Presented By: Samik Patel MD. Martinovski M 1, Patel S 1, Navratil A 2, Zeni T 3, Jonker M 3, Ferraro J 1, Albright J 1, Cleary RK 1
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1 Effects of Resident or Fellow Participation in Sleeve Gastrectomy and Gastric Bypass: Results from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Martinovski M 1, Patel S 1, Navratil A 2, Zeni T 3, Jonker M 3, Ferraro J 1, Albright J 1, Cleary RK 1 1. Department of Surgery, St. Joseph Mercy Health System, Ann Arbor, MI 2. Department of Bariatric Surgery, Carolinas Medical Center 3. Michigan Bariatric Institute, Livonia, MI Presented By: Samik Patel MD
2 Disclosures Dr. Robert Cleary has received honoraria from Intuitive Surgical Inc. for educational speaking
3 Current Literature in Bariatric Surgery Resident or fellow participation in laparoscopic bariatric surgery has been evaluated in a few studies 1. Effects of Resident Involvement on Complication Rates after Laparoscopic Roux-en-Y Gastric Bypass 16 - Krell R, et. al. Journal of American College of Surgeons (2014), Michigan Bariatric Surgery Collaborative - 17,057 laparoscopic RYGB patients (from Jul 2006-Aug 2012) - Operative time and complication rate higher with residents, higher odds of wound infection and VTE (time dependent) 2. Does Fellow Participation in Laparoscopic Roux-en-Y Gastric Bypass Affect Perioperative Outcomes? 17 - Bhayani NH. et. al. Surgical Endoscopy (2012), Providence Cancer Center in Portland, OR - 18,333 Laparoscopic RYGB (4349 fellow cases), ACS NSQIP Fellows with higher odds of SSI, UTI, DVT, and sepsis (early 1st half of fellowship) - Outcomes similar to attending cases (2nd half of fellowship) 3. Are Bariatric Operations Performed by Residents Safe and Efficient? (Surgery for Obesity and Related Diseases in 2016) 18 - Major P. et. al. Retrospective, 408 patients (233 SG and 175 RYGB), 2 groups (trainee and mentor) - Mean duration of SG and RYGB: greater in trainee group compared to mentor group - Risk of intraoperative adverse effects and surgical complications not affected with resident involvement 4. Laparoscopic RYGB and the Role of the Surgical Resident (American Journal of Surgery in 2004) 19 - Rovito PF. et. al. Retrospective, 204 laparoscopic RYGB with resident participation (Mar 2000-Apr 2002) - Laparoscopic RYGB is safe with residents, operative times longer, and complications existed however not clinically significant
4 Purpose To evaluate the impact of resident and fellow participation on outcomes after bariatric surgery using the MBSAQIP, a national clinical registry
5 Methods MBSAQIP Database Retrospective analysis (Jan-Dec 2015) Laparoscopic SG or RYGB Baseline characteristics 30-day perioperative outcomes Analyzed and adjusted using logistic regressions
6 Resident Versus Fellow Outcome Resident Fellow Resident vs Fellow SSI 196 (0.86%) 143 (1.17%) OP LENGTH > MEDIAN (63.54%) 8522 (69.52%) <0.001 MORBIDITY 1529 (6.71%) 884 (7.21%) MORTALITY (30 DAY) 28 (0.12%) 13 (0.11%) 1 READMISSION (30 DAY) 1099 (4.82%) 590 (4.81%) 1 REOPERATION (30 DAY) 313 (1.37%) 180 (1.47%) 1 No significant differences in: sepsis, readmission, reoperation, cardiac complication, wound disruption, acute renal failure, stroke, UTI, PE, vein thrombosis, pneumonia, anastomotic leak, anastomotic ulcer, stricture, abdominal sepsis, perforation, intestinal obstruction, gastro-gastro fistula, gallstone disease, wound infection, bleeding, any morbidity.
7 Resident Versus Attending Outcome Resident Attending Resident vs Attending READMISSION (30 DAY) 1099 (4.82%) 4122 (4.2%) <.001 CARDIAC COMPLICATION 31 (0.14%) 71 (0.07%) UTI 118 (0.52%) 285 (0.29%) <.001 OP LENGTH > MEDIAN (63.54%) (43.9%) <.001 MORBIDITY 1529 (6.71%) 5736 (5.85%) <.001 MORTALITY (30 DAY) 28 (0.12%) 117 (0.12%) 1 REOPERATION (30 DAY) 313 (1.37%) 1417 (1.45%) 1 No significant differences in: 30-day mortality, sepsis, reoperation, wound disruption, acute renal failure, stroke, PE, vein thrombosis, pneumonia, anastomotic leak, anastomotic ulcer, stricture, abdominal sepsis, perforation, intestinal obstruction, gastro-gastro fistula, gallstone disease, wound infection, bleeding.
