Division of Cardiothoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
Warren Alpert Medical School, Brown University, Providence, Rhode Island.
Ann Thorac Surg. 2019 Jul;108(1):262-267. doi: 10.1016/j.athoracsur.2019.02.008. Epub 2019 Mar 14.
We have previously demonstrated that cardiac surgery trainees can safely perform operations "skin-to-skin" with adequate attending surgeon supervision.
We used 100 consecutive cases (82 coronary artery bypass grafts, 9 aortic valve replacements, 7 coronary artery bypass grafts plus aortic valve replacements, 2 others) performed by residents (group R) to match 1:1 by procedure to nonconsecutive cases done by a single attending surgeon (group A) from July 2014 to October 2016. Patients were stratified based on whether the attending surgeon or trainee performed every critical step of the operation skin-to-skin. Outcomes included death, major morbidity, and readmission.
Patients in the two groups were similar with respect to demographic characteristics and comorbidities. The median follow-up time for patients in this study was 28 months (interquartile range: 23 to 35 months). There were seven deaths (3.5%; four in group A, three in group R, p = 0.7). Of the 43 patients (21.5%) who were readmitted during the study term, 27 patients (13.5%) were readmitted for causes related to the operation (11 in group A, 16 in group R, p = 0.02). The most common reasons for readmissions related to the operation were chest pain (n = 11), pleural effusion that required drainage (n = 8), pneumonia (n = 4), and unstable angina that required percutaneous coronary intervention (n = 3). No statistically significant differences were found in reasons for readmission between group A and group R.
The equivalence of postoperative outcomes previously demonstrated at 30 days persists at midterm follow-up. Our data indicate that trainees can be educated in operative cardiac surgery under the current paradigm without sacrificing outcome quality. It is reasonable to expect academic programs to continue providing trainees with experience as primary operating surgeons.
我们之前已经证明，心脏外科受训者可以在有足够主治外科医生监督的情况下安全地进行“皮肤对皮肤”手术。
我们使用了 100 例连续病例（82 例冠状动脉旁路移植术、9 例主动脉瓣置换术、7 例冠状动脉旁路移植术加主动脉瓣置换术、2 例其他手术），通过程序与 2014 年 7 月至 2016 年 10 月期间由同一位主治外科医生进行的非连续病例进行 1:1 匹配（组 A）。根据主治外科医生或受训者是否完成手术的每一个关键步骤，将患者分层。结果包括死亡、主要发病率和再入院。
两组患者的人口统计学特征和合并症相似。本研究中患者的中位随访时间为 28 个月（四分位距：23 至 35 个月）。共有 7 例死亡（3.5%；4 例在组 A，3 例在组 R，p=0.7）。在研究期间，共有 43 例患者（21.5%）再次入院，其中 27 例（13.5%）与手术相关（11 例在组 A，16 例在组 R，p=0.02）。与手术相关的再入院最常见的原因是胸痛（n=11）、需要引流的胸腔积液（n=8）、肺炎（n=4）和需要经皮冠状动脉介入治疗的不稳定型心绞痛（n=3）。组 A 和组 R 之间的再入院原因无统计学差异。
在中期随访时，先前在 30 天内证明的术后结果是等效的。我们的数据表明，在当前模式下，可以在心脏外科手术中对受训者进行教育，而不会牺牲手术质量。可以合理地期望学术项目继续为受训者提供作为主要手术医生的经验。
