Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
Division of Trauma, Acute Care and Critical Care Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania.
JAMA Surg. 2021 May 1;156(5):472-478. doi: 10.1001/jamasurg.2021.0041.
Previous studies comparing emergency surgery outcomes with surgeon experience have been small or used administrative databases without controlling for patient physiology or operative complexity.
To evaluate the association of acute care surgeon experience with patient morbidity and mortality after emergency surgical procedures.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study evaluated the association of surgeon experience with emergency surgery outcomes at 5 US academic level 1 trauma centers where the same surgeons provided emergency general surgical care. A total of 772 patients who presented with a traumatic injury and required an emergency surgical procedure or who presented with or developed a condition requiring an emergency general surgical intervention were operated on by 1 of 56 acute care surgeons. Surgeon groups were divided by experience of less than 6 years (early career), 6 to 10 years (early midcareer), 11 to 30 years (late midcareer), and 30 years or more (late career) from the end of training. Surgeons with less than 3 years of experience were also compared with the entire cohort. Hierarchical logistic regression models were constructed controlling for Emergency Surgery Score, case complexity, preoperative transfusion, and trauma or emergency general surgery. Data were collected from May 2015 to July 2017 and analyzed from February to May 2020.
Mortality, complications, length of stay, blood loss, and unplanned return to the operating room.
Of 772 included patients, 469 (60.8%) were male, and the mean (SD) age was 50.1 (20.0) years. Of 772 operations, 618 were by surgeons with less than 10 years of experience. Early- and late-midcareer surgeons generally operated on older patients and patients with more septic shock, acute kidney failure, and higher Emergency Surgery Scores. Patient mortality, complications, postoperative transfusion, organ-space surgical site infection, and length of stay were similar between surgeon groups. Patients operated on by early-career surgeons had higher rates of unplanned return to the operating room compared with those operated on by early-midcareer surgeons (odds ratio [OR], 0.66; 95% CI, 0.40-1.09), late-midcareer surgeons (OR, 0.34; 95% CI, 0.13-0.90), and late-career surgeons (OR, 1.11; 95% CI, 0.45-2.75). Patients operated on by surgeons with less than 3 years of experience had similar mortality compared with the rest of the cohort (OR, 1.97; 95% CI, 0.85-4.57) but higher rates of complications (OR, 2.07; 95% CI, 1.05-4.07).
In this study, experienced surgeons generally operated on older patients with more septic shock and kidney failure without affecting risk-adjusted mortality. Increased complications and unplanned return to the operating room may improve with experience. Early-career surgeons' outcomes may be improved if they are supported while experience is garnered.
先前比较急诊手术结果与外科医生经验的研究规模较小，或者使用没有控制患者生理状况或手术复杂性的行政数据库。
评估急症外科医生经验与急症手术患者发病率和死亡率的关系。
设计、设置和参与者：本队列研究评估了 5 家美国学术水平 1 级创伤中心的外科医生经验与急症手术结果的关系，这些中心的同一位外科医生提供急症普通外科护理。共有 772 名因创伤而需要急症手术或因出现或发展为需要急症普通外科干预的情况而就诊的患者，由 56 名急症外科医生中的 1 名进行手术。外科医生组按经验分为少于 6 年（早期职业）、6 至 10 年（早期中期职业）、11 至 30 年（晚期中期职业）和 30 年或以上（晚期职业）。还比较了少于 3 年经验的外科医生与整个队列。建立了分层逻辑回归模型，控制了紧急手术评分、手术复杂性、术前输血以及创伤或急症普通外科。数据于 2015 年 5 月至 2017 年 7 月收集，并于 2020 年 2 月至 5 月进行分析。
死亡率、并发症、住院时间、失血量和计划外返回手术室。
在纳入的 772 名患者中，469 名（60.8%）为男性，平均（SD）年龄为 50.1（20.0）岁。772 例手术中，618 例由经验不足 10 年的外科医生进行。早期和晚期中期职业的外科医生通常为年龄较大的患者和患有更多脓毒症休克、急性肾衰竭和更高紧急手术评分的患者进行手术。外科医生组之间的患者死亡率、并发症、术后输血、器官间隙手术部位感染和住院时间相似。与早期中期职业的外科医生相比，早期职业的外科医生的患者计划外返回手术室的比例更高（比值比[OR]，0.66；95%CI，0.40-1.09）、晚期中期职业的外科医生（OR，0.34；95%CI，0.13-0.90）和晚期职业的外科医生（OR，1.11；95%CI，0.45-2.75）。经验不足 3 年的外科医生手术的患者死亡率与其余患者相似（OR，1.97；95%CI，0.85-4.57），但并发症发生率较高（OR，2.07；95%CI，1.05-4.07）。
在这项研究中，经验丰富的外科医生通常为患有更多脓毒症和肾衰竭的老年患者进行手术，而不会影响风险调整后的死亡率。并发症和计划外返回手术室的增加可能随着经验的增加而改善。如果在获得经验的同时为早期职业的外科医生提供支持，他们的手术结果可能会得到改善。
