More Evidence Overlapping Surgeries Are Safe

Diana Swift

November 08, 2017

More evidence that appropriately performed overlapping surgeries do not impair patient outcomes has emerged from a large observational study published online today in JAMA Surgery.

In a series of 2275 mainly complex cases involving both overlapping and nonoverlapping neurosurgery performed between 2014 and 2015, researchers found no differences between the two groups in mortality, morbidity, or functional status at discharge and 90-day follow-up.

The authors, led by Brian M. Howard, MD, from Emory University's Department of Neurosurgery in Atlanta, Georgia, note this is the first of several recent studies highlighting the safety of the practice to follow-up patients beyond 30 days.

The common but sometimes controversial practice, also known as sequenced surgery, has the potential to expand access to care "by maximizing efficiency and making highly sought-after specialists available to a greater number of patients," Dr Howard and colleagues write. Furthermore, with careful training of new surgeons, due supervision, and progressive autonomy, this approach may be crucial to maintaining a competent surgical workforce.

Patients in the study had a mean age of 52.1 (standard deviation, 16.4) years, and 55.3% were women. A total of 972 surgeries (42.7%) were nonoverlapping, and 1303 (57.3%) were overlapping, with overlapping referring to procedures in which the attending surgeon moves from one operation to a second after completing all critical components in the first, leaving colleagues to complete noncritical elements of the first procedure.

Overlapping procedures were more frequently elective, at 93.1% vs 86.6% (P < .001), the authors noted. The most common category was tumor surgery, followed by functional and vascular surgery. In 19.8% (n = 451) of all procedures, a cosurgeon was present.

The authors note, however, that median surgical times were significantly longer in the overlapping vs the nonoverlapping cohort, with an in-room time of 219 vs 188 minutes and a skin-to-skin time of 141 vs 113 minutes (P < .001 for both).

Concern has been raised that prolonged exposure to anesthesia while patients await the arrival of the attending surgeon may lead to complications such as respiratory failure and wound infection. In this study, longer in-room time was associated with morbidity, but not mortality or follow-up mortality risk score. Skin-to-skin time was not associated with mortality, morbidity, or worsened functional status.

The risk for adverse outcomes was increased, however, by measures of baseline illness severity. Admission to the intensive care unit and increased length of stay both correlated with mortality, with intensive care unit admission having an odds ratio (OR) of 25.5 (95% confidence interval [CI], 6.22 - 104.67) and length of stay an OR of 1.03 (95% CI, 1.00 - 1.05).

For morbidity, intensive care unit care had an OR of 1.85 (95% CI, 1.43 - 2.40) and length of stay an OR of 1.06 (95% CI, 1.04 - 1.08). For poor functional status, length of stay was associated with an OR of 1.03 (95% CI, 1.02 - 1.05).

"Data such as these will help determine health care standards and policies that have the potential to broadly affect the delivery of surgical care in the United States," Dr Howard and colleagues write of their findings. "An evidence-based approach to policy surrounding [overlapping surgery] is crucial not only to maximize patient safety but also to make highly specialized surgical care available to as many patients as possible." They caution, however, that "[s]urgeons must use their experience, keen intuition, and respect for their own ability and limitations to carefully select patients for [overlapping surgery]."

In an invited commentary, David B. Hoyt MD, executive director of the Chicago, Illinois-based American College of Surgeons, who was not involved in the study, calls the findings "very important," and evidence that properly performed overlapping surgery results in no differences in mortality, complications, and neurologic outcomes.

"This practice can increase efficiency and allow the expertise of an individual neurosurgeon to be more widely available," he writes "It can also help a surgical resident establish a sense of authenticity during training by having responsibility for some parts of an operation as they grow and develop."

Dr Hoyt stresses the need, however, for an informed patient consent process that maintains patient autonomy. "We must never lose sight of our responsibility to keep the individual patient informed."

The new data are in line with a previously reported study of 14,872 neurosurgery procedures that showed that patient outcomes are either equivalent or improved with overlapping surgery, even in highly complex cases.

The authors and the editorial commentator have disclosed no conflicts of interest.

JAMA Surg. Published online November 8, 2017. Article full text, Commentary extract

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