Department of Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, MA.
Department of Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, MA.
Ann Vasc Surg. 2021 Jan;70:245-251. doi: 10.1016/j.avsg.2020.06.056. Epub 2020 Jul 6.
The present study compares the senior level operative experience of graduates from the traditional vascular surgery fellowship (5 + 2) and integrated vascular surgery training programs (0 + 5) using contemporary operative case log data.
The Accreditation Council for Graduate Medical Education integrated vascular surgery, vascular surgery fellowship, and general surgery case logs for trainees graduating between 2013 and 2018 were queried for vascular surgery procedures. "Senior" cases were categorized as cases logged as "surgeon fellow" by 5 + 2 trainees or "surgeon chief" (post graduate year-4,5) by 0 + 5 trainees. Overall case volume was defined as the combined volume of cases logged as "surgeon junior," "surgeon chief," "surgeon fellow," "teach assist," "first assist," or "secondary procedure." To reflect total vascular experience, all vascular cases done during general surgery residency were combined with cases performed during vascular surgery fellowship. Mean case volumes were compared for all operations/procedures.
The 5 + 2 trainees had higher mean volume of open repair of suprarenal aortic aneurysms (2.4 vs. 1.4, P = 0.0026) and open repair of thoracic aortic aneurysms (0.5 vs. 0.3, P = 0.004) at the fellow level compared to 0 + 5 surgeon chief cases. Additionally, 5 + 2 trainees performed more endovascular repair of abdominal aortoiliac aneurysm (44.7 vs. 28.4, P < 0.0001), endovascular repair of iliac artery aneurysm (1.9 vs. 1.2, P = 0.0003), and endovascular repair of thoracic aortic aneurysm (14.9 vs. 8.4, P < 0.0001). The 5 + 2 fellows performed more vein bypasses than 0 + 5 chief residents (femoral-popliteal 9.8 vs. 6.4, P = 0.002; infrapopliteal 13.9 vs. 8.8, P = 0.0490), extra-anatomic bypasses (axillofemoral 4.2 vs. 2.9, P = 0.0004; femoral-femoral 5.6 vs. 3.1, P = 0.034), carotid endarterectomies (47.3 vs. 29.3, P < 0.0001), carotid artery stenting (9.6 vs. 4.5, P = 0.0001), celiac/SMA endarterectomy or bypass (3.7 vs. 1.9, P < 0.0001), renal artery balloon angioplasty/stenting (5.0 vs. 2.5, P = 0.0006), thoracic outlet decompression (5.4 vs. 1.9, P < 0.0001), traumatic repairs [thoracic vessels (0.5 vs. 0.1, P < 0.0001), neck vessels (0.7 vs. 0.3, P = 0.0004), abdominal vessels (3.0 vs. 1.7, P = 0.0005), and peripheral vessels (6.6 vs. 3.1, P = 0.034)], as well as a higher mean volume of arteriovenous (AV) fistulas (30.7 vs. 15.7, P < 0.0001), AV grafts (10.7 vs. 5.1, P < 0.0001), and revision of AV access (16.1 vs. 8.0, P = 0.0003).
Although both pathways graduate trainees with a similar overall surgical experience, 5 + 2 trainees log significantly more "Senior" cases. Further studies investigating potential variation in operative autonomy between both pathways are necessary.
本研究通过比较传统血管外科住院医师培训（5+2）和血管外科整合培训项目（0+5）的毕业生的高级别手术经验，使用当代手术病例记录数据进行比较。
查询 2013 年至 2018 年毕业的住院医师培训人员的毕业后医学教育委员会认证的综合血管外科、血管外科住院医师和普通外科手术记录，以获取血管外科手术程序。“高级”病例被归类为 5+2 培训生记录为“外科住院医师”的病例，或 0+5 培训生记录为“外科首席医生”（研究生第 4、5 年）的病例。总体手术量定义为记录为“外科初级医生”、“外科首席医生”、“外科住院医师”、“助教”、“第一助手”或“次要手术”的病例的合并量。为了反映总的血管外科经验，将普通外科住院医师培训期间进行的所有血管手术与血管外科住院医师培训期间进行的手术相结合。所有手术/程序的平均手术量进行比较。
与 0+5 首席外科医生的病例相比，5+2 培训生在外科住院医师水平上进行的肾上腹主动脉瘤开放修复（2.4 比 1.4，P=0.0026）和胸主动脉瘤开放修复（0.5 比 0.3，P=0.004）的平均手术量更高。此外，5+2 培训生进行了更多的腹主动脉瘤腹主动脉瘤的血管内修复（44.7 比 28.4，P<0.0001）、髂动脉瘤的血管内修复（1.9 比 1.2，P=0.0003）和胸主动脉瘤的血管内修复（14.9 比 8.4，P<0.0001）。5+2 住院医师进行了更多的静脉旁路手术，而 0+5 首席住院医师进行了更多的额外解剖旁路手术（股-腘旁路 9.8 比 6.4，P=0.002；小腿旁路 13.9 比 8.8，P=0.049）（腋股旁路 4.2 比 2.9，P=0.0004；股-股旁路 5.6 比 3.1，P=0.034）、颈动脉内膜切除术（47.3 比 29.3，P<0.0001）、颈动脉支架置入术（9.6 比 4.5，P=0.0001）、腹腔干/肠系膜上动脉内膜切除术或旁路（3.7 比 1.9，P<0.0001）、肾动脉球囊血管成形术/支架置入术（5.0 比 2.5，P=0.0006）、胸廓出口减压术（5.4 比 1.9，P<0.0001）、创伤性修复[胸血管（0.5 比 0.1，P<0.0001）、颈部血管（0.7 比 0.3，P=0.0004）、腹部血管（3.0 比 1.7，P=0.0005）和外周血管（6.6 比 3.1，P=0.034）]，以及动静脉（AV）瘘（30.7 比 15.7，P<0.0001）、AV 移植物（10.7 比 5.1，P<0.0001）和 AV 通路修复（16.1 比 8.0，P=0.0003）的平均手术量更高。
尽管这两种途径的毕业生都具有相似的整体手术经验，但 5+2 培训生的“高级”病例记录明显更多。有必要进一步研究这两种途径之间潜在的手术自主性差异。
