Almassi G Hossein, Carr Brendan M, Bishawi Muath, Shroyer A Laurie, Quin Jacquelyn A, Hattler Brack, Wagner Todd H, Collins Joseph F, Ravichandran Pasala, Cleveland Joseph C, Grover Frederick L, Bakaeen Faisal G
Department of Cardiothoracic Surgery, Medical College of Wisconsin and Veterans Affairs Medical Center, Milwaukee, Wis.
Department of Surgery, Northport Veterans Affairs Medical Center and Stony Brook School of Medicine, Stony Brook, NY.
J Thorac Cardiovasc Surg. 2015 Dec;150(6):1428-35, 1437.e1; discussion 1435-7. doi: 10.1016/j.jtcvs.2015.08.124. Epub 2015 Sep 18.
Controversy exists regarding ideal approaches in teaching residents complex and/or new surgical techniques in part because consequences on patient outcomes are largely unknown. This study compared patient outcomes for cases in which residents (rather than attending surgeons) performed most of the distal anastomoses as primary surgeons, during on- and off-pump coronary artery bypass grafting (CABG).
This preapproved substudy of the Randomized On/Off Bypass (ROOBY) trial compared clinical outcomes and 1-year graft patency for cases in which residents versus attending surgeons were the primary operator. Comparisons were made between on-pump and off-pump techniques.
From July 2003 through May 2007, a total of 1272 ROOBY nonemergent CABG patients were randomized at 16 Veterans Affairs centers where residents were active participants. Residents were the primary surgeon (ie, performed ≥50% of the distal anastomoses) more frequently in on-pump (77.9%) than in off-pump (67.4%) cases. Between these 2 techniques, no differences were found [corrected] in baseline patient characteristics; short-term and 1-year morbidity and mortality rates were no different for residents versus attendings in CABG cases. FitzGibbon A graft patency rates were similar for resident versus attendings completed distal anastomoses for on-pump (83.0% vs 82.4%) compared with off-pump (77.2% vs 76.6%) procedures.
In the ROOBY trial, short-term and 1-year patient outcomes and graft patency rates did not differ between resident and attending surgeons, demonstrating that with appropriate patient selection and resident supervision, residents can perform advanced, novel surgical techniques with outcomes similar to those of attending surgeons.
在向住院医师传授复杂和/或新的外科技术时，理想的教学方法存在争议，部分原因是其对患者预后的影响很大程度上尚不清楚。本研究比较了在非体外循环和体外循环冠状动脉旁路移植术（CABG）中，住院医师（而非主治外科医生）作为主要外科医生完成大部分远端吻合术的病例的患者预后。
这项预先批准的随机非体外循环/体外循环（ROOBY）试验的子研究比较了住院医师与主治外科医生作为主要操作者的病例的临床结局和1年移植血管通畅率。对体外循环和非体外循环技术进行了比较。
从2003年7月到2007年5月，共有1272例ROOBY非急诊CABG患者在16个退伍军人事务中心被随机分组，这些中心的住院医师是积极参与者。在体外循环病例中，住院医师作为主要外科医生（即完成≥50%的远端吻合术）的频率（77.9%）高于非体外循环病例（67.4%）。在这两种技术之间，[校正后]基线患者特征没有差异；CABG病例中住院医师与主治医生的短期和1年发病率及死亡率没有差异。与非体外循环手术（77.2%对76.6%）相比，体外循环手术中住院医师与主治医生完成远端吻合术的菲茨吉本A类移植血管通畅率相似（83.0%对82.4%）。
在ROOBY试验中，住院医师和主治外科医生的短期和1年患者结局及移植血管通畅率没有差异，表明通过适当的患者选择和住院医师监督，住院医师可以进行先进的、新颖的外科技术，其结局与主治外科医生相似。
