S. Dasani1, K. D. Simmons1, E. Bailey1, R. Hoffman1, K. Collier1, R. R. Kelz1 1University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA
Introduction: Uncommon operations are defined by the Surgical Council on Resident Education as rare, often urgent, operations. Outcomes of these procedures remain largely understudied. Uncommon operations may confer greater operative risk than complex operations and have the educational challenge of occurring infrequently. This study examines the incidence of post-operative events and the role of the resident following uncommon operations.
Methods: We identified uncommon general surgical operations using the ACS National Surgical Quality Improvement Program (NSQIP) Participant Use file (2008-2011). Death or serious morbidity (DSM) within 30 days of the operation was the primary outcome of interest. Failure to rescue (FTR) and prolonged operative time (PRopt) were examined as secondary outcome measures. PRopt was defined by procedure type as ≥ to the 90%ile of operative time. Resident participation was defined as resident involved (RI) or no resident involved (NRI), and stratified by post-graduate year (PGY): 1-3, 4-5, and 6+. Independent multivariate logistic regression models were developed to examine the association between any RI or PGY and outcomes.
Results: Resident participant data was available for 21,453 (84.5%) of the uncommon operations with NRI in 25.4% (5,447) and participation by a PGY1-3 in 12.6% (2,699), a PGY4-5 in 50.4% (10,817), and a PGY6+ in 11.6% (2,490). The observed DSM rate was 28.6% and the observed FTR rate was 5.8%. Results of binary analyses are displayed in the prose and PGY results are seen in the table. Overall, there was no difference in DSM by RI status (NRI: 1,528; 28.1% vs RI: 4,602; 28.8%; p=0.324); however, the PGY level was associated with DSM (Table 1). Any RI was associated with a lower rate of FTR (5.1%) when compared to NRI (8.3%, p<0.001) with decreasing FTR events by increasing PGY (Table 1). After adjustment for patient risk factors, any RI remained associated with a lower likelihood of FTR than NRI (OR: 0.66, 95% CI: 0.50-0.89) with decreasing likelihood of FTR by increasing PGY (Table 1). RI was associated with PRopt in univariate and multivariate analyses (Table 1).
Conclusion: Uncommon operations were associated with substantial DSM. The involvement of PGY4-5 residents was associated with the greatest likelihood of DSM. Regardless of the PGY of the involved resident, all cases with RI demonstrated a lower likelihood of risk-adjusted FTR. The explanation for these findings is not clear; however, the involvement of more senior residents in the technical aspects of uncommon operations may lead to improved results.
