EuroSCORE was significantly predictive of in-hospital mortality [odd ratio (OR) 1.38, 95 %CI 1.20-1.57, p < 0.001], composite outcome (OR 1.26, 95 %CI 1.15-1.37, p < 0.001) and mid-term mortality (HR 1.24, 95 %CI 1.18-1.31, p < 0.001) but not the operator categories. Further analysis of subcohort undergoing first-time, isolated CABG (n = 1070) showed that EuroSCORE remained predictive of adjusted in-hospital mortality (OR 1.39, 95 %CI 1.13-1.71, p = 0.002), composite outcome (OR 1.33, 95 %CI 1.19-1.49, p < 0.001) and mid-term mortality (HR 1.22, 95 %CI 1.10-1.35, p < 0.001). The operator categories were not associated with adjusted outcome measures including revascularisation rate after CABG.

CONCLUSION

Supervised training in adult cardiac surgery can be achieved safely at the early learning curve phase without compromising both early and mid-term clinical outcomes.

Resident education in the era of patient safety: a nationwide analysis of outcomes and complications in resident-assisted oncologic surgery

BACKGROUND

Complex, oncologic surgery is an important component of resident education. Our objective was to evaluate the impact of resident participation in oncologic procedures on overall 30-day morbidity and mortality.

METHODS

A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program Participant User Files for 2005-2009. Colorectal, hepatopancreaticobiliary, and gastroesophageal oncology procedures were included. Multivariate logistic regression was used to assess the impact of trainee involvement on 30-day morbidity and mortality after adjusting for potential confounders.

RESULTS

A total of 77,862 patients were included for analysis, 53,885 (69.2%) involving surgical trainees and 23,977 (30.8%) without trainees. The overall 30-day morbidity was significantly higher in the trainee group [27.2 vs. 21%, adjusted odds ratio (AOR) 1.19, 95% confidence interval (CI) 1.15-1.24, p < 0.0001)]; however, there was significantly lower 30-day postoperative mortality in the trainee group (1.9 vs. 2.1%, AOR 0.87, 95% CI 0.77-0.98, p = 0.02) and significantly lower failure-to-rescue rate (defined as mortality rate among patients suffering one or more postoperative complications) (5.9 vs. 7.6%, AOR 0.79, 95% CI 0.68-0.90, p = 0.001). The overall 30-day morbidity was highest in the PGY 5 level (29%) compared to 24% for PGY 1 or 2 and 23% for PGY 3 (AOR per level increase 1.05, 95% CI 1.03-1.07, p < 0.0001).

CONCLUSIONS

Trainee participation in complex, oncologic surgery is associated with significantly higher rates of 30-day postoperative complications in NSQIP-participating hospitals; however, this effect is countered by overall lower 30-day mortality and improved rescue rate in preventing death among patients suffering complications.

Does orthopedic training compromise the outcome in total hip arthroplasty?

BACKGROUND

This study compares the outcomes of total hip arthroplasty surgery performed by a consultant with those performed by supervised and unsupervised orthopedic trainees.

METHODS

We reviewed 6 years of patient data from the New Zealand Joint Registry in patients undergoing total hip arthroplasty comparing the outcome measures of revision surgery and Oxford hip score at 6 months with the experience of the primary surgeon.

RESULTS

Over the study period 35,415 patients underwent elective total hip arthroplasty; 30,344 performed by a consultant, 2982 by a supervised trainee and 1067 by an unsupervised trainee. There was an overall revision rate of 0.77 per 100 component years. The revision rate was 0.75 (95% confidence interval [CI] 0.68-0.82) for consultants, 0.97 (95% CI, 0.72-1.28) for supervised trainees and 0.70 (95% CI, 0.36-1.22) for unsupervised trainees with no significant differences. There was no significant difference in the reason for revision surgery between the 3 groups.

CONCLUSIONS

The mean Oxford hip score was higher for consultants at 40.70 compared with 38.95 and 38.27 for supervised and unsupervised trainees respectively. These results are reassuring and indicate orthopedic training does not adversely compromise arthroplasty patient outcomes.

Safety of training and assessment in operating theatres--a systematic review and meta-analysis

OBJECTIVE

Procedural outcomes can be used to assess the performance of specialists and trainees. This article establishes a systematic evidence base for the safety of training in the operating theatre. It also explores the possibility of using early, intermediate and late procedural outcomes of cardiac surgical operations to evaluate the performance of the clinicians and the healthcare system.

METHODS

Medline, EMBASE and PsycINFO databases were searched. Comparative studies evaluating quality indicators of cardiac surgical procedures (coronary artery bypass grafting (CABG) and valve surgery) were included. guidelines from the preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used.

RESULTS

Fourteen studies met the inclusion criteria. For CABG, meta-analysis of outcomes did not show any significant differences between the technical and non-technical skills of trainees versus specialists apart from bypass time (less for specialists) and intensive care unit (ICU) length of stay (less for trainees). Studies reporting outcomes on valve surgery also did not report any statistically significant differences amongst the outcomes.

CONCLUSION

This systematic review did not discern any significant differences between the procedural outcomes of trainees and specialists, which indicates that trainees are safe to operate under senior supervision. In addition, this article recommends that various procedural outcomes can be used to evaluate the performance of clinicians and healthcare systems. Prospective studies need to be performed, taking into account the specific contribution of trainees and specialists during the procedure. This will give a clearer indication of safety and performance of trainees and specialists in the operating theatre.

Training in mitral valve surgery need not affect early outcomes and midterm survival: a multicentre analysis

OBJECTIVE

Mitral valve surgery may be regarded as less favourable for training, due to greater mortality risk, technical complexity, and difficulty for the supervisor to observe. We examined this perception by reviewing a multicentre experience.

METHODS

We analysed a multicentre database over a 7-year period containing 2216 isolated and combined mitral procedures. Of these, 2048 were performed by consultants and 168 by trainees (92% vs 8%) of varying seniority. Preoperative characteristics, early postoperative outcomes and 6-year survival were compared between groups. Propensity-score matching was performed to correct for group differences.

RESULTS

Trainees were less likely to operate on patients, who had previously undergone coronary surgery (consultant 4.3% vs trainee 1.2%, p=0.043) and those with moderate to severe mitral regurgitation (86% vs 81%, p=0.012). There were no other statistically significant differences in preoperative variables, such as urgency, endocarditis and left-ventricular dysfunction. There were similar rates of mitral valve repair (48% vs 51%, p=0.48). Trainees were more likely to operate on rheumatic valve pathology (20% vs 28%, p=0.012). Intra-operatively, trainees had longer aortic cross-clamp times (119 ± 52 vs 136 ± 50 min, p=0.0001). At 30 days, mortality was comparable (4.5% vs 3.6%, p=0.56) with a trend towards higher any mortality/morbidity in consultant procedures (33% vs 26%, p=0.059). At 6 years, survival was similar (79 ± 1.4% vs 78 ± 4.0%, p=0.73). After derivation of 142 propensity-score-matched patient pairs, trainees cases still experienced longer cross-clamp times (121 ± 58 vs 137 ± 52 min, p=0.023), but there was similar 30-day mortality (4.2% vs 3.5%, p>0.99) and any mortality/morbidity (28% vs 24%, p=0.52). Six-year survival between matched pairs was also similar (74 ± 7.2% vs 80 ± 4.4%, p=0.64). Trainee status did not predict early or late adverse events after multivariate Cox regression with and without propensity-score adjustment.

CONCLUSIONS

Trainee outcomes are not inferior even when corrected for risk. This suggests that excellent operative training and supervision can be achieved in mitral valve surgery.