Outcomes associated with resident involvement in laparoscopic colorectal surgery suggest a need for earlier and more intensive resident training

Retrospective analysis of surgical and oncological results of laparoscopic surgeries performed by residents of coloproctology

INTRODUCTION

with the improvement and wide acceptance of laparoscopy in colorectal operations, there was a need for specific training of surgeons in training. There are few studies evaluating the postoperative results of laparoscopic colectomies performed by resident physicians and their impact on patient safety.

PURPOSE

to analyze the surgical and oncological results of laparoscopic colectomies performed by coloproctology residents and compare them with data in the literature.

METHODS

this is a retrospective analysis of patients undergoing laparoscopic colorectal surgery performed by resident physicians at the Hospital das Clínicas de Ribeirão Preto, between 2014 and 2018. The clinical characteristics of the patients were studied, as well as the main surgical and oncological aspects in a period of one year.

RESULTS

we analyzed 191 operations, whose main surgical indication was adenocarcinoma, most of them stage III. The mean duration of surgeries was 210±58 minutes. There was a need for a stoma in 21.5% of the patients, mainly loop colostomy. The conversion rate was 23%, with 79.5% due to technical difficulties, and the main predictors of conversion were obesity and intraoperative accidents. The median length of stay was 6 days. Preoperative anemia was associated with a higher rate of complications (11.5%) and reoperations (12%). Surgical resection margins were compromised in 8.6% of cases. The one-year recurrence rate was 3.2% and the mortality rate was 6.3%.

CONCLUSIONS

videolaparoscopic colorectal surgery performed by residents showed efficacy and safety similar to data found in the literature.

Association of Resident Independence With Short-term Clinical Outcome in Core General Surgery Procedures

Importance

Prior studies evaluating the effect of resident independence on operative outcome draw from case mixes that cross disciplines and overrepresent cases with low complexity. The association between resident independence and clinical outcome in core general surgical procedures is not well defined.

Objective

To evaluate the level of autonomy provided to residents during their training, trends in resident independence over time, and the association between resident independence in the operating room and clinical outcome.

Design, Setting, and Participants

Using the Veterans Affairs Surgical Quality Improvement Program database from 2005 to 2021, outcomes in resident autonomy were compared using multivariable logistic regression and propensity score matching. Data on patients undergoing appendectomy, cholecystectomy, partial colectomy, inguinal hernia, and small-bowel resection in a procedure with a resident physician involved were included.

Exposures

Resident independence was graded as the attending surgeon scrubbed into the operation (AS) or the attending surgeon did not scrub (ANS).

Main Outcomes and Measures

Outcomes of interest included rates of postoperative complication, severity of complications, and death.

Results

Of 109 707 patients who met inclusion criteria, 11 181 (10%) underwent operations completed with ANS (mean [SD] age of patients, 61 [14] years; 10 527 [94%] male) and 98 526 (90%) operations completed with AS (mean [SD] age of patients, 63 [13] years; 93 081 [94%] male). Appendectomy (1112 [17%]), cholecystectomy (3185 [11%]), and inguinal hernia (5412 [13%]) were more often performed with ANS than small-bowel resection (527 [6%]) and colectomy (945 [4%]). On multivariable logistic regression adjusting for procedure type, age, body mass index, functional status, comorbidities, American Society of Anesthesiologists class, wound class, case priority, admission status, facility type, and year, factors associated with a complication included increasing age (adjusted odds ratio [aOR], 1.19 [95% CI, 1.16-1.22]), emergent case priority (aOR, 1.41 [95% CI, 1.33-1.50]), and resident independence (aOR, 1.12 [95% CI, 1.03-1.22]). On propensity score matching, AS cases were score matched 1:1 to ANS cases based on the variables listed above. Comparing matched cohorts, there was no difference in complication rates (817 [7%] vs 784 [7%]) or death (91 [1%] vs 102 [1%]) based on attending physician involvement.

Conclusions and Relevance

Core general surgery cases performed by senior-level trainees in such a way that the attending physician is not scrubbed into the case are being done safely with no significant difference in rates of postoperative complication.

Impact of surgeon and hospital factors on length of stay after colorectal surgery systematic review

Background

Although length of stay (LOS) after colorectal surgery (CRS) is associated with worse patient and system level outcomes, the impact of surgeon and hospital-level factors on LOS after CRS has not been well investigated. The aim of this study was to synthesize the evidence for the impact of surgeon and hospital-level factors on LOS after CRS.

