Department of Obstetrics and Gynecology, Temple University Hospital, Philadelphia, PA.
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Am J Obstet Gynecol. 2014 Nov;211(5):484.e1-7. doi: 10.1016/j.ajog.2014.06.024. Epub 2014 Jun 17.
The purpose of this study was to determine the impact of resident involvement on morbidity after total laparoscopic hysterectomy for benign disease.
We performed a retrospective review of a National Surgical Quality Improvement Program database of total laparoscopic hysterectomy for benign disease that was performed with resident involvement vs attending alone between Jan. 1, 2008, and Dec. 31, 2011. Surgical operative times and morbidity and mortality rates were compared. Binary logistic regression was used to control for covariates that were significant on univariate analysis (P < .05).
A total of 3441 patients were identified as having undergone a total laparoscopic hysterectomy for benign disease. The mean age of patients was 47.4 ± 11.1 years; the mean body mass index was 30.6 ± 7.9 kg/m(2). A resident participated in 1591 of cases (46.2%); 1850 of the procedures (53.8%) were done by an attending physician alone. Cases with resident involvement had higher mean age, Charlson morbidity scoring, and American Society of Anesthesiologists classification and were more likely to be inpatient cases. With resident involvement, the mean operative time was increased (179.29 vs 135.46 minutes; P < .0001). There were no differences in the rates of experiencing at least 1 complication (6.8% for resident involvement vs 5.4% for attending alone; P = .5), composite severe morbidity (1.3% resident vs 1.0% attending alone), or 30-day mortality rate (0% resident vs 0.1% attending alone). Additionally, there were no differences between groups in the infectious, wound, neurorenal, thromboembolic, septic, and cardiopulmonary complications. Cases with resident involvement had significantly increased rates of postoperative transfusion of packed red blood cells (2% vs 0.4%; P < .0001), reoperation (2.2% vs 1.3%; P = .048), and a 30-day readmission (5.5% vs 2.9%; P = .015). In models that were adjusted for factors that differed between the 2 groups, cases with resident involvement had increased odds of receiving postoperative blood transfusion (odds ratio [OR], 4.98; 95% confidence interval [CI], 2.18-11.33), reoperation (OR, 1.7, 95% CI, 1.01-2.89) and readmission (OR, 1.93, 95% CI, 1.09-3.42).
Resident involvement in total laparoscopic hysterectomy for benign disease was associated with clinically appreciable longer surgical time and small differences in the rates of postoperative transfusions, reoperation, and readmission. However, the rates of overall complications, severe complications, and 30-day mortality rate remain comparable.
本研究旨在确定住院医师参与对良性疾病全腹腔镜子宫切除术术后发病率的影响。
我们对国家外科质量改进计划数据库中 2008 年 1 月 1 日至 2011 年 12 月 31 日期间行全腹腔镜子宫切除术治疗良性疾病的病例进行了回顾性分析，这些病例中住院医师参与的比例与主治医师单独参与的比例进行了比较。比较了手术操作时间和发病率及死亡率。采用二元逻辑回归控制单变量分析中差异有统计学意义的协变量（P<.05）。
共确定 3441 例因良性疾病行全腹腔镜子宫切除术的患者。患者的平均年龄为 47.4±11.1 岁；平均体重指数为 30.6±7.9kg/m2。1591 例（46.2%）有住院医师参与；1850 例（53.8%）由主治医师单独完成。有住院医师参与的病例平均年龄较大，Charlson 合并症评分和美国麻醉医师协会分级较高，且更有可能为住院病例。有住院医师参与时，平均手术时间延长（179.29 分钟比 135.46 分钟；P<.0001）。至少发生 1 种并发症的发生率（住院医师参与组 6.8%，主治医师单独参与组 5.4%；P=0.5）、复合严重发病率（住院医师参与组 1.3%，主治医师单独参与组 1.0%）或 30 天死亡率（住院医师参与组 0%，主治医师单独参与组 0.1%）均无差异。此外，两组间感染、伤口、肾神经、血栓栓塞、脓毒症和心肺并发症发生率也无差异。有住院医师参与的病例术后输血（2%比 0.4%；P<.0001）、再次手术（2.2%比 1.3%；P=0.048）和 30 天内再入院（5.5%比 2.9%；P=0.015）的发生率显著增加。在调整两组间存在差异的因素的模型中，有住院医师参与的病例术后输血（比值比[OR]，4.98；95%置信区间[CI]，2.18-11.33）、再次手术（OR，1.7，95%CI，1.01-2.89）和再入院（OR，1.93，95%CI，1.09-3.42）的可能性增加。
住院医师参与良性疾病全腹腔镜子宫切除术与手术时间明显延长以及术后输血、再次手术和再入院率的微小差异相关。然而，总体并发症、严重并发症和 30 天死亡率的发生率仍相似。
