Sheyn David, Bretschneider C Emi, Canfield Dana, Duarte Mary, Mangel Jeffrey M, Mahajan Sangeeta T
From the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH.
Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH.
Female Pelvic Med Reconstr Surg. 2019 Sep-Oct;25(5):351-357. doi: 10.1097/SPV.0000000000000575.
Trainee involvement in surgical procedures has been associated with longer surgical times and increased rates of certain complications. There has been limited study of the impact trainee involvement has on outcomes in urogynecologic surgery. We sought to determine the impact of resident and fellow involvement in pelvic reconstructive surgeries on 30-day complication rates.
Using the American College of Surgeons National Surgical Quality Improvement Program database, patients who underwent pelvic floor surgery were identified between 2010 and 2015. Patients were stratified into 3 groups: no trainee, resident, or fellow involvement. The primary outcome was the composite complication rate. Three-group comparison was performed using Kruskal-Wallis analysis. If statistically significant, then pairwise analysis was performed between the reference group (attending alone) and experimental groups (resident or fellow). Additional pairwise analysis was performed between the fellow and resident groups. Logistic regression was used to identify factors associated with an increased risk of complications.
Seven thousand seven hundred fifty-two surgical cases met all criteria for inclusion; 2440 (31.4%) included residents, and 646 (8.3%) included fellows. The median operating times were significantly higher in the resident and fellow groups compared with the attending-alone group (109 minutes [interquartile range, 55-164 minutes) compared with 110 minutes [interquartile range, 61-174 minutes] compared with 72 minutes [interquartile range, 38-113 minutes], P < 0.001). After multivariable logistic regression, trainee participation did not result in an increase in complication rate. Preoperative transfusion (adjusted odds ratio [aOR], 7.82; 95% confidence interval [CI], 2.03-30.09), coagulopathy (aOR, 3.18; 95% CI, 1.74-5.82), nonwhite race (aOR, 1.57; 95% CI, 1.31-1.89), insulin-dependent diabetes (aOR, 1.68; 95% CI, 1.03-2.72), American Society of Anesthesiologists class greater than 2 (aOR, 1.46; 95% CI, 1.21-1.77), length of stay (aOR, 1.04, 95%CI:1.02-1.06), operating time (aOR, 1.01; 95% CI, 1.00-1.03), and undergoing a sling procedure (aOR, 1.18; 95% CI, 1.01-1.41) were associated with higher complication rates.
Resident and fellow involvement during pelvic reconstructive surgery is associated with longer operating times but does not increase the risk of complications within 30 days of the procedure.
实习医生参与手术与手术时间延长及某些并发症发生率增加有关。关于实习医生参与对泌尿妇科手术结局的影响，研究有限。我们试图确定住院医师和专科住院医生参与盆底重建手术对30天并发症发生率的影响。
利用美国外科医师学会国家外科质量改进计划数据库，确定2010年至2015年间接受盆底手术的患者。患者分为3组：无实习医生参与、有住院医师参与或有专科住院医生参与。主要结局是综合并发症发生率。采用Kruskal-Wallis分析进行三组比较。若具有统计学意义，则在参照组（仅由主治医生操作）和实验组（有住院医师或专科住院医生参与）之间进行两两分析。在专科住院医生组和住院医师组之间进行额外的两两分析。采用逻辑回归确定与并发症风险增加相关的因素。
7752例手术病例符合所有纳入标准；2440例（31.4%）有住院医师参与，646例（8.3%）有专科住院医生参与。与仅由主治医生操作的组相比，住院医师组和专科住院医生组的中位手术时间显著更长（分别为109分钟[四分位间距，55 - 164分钟]、110分钟[四分位间距，61 - 174分钟]，而仅由主治医生操作的组为72分钟[四分位间距，38 - 113分钟]，P < 0.001）。多变量逻辑回归分析后，实习医生的参与并未导致并发症发生率增加。术前输血（调整优势比[aOR]，7.82；95%置信区间[CI]，2.03 - 30.09）、凝血病（aOR，3.18；95% CI，1.74 - 5.82）、非白人种族（aOR，1.57；95% CI，1.31 - 1.89）胰岛素依赖型糖尿病（aOR，1.68；95% CI，1.03 - 2.72）、美国麻醉医师协会分级大于2（aOR，1.46；95% CI，1.21 - 1.77）、住院时间（aOR，1.04，95% CI：1.02 - 1.06）、手术时间（aOR，1.01；95% CI，1.00 - 1.03）以及进行吊带手术（aOR，1.18；95% CI，1.01 - 1.41）与较高的并发症发生率相关。
盆底重建手术中住院医师和专科住院医生的参与与手术时间延长有关，但不会增加术后30天内的并发症风险。