Methods

A comprehensive database search was conducted using terms related to LOS and CRS. Studies were included if they reported the effect of surgeon or hospital factors on LOS after elective CRS. The evidence for the effect of each surgeon and hospital factor on LOS was synthesized using vote counting by direction of effect, taking risk of bias into consideration.

Results

A total of 13 946 unique titles and abstracts were screened, and 69 studies met the inclusion criteria. All studies were retrospective and assessed a total of eight factors. Surgeon factors such as increasing surgeon volume, colorectal surgical specialty, and progression along a learning curve were significantly associated with decreased LOS (effect seen in 87.5 per cent, 100 per cent, and 93.3 per cent of studies respectively). In contrast, hospital factors such as hospital volume and teaching hospital status were not significantly associated with LOS.

Conclusion

Provider-related factors were found to be significantly associated with LOS after elective CRS. In particular, surgeon-related factors related to experience specifically impacted LOS, whereas hospital-related factors did not. Understanding the mechanisms underlying these relationships may allow for tailoring of interventions to reduce LOS.

Role of Digital Resources in Minimally Invasive Colorectal Surgery Training

Laparoscopic techniques have become the standard for many benign and malignant colorectal pathologies. Recently, the application of robotic-assisted technologies has been, and continues to be, explored. These new technologies require different skill sets and bring novel training challenges, and today's trainees must demonstrate competence in more techniques than ever. Compounding this is the reducing time spent operating in current training programs due to caps on working hours and service pressures. The need for adjunctive training strategies outside the operating room has prompted development of multimedia and digital resources to build the cognitive skills crucial in both nontechnical and technical aspects of surgery. Many are based on principles of cognitive task analysis, breaking down operations, and key decisions into nodal points to be mentally rehearsed. Resources built on this technique have shown improvements in both operative and nonoperative skills, suggesting these resources can advance trainees along the learning curve in minimally invasive surgical techniques. More work to fully elucidate the clinical benefits of such resources is required before their role as a substitute for lost operative training hours can be established. Despite this, alongside other developing technologies such as simulation, they are a promising addition to the armamentarium of the modern-day colorectal trainee.

Adoption rates of laparoscopic techniques for colorectal resections among Brazilian surgeons: limiting factors affecting incorporation into daily practice

Routine adoption of laparoscopy in clinical practice and Medical Residency has not been widely evaluated in Brazil so far.

Aim To take an overview on the adoption and limitations concerning the use of laparoscopic techniques among Brazilian colorectal surgeons.

Methods A questionnaire was sent to 1870 SBCP filiated members, containing personal and professional data such as sex, age, length and local of practice, SBCP filliation, number of procedures, treatment of cancer and laparoscopy limitations.

Results 418 members (22.4%) sent their response (80% men and 20% women). 110 members (26.3%) affirmed they don’t perform any laparoscopic procedure, while 308 (73.7%) have already adopted laparoscopy as a routine. An average number of 7.6 laparoscopic colorectal procedures were declared to be performed per month (1 to 40 procedures). Laparoscopic adoption rates were favourably influenced by young age members (46% vs. 28%) and affiliation to University hospitals (p = 0.01). Conversely, surgeons from private clinic showed a greater tendency of no adoption. Among the 308 responders, 106 (34.4%) have already surpassed more than 100 laparoscopic cases, and 167 (54.2%) reported an experience of more than 50 operated patients. The group of surgeons not using minimally invasive techniques incriminated lack of training (73.6%) and laparoscopic instruments availability (27.3%) as the main reasons for no adoption.

Conclusions Adoption rate of laparoscopic techniques to treat colorectal diseases is still low (at least 17%). Future efforts should focus on providing supervised training, proctorship during the initial experience and help instrumental acquisition in centers willing to change their routine and perspectives.

