J. Kudsi1, K. Hayes1, R. Amdur1, P. Lin1, K. Vaziri1 1George Washington University,Department Of General Surgery,Washington, DISTRICT OF COLUMBIA, USA
Introduction:
The current surgical residency training is based on a model of graduated responsibility, giving greater responsibility based on an individual trainees’ ability. To assess the effect of this model on care of the bariatric surgery patient; we decided to study the impact of resident involvement in bariatric surgery stratified by level of training. The aim of this study is to assess the impact of resident involvement on perioperative outcome in bariatric procedures including sleeve gastrectomy (SG) and gastric bypass (GB).
Methods:
Four-year retrospective review 2006-2010 of ACS-NSQIP database for 19,616 lap/open GB (87.8%), and 2,730 lap/open SG (12.2%). All concurrent procedures were excluded except: EGD, liver biopsy, wedge liver biopsy, and lap biopsy. Other exclusions included cases with both laparoscopic and open procedures, emergency cases, cases missing PGY, and those with PGY level higher than 5.
Pre-treatment patient characteristics and outcomes were compared across levels of the resident variable Juniors PGY 1/2/3 (J) vs seniors PGY 4-5 (S) vs no residents (N) using chi-square for categorical variables and analysis of variance for continuous variables.
13 composite outcomes were compared; wound (superficial surgical site infection, deep wound infection, organ space infection, dehiscence), pulmonary (pneumonia, prolonged intubation, reintubation), sepsis/septic shock, deep venous thrombosis/pulmonary embolism (DVT/PE), bleeding, cardiac (MI, cardiac arrest), renal (AKI, dialysis) and urinary tract infection (UTI), operative time>4h, Length of Stay (LOS)>3days, return to OR, and mortality. All confounding variables were controlled.
Results:
There were 19,616 GB (87.8%), and 2,730 SG (12.2%). Surgical assist distribution was: Junior 3,554 (15.9%), Senior 5,406 (24.2%), N 13,386 (59.9%).
Cases that included Senior residents more often involved African American patients than cases treated by no resident or junior residents. Non-resident cases had slightly lower BMI, fewer non-independent patients, and less COPD, than cases that involved residents. Cases with Junior residents had the highest rate of dyspnea.
There was no difference in mortality. Senior residents had significantly worse outcomes compared to junior and non-residents in LOS>3 days (S 12.4%, J 10.9%, N 8.3%, P<.0001), wound complications (S 3.6%, J 2.8%, N 2.7% P.007), pulmonary complications (S 1.2%, J 0.7%, N 0.9 P .033), sepsis/ septic shock (S 1.3%, J 1.1%, N 0.8% P .0022), cardiac events (S 0.33, J 0.14, N 0.12, P 0.005) and OR time>4h (S 4.16, J 4.11, N 1.6, P < 0.0001). Junior residents had worse outcome in renal complications (S 0.46, J 0.51, N 0.23, P 0.006).
Conclusion:
Bariatric procedures with senior resident assistance have worse outcomes when compared to junior or non-resident assistance. These results suggest further evaluation of the graduated responsibility model in bariatric operative education.