Emergency Surgery Complications, but Not Mortality, Linked With Surgeons' Experience

By Marilynn Larkin

March 19, 2021

NEW YORK (Reuters Health) - Emergency surgery patients cared for by early-career "acute-care" surgeons have similar mortality rates as patients with more senior surgeons but are more likely to need to go back to the operating room, a new study suggests.

"Acute care surgery is a relatively new paradigm in surgical training where surgeons are trained to care for all general surgical emergencies and all traumatic injuries other than orthopedic, brain and spinal cord injuries," Dr. Kevin Schuster of Yale School of Medicine in New Haven told Reuters Health by email. "These surgeons regularly care for highly complex patients who are critically ill or injured and require complex surgical interventions."

"We believe patients would likely benefit from systems that allow early career surgeons to work more closely with senior surgeons while they continue to develop their technical and decision-making skills," he said.

As reported in JAMA Surgery, Dr. Schuster and colleagues studied the association of surgeon experience with emergency surgery outcomes at five U.S. level-1 trauma centers. Overall, 56 acute-care surgeons operated on 772 patients (mean age, 50; 61% men) who required emergent general surgery or trauma surgery.

Surgeons were grouped by post-training experience: less than six years (early career); six to 10 years (early midcareer); 11 to 30 years (late midcareer); and 30 years or more (late career). Surgeons with less than three years of experience were compared with the entire cohort.

Most patients - 618, or 80% -- were managed by surgeons with less than 10 years of experience. Early- and late-midcareer surgeons generally operated on older patients and those with more septic shock, acute kidney failure, and higher Emergency Surgery scores.

No significant between-group differences were seen in patient mortality, complications, postoperative transfusion, organ-space surgical site infection, or length of stay.

After controlling for acuity and case complexity, there was a nonsignificant association of fewer unplanned returns to the operating room with increased surgeon experience followed by reversal of the association with late-career surgeons. For early-career surgeons compared to the other groups, odds ratios for unplanned return to the operating room were 0.66 for early-midcareer surgeons, 0.34 for late-midcareer surgeons, and 1.11 for late-career surgeons.

Mortality was similar for those operated on by surgeons with less than three years of experience compared with the rest of the cohort (OR, 1.97); however, complication rates were higher (OR, 2.07).

The authors conclude, "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," they suggest. "Early-career surgeons' outcomes may be improved if they are supported while experience is garnered."

Dr. Timothy Pritts, Chief, Section of General Surgery and Vice Chair, Clinical Operations at the University of Cincinnati College of Medicine in Ohio commented by email to Reuters Health, "The data examined in this study are significantly more detailed than in previous studies."

"Acute-care surgeons must make complex decisions in critically ill patients in a rapid fashion, often with incomplete data," he noted. "The finding that there were no mortality differences between the groups of surgeons studied highlights the high quality of care that these very sick patients received. The reasons for more frequent returns to the operating room are unclear from this study and are worthy of further investigation."

"Within our group, more recently trained surgeons receive very intense mentoring during their initial practice period," he said. "The findings highlight just how critically ill this patient population is and how challenging the care can be."

"The availability of senior surgeons to provide mentorship may vary from institution to institution, or there may be a culture where younger surgeons may be hesitant to ask for help," he added. "The findings highlight the need for a culture of constant communication, liberal use of intra-operative consultation, and a low threshold for calling for help from more senior surgeons."

SOURCE: https://bit.ly/38RdrfN JAMA Surgery, online March 10, 2021.

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