Laparoscopic appendectomy as an index procedure for surgical trainees: clinical outcomes and learning curve

Surgical training is essential to maintain safety standards in healthcare. The aim of this study is to evaluate learning curves and short-term postoperative outcomes of laparoscopic appendectomy (LA) performed by trainees (TRN) and attendings (ATT). The present study included the medical records of patients with acute appendicitis who underwent a fully LA in our department between January 2013 and December 2018. Cases were divided into trainees (TRN and ATT groups based on the experience of the operating surgeon. The primary outcome measures were 30-day morbidity and mortality. Preoperative patients' clinical characteristics, intraoperative findings, operative times, and postoperative hospitalization were compared. Operative times were used to extrapolate learning curves and evaluate the effects of changes in faculty using CUSUM charts. A propensity score matching analysis was performed to reduce differences between cohorts regarding both preoperative characteristics and intraoperative findings. A total of 1173 patients undergoing LA for acute appendicitis were included, of whom 521 (45%) in the TRN group and 652 (55%) in the ATT group. No significant differences were found between the two groups in terms of complication rates, operative times and length of hospital stay. However, CUSUM chart analysis showed decreased operating times in the TRN group. Operative times improved more quickly for advanced cases. The results of this study indicate that LA can be performed by trainees without detrimental effects on clinical outcomes, procedural safety, and operative times. However, the learning curve is longer than previously acknowledged.

Impact of resident involvement on cervical and lumbar spine surgery outcomes

BACKGROUND CONTEXT

Resident involvement in the operating room is a vital component of their medical education. Conflicting and limited research exists regarding the effects of surgical resident participation on spine surgery patient outcomes.

PURPOSE

To determine the effect of resident involvement on surgery duration, length of hospital stay and 30-day postoperative complication rates in common spinal surgery using the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database.

STUDY DESIGN

Multicenter retrospective cohort study.

PATIENT SAMPLE

A total of 1,441 patients met the inclusion criteria: 1,142 patients had surgeries with an attending physician alone and 299 patients had surgeries with trainee involvement. All anterior cervical or posterior lumbar surgery patients were identified. Patients who had missing trainee involvement information, surgery for cancer, preoperative infection or dirty wound classification, spine fractures, traumatic spinal cord injury, intradural surgery, thoracic surgery, and emergency surgery were excluded.

OUTCOME MEASURES

The main outcomes of interest analyzed from the ACS-NSQIP database included surgical complications, medical complications, length of hospital stay, and surgery duration.

METHODS

Propensity score for risk of any complication was calculated to account for baseline characteristic differences between the attending alone and trainee present group. Multivariate logistic regression was used to investigate the impact of resident involvement on surgery duration, length of hospital stay, and 30-day postoperative complication rates.

RESULTS

After adjusting using the calculated propensity score, the multivariate analysis demonstrated that there was no significant difference in any complication rates between surgeries involving trainees compared to surgeries with attending surgeons alone. Surgery times were found to be significantly longer for surgeries involving trainees. To further explore this relationship, separate analyses were performed for tertiles of predicted surgery duration, cervical or lumbar surgery, fusion or nonfusion, and inpatient or outpatient surgery. The effect of trainee involvement on increasing surgery time remained significant for medium predicted surgery duration, longer predicted surgery duration, cervical surgery, lumbar surgery, fusion surgery, and inpatient surgery. There were no significant differences reported for any other factors.

CONCLUSIONS

After adjusting for confounding, we demonstrated in a national database that resident involvement in surgeries did not increase complication rates. We demonstrated that surgeries with more complex features may lead to an increase in operative time when trainees are involved. Further study is required to determine how to efficiently integrate resident involvement in surgeries without affecting their medical education.

Training in endocrine surgery

BACKGROUND/PURPOSE

In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe.

METHODS

A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate.

RESULTS

For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs.

CONCLUSIONS

Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.

Resident involvement in minimally-invasive vs. open procedures

BACKGROUND

The objective of this study was to evaluate the impact of resident involvement on surgical outcomes in laparoscopic compared to open procedures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program 2007-2012 was queried for open and laparoscopic ventral hernia repair (VHR), inguinal hernia repair (IHR), splenectomy, colectomy, or cholecystectomy (CCY). Multivariable regression analyses were performed to assess the impact of resident involvement on surgical outcomes.

RESULTS

In total, 88,337 VHR, 20,586 IHR, 59,254 colectomies, 3301 splenectomies, and 95,900 CCY were identified. Resident involvement was predictive for major complication during open VHR (AOR, 1.29; p < 0.001), but not during any other procedure. Resident participation significantly prolonged operative time for open, as well as laparoscopic VHR, IHR, colectomy, splenectomy, and CCY (all p < 0.01).