8 Fellow Versus Attending Outcome Fellow Attending Fellow vs Attending SEPSIS 29 (0.24%) 123 (0.13%) READMISSION (30 DAY) 590 (4.81%) 4122 (4.2%) SSI 143 (1.17%) 736 (0.75%) <.001 PULMONARY EMBOLISM 25 (0.2%) 103 (0.11%) UTI 74 (0.6%) 285 (0.29%) <.001 OP LENGTH > MEDIAN 8522 (69.52%) (43.9%) <.001 MORBIDITY 884 (7.21%) 5736 (5.85%) <.001 MORTALITY (30 DAY) 13 (0.11%) 117 (0.12%) 1 REOPERATION ( 30 DAY) 180 (1.47%) 1417 (1.45%) 1 No significant differences in: 30-day mortality, reoperation, wound disruption, acute renal failure, stroke, vein thrombosis, pneumonia, anastomotic leak, anastomotic ulcer, stricture, abdominal sepsis, perforation, intestinal obstruction, gastro-gastro fistula, gallstone disease, wound infection, bleeding.
9 Limitations Retrospective chart review study Several baseline characteristics and perioperative outcomes were statistically significant, however not clinically significant Percentage of involvement of residents and fellows in operations was not quantified 9
10 Conclusion Resident and fellow participation in SG and RYGB showed no difference in 30-day reoperation or mortality Resident and fellow involvement was associated with longer operative time and increased incidence of SSIs, readmissions, UTIs, and morbidity compared to attending cases Nonetheless, strategies to improve technical competence during surgical training are needed
11 References 1. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357: Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004;240: ; discussion Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357: Advani V, Ahad S, Gonczy C, et al. Does resident involvement effect surgical times and complication rates during laparoscopic appendectomy for uncomplicated appendicitis? An analysis of 16,849 cases from the ACS-NSQIP. Am J Surg. 2012;203: discussion Graat LJ, Bosma E, Roukema JA, Heisterkamp J. Appendectomy by residents is safe and not associated with a higher incidence of complications: a retrospective cohort study. Ann Surg. 2012;255: Itani KM, DePalma RG, Schifftner T, et al. Surgical resident supervision in the operating room and outcomes of care in Veterans Affairs hospitals. Am J Surg. 2005;190: Kiran RP, Ali UA, Coffey JC, et al. Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program. Ann Surg. 2012;256: Khuri SF, Najjar SF, Daley J, et al. Comparison of surgical outcomes between teaching and nonteaching hospitals in the Department of Veterans Affairs. Ann Surg. 2001;234: discussion Patel SP, Gauger PG, Brown DL, et al. Resident participation does not affect surgical outcomes, despite introduction of new techniques. J Am Coll Surg. 2010;211: Raval MV, Wang X, Cohen ME, et al. The influence of resident involvement on surgical outcomes. J Am Coll Surg. 2011;212: Robinson RP. The impact of resident teaching on total hip arthroplasty. Clin Orthop Relat Res. 2007;465: Tseng WH, Jin L, Canter RJ, et al. Surgical resident involvement is safe for common elective general surgery procedures. J Am Coll Surg. 2011;213: discussion Yaghoubian A, de Virgilio C, Lee SL. Appendicitis outcomes are better at resident teaching institutions: a multi-institutional analysis. Am J Surg. 2010;200: discussion Schauer P, Ikramuddin S, Hamad G, Gourash W. The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc. 2003;17: Fanous M, Carlin A. Surgical resident participation in laparoscopic Roux-en-Y bypass: is it safe? Surgery. 2012;152: Krell RW, Birkmeyer NJ, Reames BN, Carlin AM, Birkmeyer JD, Finks JF. Effects of Resident Involvement on Complication Rates after Laparoscopic Gastric Bypass. Journal of the American College of Surgeons. 2014;218(2): doi: /j.jamcollsurg Bhayani NH, Gupta A, Kurian AA, et al. Does fellow participation in laparoscopic Roux-en-Y gastric bypass affect perioperative outcomes? Surg Endosc. 2012;26: Major Piotr, et al. Are Bariatric Operations Performed by Residents Safe and Efficient? Surgery for Obesity and Related Diseases Rovito PF. et. al. Laparoscopic RYGB and the Role of the Surgical Resident. American Journal of Surgery
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