Gifford Edward D, Nguyen Virginia T, Kim Jerry J, Schwartz Samuel I, Chisum Patrick, Kaji Amy H, Kim Dennis Y, de Virgilio Christian
Department of Surgery, Harbor-UCLA Medical Center, Torrance, California.
Harbor-UCLA Medical Center, Torrance, California.
J Surg Educ. 2015 Jul-Aug;72(4):761-6. doi: 10.1016/j.jsurg.2015.02.001. Epub 2015 Apr 18.
An arteriovenous fistula (AVF), performed for hemodialysis access, provides one of the few remaining opportunities for general surgery residents to perform an open vascular anastomosis (VA). Limited data exist regarding the learning curve of residents performing this procedure. The objective of this study was to determine how residents improve in performance of VA by implementing real-time tracking of anastomosis time as well as technical errors.
From April 2012 to January 2014, we conducted a prospective intraoperative assessment of 9 postgraduate year 3 general surgery residents during the performance of AVFs using a checklist of common errors in VA. Time for AVF anastomosis completion and number and types of technical errors during anastomosis were recorded. Primary end points were the change in anastomosis time and change in technical errors over time.
A total of 86 AVFs were performed and assessed intraoperatively. Each resident performed a median of 10 AVFs (interquartile range [IQR]: 7-11). The mean anastomosis time was 18.1 minutes. The mean number of technical errors was 13.8 per case. Overall, for every additional AVF performed, mean anastomosis time decreased by 0.63 minutes (95% CI: 0.45-0.81, p < 0.0001) and the mean number of technical errors decreased by 1.0 (95% CI: 0.7-1.3, p < 0.0001). The greatest improvement in overall errors (mean difference = 7.9, p = 0.03) and time (mean difference = 4.7min, p = 0.03) occurred after the performance of 3 AVFs. However, when analyzed by individual resident, the R(2) value for anastomotic time by number of AVFs performed ranged from 0.01 to 0.69. Similarly, for technical errors, the R(2) value by number of AVFs performed ranged from 0.04 to 0.62.
In novice surgical residents performing AVFs, improvement in VA skill can readily be tracked via anastomosis time and technical errors. Collectively, there is a strong association between number of cases performed and reduction in time and errors. However, individually, the number of cases completed did not correlate well with time and errors. These findings suggest that for VA skills, determining progression from novice to competence cannot rely on case volume but rather needs to be individualized.
为进行血液透析通路而建立的动静脉内瘘（AVF），为普通外科住院医师提供了为数不多的进行开放性血管吻合术（VA）的机会之一。关于住院医师进行该手术的学习曲线的数据有限。本研究的目的是通过实时跟踪吻合时间以及技术错误，来确定住院医师在VA操作中的表现是如何提高的。
从2012年4月至2014年1月，我们使用VA常见错误清单，对9名三年级普通外科住院医师在进行AVF手术时进行了前瞻性术中评估。记录AVF吻合完成时间以及吻合过程中的技术错误数量和类型。主要终点是吻合时间的变化以及技术错误随时间的变化。
共进行了86例AVF手术并在术中进行了评估。每位住院医师平均进行了10例AVF手术（四分位间距[IQR]：7 - 11）。平均吻合时间为18.1分钟。每例手术的平均技术错误数量为13.8个。总体而言，每多进行一例AVF手术，平均吻合时间减少0.63分钟（95%置信区间：0.45 - 0.81，p < 0.0001），平均技术错误数量减少1.0个（95%置信区间：0.7 - 1.3，p < 0.0001）。在进行3例AVF手术后，总体错误（平均差异 = 7.9，p = 0.03）和时间（平均差异 = 4.7分钟，p = 0.03）有最大改善。然而，按个体住院医师分析时，吻合时间与所进行的AVF手术数量的R(2)值范围为0.01至0.69。同样，对于技术错误，所进行的AVF手术数量的R(2)值范围为0.04至0.62。
在进行AVF手术的新手外科住院医师中，可通过吻合时间和技术错误轻松跟踪VA技能的提高。总体而言，手术例数与时间和错误减少之间存在很强的关联。然而，个体而言，完成的病例数与时间和错误之间的相关性不佳。这些发现表明，对于VA技能，确定从新手到熟练的进展不能仅依赖病例数量，而需要个体化。