CONCLUSIONS

The results of this study suggest that resident participation has a similar impact on surgical outcomes during laparoscopic and open surgery, and is generally safe.

Does Perceived Resident Operative Autonomy Impact Patient Outcomes?

OBJECTIVE

We investigated the association of perceived trainee autonomy with patient clinical outcomes following colorectal surgery.

DESIGN

This was a prospective multi-institutional study that consisted of surgery trainees completing a survey tool immediately after participating in colorectal resections to rate their self-perceived autonomy and case characteristics. Self-perception of autonomy was classified as observer, assistant, surgeon, or teacher. The completed trainee surveys were linked with patient information available through each hospital's internal NSQIP directory. The primary outcome was death and serious morbidity (DSM) and secondary outcome was 30-day readmissions. Separate mixed effects regression models were used to examine the association between perceived trainee autonomy and DSM or 30-day readmissions. Fixed effects were used to control for the effects of the training environment. The models were constructed to adjust for patient and trainee characteristics associated with each outcome independently.

SETTING

This study was conducted at 7 general surgery training programs (5 academic medical centers and 2 independent training programs) with general surgery or colorectal surgery services.

PARTICIPANTS

This study included a total of 63 residents and fellows rotating on surgery services that performed colorectal resections at the included 7 general surgery training programs from January until March 2016.

RESULTS

The 63 trainees that participated in this study completed 417 surveys with over a 95% response rate. National Surgical Quality Improvement Program (NSQIP) patient records were available for 67% (n = 273) of completed surveys. The clinical year of the trainees were 6.1% PGY 1/2, 36% Post graduate year (PGY) 3, 40.9% PGY 4/5, and 17% fellows. Residents perceived their participation in the case to be that of an observer in 9.2% of surveys, an assistant in 51.6% of surveys, and the surgeon/teacher in 39.3% of surveys. About 50% of patients were male, 80% were White, the majority had an American Society of Anesthesiologists classification of 3, almost half had prior abdominal surgery, and over 80% of surgeries were elective. The primary operation types performed were laparoscopic (40.3%) and open (35.9%) partial colectomies. The rate of DSM in patients was approximately 24% when trainees perceived their role as observers, 23% when trainees perceived their role as assistants, and 18% when trainees perceived their role as surgeons/teachers. After adjustment for patient, trainee, and training environment, we found that the perceived level of trainee autonomy of a surgeon/teacher was associated with a 4-fold lower rate of DSM (odds ratio: 0.23, confidence of interval: 0.05-0.97, p = 0.045) compared to observers. The rate of readmissions was approximately 20% when trainees perceived their role as observers, 14% when trainees perceived their role as assistants and 9% when trainees perceived their role as surgeons/teachers. After adjustment for patient, trainee, and training environment, we found that the perceived level of trainee autonomy of a surgeon/teacher was significantly associated with a 10-fold lower rate of 30-day readmissions (odds ratio: 0.09, confidence of interval: 0.01-0.70, p = 0.022) compared to observers.

CONCLUSIONS

There was an association between increased perceived trainee autonomy and improved patient outcomes, suggesting that when trainees identify with an increased role in the operation, patients may have improved care. Further research is needed to understand this association further.

Development of a Whole-Task Simulator for Carotid Endarterectomy

BACKGROUND

Surgical education relies on operative exposure with live patients. Carotid endarterectomy (CEA) demands an experienced surgeon with a very low complication rate. The high-risk nature of this procedure and the decline in number of CEAs performed annually has created a gap in residency training.

OBJECTIVE

To develop a high-fidelity whole-task simulation for CEA that demonstrates content, construct, and face validity.

METHODS

Anatomically accurate models of the human neck were created using multilayered poly-vinyl alcohol hydrogels. Graded polymerization of the hydrogel was achieved by inducing crosslinks during freeze/thaw cycles, stiffening the simulated tissues to achieve realistic tactile properties. Venous bleeding was simulated using pressure bags and a ventricular assistive device created pulsatile flow in the carotid. Ten surgeons performed the simulation under operating room conditions, and metrics were compared among experience levels to determine construct validity. Participants completed surveys about realism and usefulness to evaluate face validity.

