Ross Samuel W, Oommen Bindhu, Kim Mimi, Walters Amanda L, Green John M, Heniford B Todd, Augenstein Vedra A
Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA,
Surg Endosc. 2014 Nov;28(11):3092-100. doi: 10.1007/s00464-014-3586-7. Epub 2014 Jun 6.
The purpose of this study was to analyze the effect of residents on patient outcomes in laparoscopic ventral hernia repair (LVHR).We hypothesized that increasing postgraduate year (PGY) level would correlate with better outcomes.
The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2011 for elective LVHR. Attending only cases were used as the control, and resident cases were stratified into junior (PGY 1-3), chief (4-5), and fellow (6+) cases. Standard statistical tests and multivariate regression controlling for age, body mass index, Charlson comorbidity index, smoking, functional status, and inpatient cases were performed for trainee involvement and PGY level.
There were 6,841 ventral hernia repairs that met inclusion criteria: 2,773 attending and 4,068 resident cases. There were 1,644 junior, 1,983 chief, and 441 fellow cases. Patients were similar between the attending and resident groups. The resident group had a higher rate of inpatient cases, general complications, longer operative time, and hospital length of stay. After controlling for confounders in multivariate analysis, only operative time was significantly different; resident cases were 17.7 min longer (CI 15.0-20.6; p < 0.001). There was no significant difference in the rate of wound or major complications, readmission, reoperation, or mortality between attending and resident cases. Demographics were not significantly different between the PGY level strata. On multivariate regression by PGY level with attending alone as the reference, only operative time was significantly different. Juniors (15.7 min, CI 12.2-19.2), chiefs (18.0 min, CI 14.7-21.3), and fellows (24.9 min, CI 19.1-30.7) had significantly longer cases than attending alone; all p < 0.001.
Trainee involvement during LVHR does not change the clinical outcomes for patients as compared to those performed by an attending only. Operative time is significantly longer with increasing PGY level, perhaps indicating the complexity of the operation or increasing trainee involvement as primary surgeon. However, patient care does not suffer, affirming the current surgical training curriculum is appropriate.
本研究旨在分析住院医师参与腹腔镜腹疝修补术（LVHR）对患者预后的影响。我们假设随着研究生年级（PGY）水平的提高，预后会更好。
查询2005年至2011年美国外科医师学会国家外科质量改进计划数据库中的择期LVHR病例。仅将主治医生主刀的病例作为对照，住院医师主刀的病例分为初级（PGY 1 - 3）、上级（4 - 5）和专科住院医师（6级及以上）主刀的病例。针对住院医师参与情况和PGY水平进行标准统计检验以及多因素回归分析，控制年龄、体重指数、查尔森合并症指数、吸烟、功能状态和住院病例等因素。
有6841例腹疝修补术符合纳入标准：2773例主治医生主刀病例和4068例住院医师主刀病例。其中初级住院医师主刀病例1644例，上级住院医师主刀病例1983例，专科住院医师主刀病例441例。主治医生组和住院医师组的患者情况相似。住院医师组的住院病例比例、总体并发症发生率、手术时间更长以及住院时间更长。在多因素分析中控制混杂因素后，仅手术时间存在显著差异；住院医师主刀的病例手术时间长17.7分钟（可信区间15.0 - 20.6；p < 0.001）。主治医生主刀病例和住院医师主刀病例在伤口或严重并发症发生率、再入院率、再次手术率或死亡率方面无显著差异。不同PGY水平分层之间的人口统计学特征无显著差异。以仅主治医生主刀作为对照，按PGY水平进行多因素回归分析，仅手术时间存在显著差异。初级住院医师（15.7分钟，可信区间12.2 - 19.2）、上级住院医师（18.0分钟，可信区间14.7 - 21.3）和专科住院医师（24.9分钟，可信区间19.1 - 30.7）主刀的病例手术时间显著长于仅主治医生主刀的病例；所有p < 0.001。
与仅由主治医生进行的手术相比，住院医师参与LVHR手术并未改变患者的临床预后。随着PGY水平的提高，手术时间显著延长，这可能表明手术的复杂性增加或住院医师作为主刀医生的参与度增加。然而，患者护理并未受影响，这肯定了当前的外科培训课程是合适的。
