培训住院医师进行主动脉根部手术的障碍有哪些？

Polanco Antonio, Breglio Andrew M, Itagaki Shinobu, Weiss Aaron, Stelzer Paul, Chikwe Joanna

Mount Sinai Medical Center, Department of Cardiothoracic Surgery, Fifth Avenue, New York 10029, USA.

J Heart Valve Dis. 2013 Nov;22(6):776-81.

BACKGROUND AND AIM OF THE STUDY

Aortic root surgery is a technically demanding procedure that is performed infrequently by most surgeons, with national mortality rates over 10%. The study aim was to identify the barriers to training residents in this operation.

METHODS

By using univariate and multivariate logistic regression analysis, all consecutive adults (n = 356) undergoing aortic root reconstruction at The Mount Sinai Medical Center between 2007 and 2011 were retrospectively compared according to whether a resident or faculty surgeon performed the procedure. Surveys were then conducted to determine reasons why residents did not perform cases, and to evaluate outcomes of aortic root surgery performed by recent graduates of the program.

RESULTS

Surgical techniques among patients included: root replacement (81%, n = 290) using homograft, composite bioprosthetic or mechanical valved conduits; Ross procedures (17%, n = 53); and other root surgery such as valve-sparing procedures (2%, n = 7). Residents performed 32% (n = 66/204) of cases when they were scrubbed. The incidence of mortality was lower for cases performed by residents (2%, n = 2) compared to faculty (4%, n = 12) (p=0.335), and no significant differences in cardiopulmonary bypass or cross-clamp times, early morbidity or late survival were observed. The most common reasons given why scrubbed residents did not perform cases were a mismatch between the skill of the resident and case complexity (46%, n = 94), followed by the faculty surgeon's preference (41%, n = 83). Recent program graduates had collectively performed 30 aortic root procedures independently as faculty surgeons, and with no mortality; however, most expressed a continued preference for more senior help on such cases.

CONCLUSION

Residents can safely perform aortic root surgery under appropriate supervision. The greatest challenge involved in improving resident training in aortic root surgery lies in routinely matching resident skills with case complexity and teaching expertise.

研究背景与目的

主动脉根部手术是一项技术要求很高的手术，大多数外科医生很少进行此类手术，全国死亡率超过10%。本研究旨在确定住院医师进行该手术培训的障碍。

方法

采用单因素和多因素逻辑回归分析，对2007年至2011年在西奈山医疗中心接受主动脉根部重建的所有连续成年患者（n = 356），根据手术由住院医师还是带教医生实施进行回顾性比较。随后进行调查，以确定住院医师不参与手术的原因，并评估该项目近期毕业生实施的主动脉根部手术的结果。

结果

患者的手术技术包括：使用同种异体移植物、复合生物假体或带机械瓣膜的管道进行根部置换（81%，n = 290）；罗斯手术（17%，n = 53）；以及其他根部手术，如保留瓣膜的手术（2%，n = 7）。住院医师参与刷手时完成了32%（n = 66/204）的病例。住院医师实施的病例死亡率（2%，n = 2）低于带教医生实施的病例（4%，n = 12）（p = 0.335），在体外循环或阻断时间、早期发病率或晚期生存率方面未观察到显著差异。刷手的住院医师不参与手术的最常见原因是住院医师的技能与病例复杂性不匹配（46%，n = 94），其次是带教医生的偏好（41%，n = 83）。该项目近期毕业生作为带教医生共独立完成了30例主动脉根部手术，且无死亡病例；然而，大多数人表示在此类病例中仍希望有更资深医生的帮助。