RESULTS

A significant difference was found in operative measures between attending and resident physicians. The mean operative time for the expert group was 63.6 min vs 138.8 for the resident group (P = .002). There was a difference in mean internal carotid artery clamp time of 43.4 vs 83.2 min (P = .04). There were only 2 hypoglossal nerve injuries, both in the resident group (P = .009).

CONCLUSION

The whole-task CEA simulator is a realistic, inexpensive model that offers comprehensive training and allows residents to master skills prior to operating on live patients. Overall, the model demonstrated face and construct validity among neurosurgery and vascular surgeons.

Put Me in the Game Coach! Resident Participation in High-risk Surgery in the Era of Big Data

BACKGROUND

With the emphasis on quality metrics guiding reimbursement, concerns have emerged regarding resident participation in patient care. This study aimed to evaluate whether resident participation in high-risk elective general surgery procedures is safe.

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program database (2005-2012) was used to identify patients undergoing one of five high-risk general surgery procedures. Resident and nonresident groups were created using a 2:1 propensity score match. Postoperative outcomes were calculated using univariate statistics and multivariable logistic regression for the two groups. Predictors of mortality and morbidity were identified using machine learning in the form of decision trees.

RESULTS

Twenty-five thousand three hundred sixty three patients met our inclusion criteria. Following matching, each group contained 500 patients and was comparable for matched characteristics. Thirty-day mortality was similar between the groups (2.4% versus 2.6%; P = 0.839). Deep surgical site infection (0% versus 1.6%; P = 0.005), urinary tract infection (5% versus 2.5%; P = 0.029), and operative time (275.6 min versus 250 min; P = 0.0064) were significantly higher with resident participation. Resident participation was not predictive of mortality or complications, while age, American society of anesthesiologists class, and functional status were leading predictors of both.

CONCLUSIONS

Despite growing time constraints and pressure to perform, surgical resident participation remains safe. Residents should be given active roles in the operating room, even in the most challenging cases.

Orthopaedic Surgery Residency Training: Consideration for a Surgical and Procedural Skills Competency

This perspectives report discusses the need to create a surgical and procedural skills competency for orthopedic surgery residency training programs.

Increased Postoperative Morbidity Associated With Prolonged Laparoscopic Colorectal Resections Is Not Increased by Resident Involvement

BACKGROUND

Although longer operative times are associated with increased postoperative morbidity, the influence of surgical residents on this association is unclear.

OBJECTIVE

The purpose of this study was to evaluate whether morbidity associated with operative times in laparoscopic colorectal surgery is increased by resident training.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted using a national database.

PATIENTS

Laparoscopic ileocolectomies, partial colectomies, and low anterior resections were identified in the National Surgical Quality Improvement Project (2005-2012). This cohort was stratified by the presence of resident involvement (postgraduate clinical year ≤5) and then divided into tertiles of operative time (low, medium, and high), allowing comparisons of cases by duration with resident involvement with cases of similar length without resident involvement.

MAIN OUTCOME MEASURES

Postoperative morbidity (infectious and noninfectious), length of hospital stay, and unplanned reoperations were the primary study outcomes.

RESULTS

A total of 20,785 procedures were identified. In aggregate, prolonged operative time was associated with both infectious (OR = 1.49, p < 0.001 with residents; OR = 1.38, p < 0.001 without residents) and noninfectious complications (OR = 1.51, p < 0.001 with residents; OR = 1.48, p < 0.001 without residents) when compared with short cases without residents. Longer hospital stay was observed both within the highest (additional 1.2 days (p < 0.001) with residents; 1.1 days (p < 0.001) without residents) and middle (additional 0.4 days (p < 0.001) with residents; 0.4 days (p = 0.001) without residents) tertiles of operative time. Within the highest tertile of operative length, there was no statistically significant difference in complication rates between cases with and without resident participation.

LIMITATIONS

The study was limited by its retrospective design and inability to define the complexity of case and extent of resident involvement.

CONCLUSIONS

Although longer operative times confer increased postoperative morbidity, there was no significant difference in complication rates within the highest tertile between cases with and without resident participation. Resident involvement does not appear to add to the risk of morbidity associated with longer and more complicated surgeries. See Video Abstract at http://links.lww.com/DCR/A440.

