Journal of Aesthetic & Reconstructive Surgery

Description

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.

Intradural Surgery

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. 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.

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

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.

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. Experience in the operating room is a vital component of surgical resident medical education. In order for surgical resident teaching programs to be optimized while also promoting the highest level of patient care, it is crucial that physicians and health-care institutions accurately understand the impact of resident involvement in surgeries on patient outcomes.

Enhanced Recovery after Surgery

Kehlet and Wilmore introduced the concept of Fast-Track (FT) protocols and Enhanced Recovery After Surgery (ERAS) in 2001. ERAS are a multicentric program that includes the fields of nursing and anesthesia, nutrition and fluid management, and minimally invasive surgery. ERAS protocols focus on reducing the postoperative complications and stress response, generally optimizing the postoperative recovery. Thus, ERAS programs reduce the postoperative hospitalization time and morbidity.

ERAS protocols were first applied in hip and knee arthroplasty and gynecological and colorectal surgeries. These protocols have been implemented in many surgical fields, such as cardiac, gastric, and urologic, as they were shown to safely reduce morbidity2 and the cost of hospitalization and also improve patient satisfaction.3 The aim of this minireview was to investigate the impact of ERAS programs in patient's postoperative outcome after Hepato-Pancreato-Biliary (HPB) surgery.

After ERAS protocols were introduced in postoperative care, 2326 studies were conducted from 2001 to 2019. ERAS programs have been implemented in 422 studies in the past 2 years. A literature review of studies in the Medline/PubMed, Cochrane, Scopus, and Google Scholar databases was conducted from 2018 to 2019. The keywords used in the bibliography search were “fast track surgery,” “ERAS programs,” “fast track,” and “surgery.” The inclusion criteria were (a) studies that were directly related to the topic and (b) studies in English and Greek languages published in peer-reviewed journals. The search strategy was applied to 422 studies, 412 of which were excluded and 10 of which met the inclusion criteria.

Although a number of prior studies have assessed the effect of trainee involvement on surgery outcomes, only a few have investigated the effect of trainee involvement on spine surgery specifically. These studies are limited in design or scope and present conflicting results. Several studies have demonstrated that resident participation did not increase complications in plastic surgery, orthopedic surgery, urology, neurosurgery, and general surgery. However, there have been other studies that concluded resident involvement increased risk of postoperative complications, operation duration, and length of hospital stay.

Residents mainly participate in surgeries at academic institutions which generally have patients with more complex cases and greater disease burdens. A major limitation of the current body of research regarding the effect of resident involvement on surgical outcomes is that limited studies accounted for the complexity of the case or surgical diagnosis in their analysis. Disregarding the importance of these two factors may result in inaccurate findings, especially when analyzing surgeries involving residents. Additional research is required to understand the full effects of resident involvement on spine surgery patient outcomes. To further the knowledge in this area, we analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to evaluate the impact of resident participation during anterior cervical or posterior lumbar fusion surgery on surgery duration, length of hospital stay, and 30-day postoperative complication rates.