What to consider when designing a laparoscopic colorectal training curriculum: a review of the literature

Multiple studies have demonstrated the benefits of laparoscopic colorectal surgery (LCS), but in several countries it has still not been widely adopted. LCS training is associated with several challenges, such as patient safety concerns and a steep learning curve. Current evidence may facilitate designing of efficient training curricula to overcome these challenges. Basic training with virtual reality simulators has witnessed meteoric advances and may be essential during the early parts of the learning curve. Cadaveric and animal model training still constitutes an indispensable training tool, due to a higher degree of difficulty and greater resemblance to real operative conditions. In addition, recent evidence favors the use of novel training paradigms, such as proficiency-based training, case selection and modular training. This review summarizes the recent advances in LCS training and provides the evidence for designing an efficient training curriculum to overcome the challenges of LCS training.

Laparoscopic Colorectal Training Gap in Colorectal and Surgical Residents

BACKGROUND AND OBJECTIVES

Laparoscopic colorectal surgery is an established safe procedure with demonstrated benefits. Proficiency in this specialty correlates with the volume of cases. We examined training in this surgical field for both general surgery and colon and rectal surgery residents to determine whether the number of cases needed for proficiency is being realized.

METHODS

We examined the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Colorectal Surgeons (ABCRS) operative statistics for graduating general surgery and colon and rectal surgery residents.

RESULTS

Although the number of advanced laparoscopy cases had increased for general surgery residents, there was still a significant gap in case volume between the average number of laparoscopic colorectal operations performed by graduating general surgery residents (21.6) and those performed by graduating colon and rectal surgery residents (81.9) in 2014.

CONCLUSION

There is a gap between general surgery and colon and rectal surgery residency training for laparoscopic colorectal surgery. General surgery residents are not meeting the volume of cases necessary for proficiency in colorectal surgery. This deficit represents a structural difference in training.

Impact of Resident Participation on Outcomes After Single-Level Anterior Cervical Diskectomy and Fusion: An Analysis of 3265 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database

STUDY DESIGN

Multicenter retrospective cohort study.

OBJECTIVE

To investigate the relationship between resident involvement in the operating room and 30-day complication rates in patients undergoing single-level anterior cervical diskectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Although an integral part of academic medicine, surgical resident participation in the operating room and its impact on patient outcomes have been a topic of debate. No large-scale study has been performed to examine this relationship in ACDF.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was retrospectively reviewed to identify all patients who underwent single-level ACDF procedures during 2006-2013. A propensity score-matching algorithm was employed to minimize baseline differences. Multivariate logistic regression analysis of unadjusted and propensity-matched cohorts was performed to examine the effect of resident participation on 30-day postoperative complication rates and length of hospital stay.

RESULTS

A total of 3265 patients met inclusion criteria. The propensity score-matching procedure yielded 1003 pairs of well-matched nonresident and resident pairs. The multivariate analysis of propensity score-matched population demonstrated that resident involvement was not associated with an increased risk for any of the complications analyzed, including overall complications, medical complications, surgical complications, mortality, cardiac arrest, deep venous thrombosis, or length of total hospital stay.

CONCLUSION

This large-scale, population-based study found that surgical resident participation in the operating room did not increase the risk of 30-day complications nor prolonged the length of hospital stay. Resident participation, however, was associated with an increased operative duration. Strategies to improve residents' technical proficiency outside of the operating room may enhance patient safety.

LEVEL OF EVIDENCE

3.

Resident participation in laparoscopic Roux-en-Y gastric bypass: a comparison of outcomes from the ACS-NSQIP database

BACKGROUND

As clinical outcome data are increasingly tied to hospital reimbursement, balancing quality care with training of surgical residents has become critical. We used the ACS-NSQIP database to determine impact of resident participation in laparoscopic gastric bypass on 30-day morbidity and mortality.

METHODS

We queried the ACS-NSQIP database from 1/2005 to 12/2012 for laparoscopic gastric bypass, dividing cases between those with or without resident involvement. Univariate and multivariate analyses of intraoperative and postoperative outcomes were assessed. A sub-analysis was performed to address whether different resident training levels affected outcomes.

RESULTS

A total of 43,477 laparoscopic gastric bypass cases were available for analysis; 22,189 had resident involvement (resident = R), and 21,288 did not (no resident = NR). Preoperative characteristics were similar between groups. On multivariate analysis, procedures with resident assistance had increased risk of the following complications: superficial site infection (R = 2.1 vs. 1.5 %, p < 0.001), renal failure (R = 0.4 vs. NR = 0.3 %, p = 0.002), urinary tract infection (R = 1.1 vs. 0.9 %, p = 0.027), and sepsis (R = 0.8 vs. NR = 0.6 %, p = 0.019). Increased operative time in the resident group (29 min, p < 0.0001) demonstrated direct linear association with resident trainee level. There was no statistical difference in the incidences of the following: pulmonary embolism, deep venous thrombosis, deep surgical site infection, organ space infection, pneumonia, unplanned intubation, mechanical ventilation >48 h, septic shock, cardiac arrest, return to the operating room, or mortality.

CONCLUSION

Resident participation in laparoscopic gastric bypass was associated with statistically significant, but clinically insignificant increase in incidence of superficial site infection, renal failure, readmission rate, and length of stay. Therefore, although resident participation in laparoscopic gastric bypass is associated with significantly increased operative time, it does not lead to increased mortality and has no clinically significant effect on morbidity.

Increase in Cesarean Operative Time Following Institution of the 80-Hour Workweek

BACKGROUND

In 2003, the Accreditation Council for Graduate Medical Education limited resident duty hours to 80 hours per week. More than a decade later, the effect of the limits on resident clinical competence is not fully understood.

OBJECTIVE

We sought to assess the effect of duty hour restrictions on resident performance of an uncomplicated cesarean delivery.

METHODS

We reviewed unlabored primary cesarean deliveries at Duke University Hospital after 34 weeks gestation, between 2003 and 2011. Descriptive statistics and linear regression were used to compare total operative time with incision to delivery time as a function of years since institution of the 80-hour workweek. Resident training level, subject body mass index, estimated blood loss, and skin closure method were controlled for in the regression model.

RESULTS

We identified 444 deliveries that met study criteria. The mean (SD) total operative time in 2003-2004 was 43.3 (14.3) minutes and 59.6 (10.7) minutes in 2010-2011 (P < .001). Multivariable regression demonstrated an increase in total operative time of 1.9 min/y (P < .001) but no change in incision to delivery time (P = .05). The magnitude of increased operative time was seen among junior residents (2.0 min/y, P < .001) compared to that of senior residents (1.2 min/y, P = .06).

CONCLUSIONS

Since introduction of the 2003 duty hour limits, there has been an increase of nearly 20 minutes in the time required for a routine cesarean delivery. It is unclear if the findings are due to a change in residency duty hours or to another aspect of residency training.

Nationwide variation in outcomes and cost of laparoscopic procedures

INTRODUCTION

Healthcare systems and surgeons are under increasing pressure to provide high-quality care for the lowest possible cost . This study utilizes national data to examine the outcomes and costs of common laparoscopic procedures based on hospital type and location.

METHODS

The National Inpatient Sample was queried from 2008 to 2011 for five laparoscopic procedures: colectomy (LC), inguinal hernia repair, ventral hernia repair (LVHR), Nissen fundoplication (NF), and cholecystectomy (LCh). Outcomes, including complication rate and inpatient mortality, were stratified by region and hospital type. Both univariate and multivariate regression analyses were performed using regression-based survey methods; risk-adjusted mean costs for hospital were calculated after adjusting for patient characteristics.

RESULTS

In univariate analysis, the rates of minor complications varied significantly between geographic regions for LCh, LC, NF, and LVHR (p < 0.05). Though LCh and LVHR had statistical variation between regions for rates of major complications (p < 0.05), all regions were equivalent in rates of inpatient mortality for the procedures (p > 0.05). Rural and urban centers had similar rates of complications (p > 0.05), except for higher rates of major complications following IHR and LC in rural centers (p < 0.02) and following Nissen fundoplication in urban facilities(p < 0.0003). Though urban centers were more expensive for all procedures (p < 0.0001), mortality was similar between groups (p > 0.05). For hospital ownership, private investor-owned facilities were substantially more expensive (p < 0.0001), but had no significant differences in complications compared to other hospital types (p > 0.05). In multivariate analysis, while patient factors helped explain differences between outcome differences in different hospital types and locations, in general, the difference in cost remained statistically significant between hospitals.

CONCLUSION

Though patient demographics and characteristics accounted for some differences in postoperative outcomes after common laparoscopic procedures, higher cost of care was not associated with better outcomes or more complex patients.