Surgeon Experience Does Not Impact Outcomes of Emergency Surgery, a Prospective Multi-center Study
Kevin M. Schuster1, *Joshua P Hazelton2, *Deviny Rattigan2, *Dennis Kim3, *Lara H Spence3, *David Turray4, *Xina Luo-Owen4, *Javier M Perez5, *Saraswati Deval5, *Melissa Blatt5
1Yale School of Medicine, New Haven, CT;2Cooper University Hospital, Camden, NJ;3Harbor UCLA Medical Center, Torrance, CA;4Loma Linda Medical Center, Loma Linda, CA;5Hackensack University Medical Center, Hackensack, NJ
Objective: Previous studies comparing outcomes of emergency surgery based on surgeon experience have been small, single institution or used administrative databases that cannot control for patient physiology or operative complexity. We hypothesized that time after training would correlate with outcomes.Setting: Five academic institutions.Design: Prospective study of surgeon experience and emergency surgery outcomes. Surgeons were grouped based on years from terminal training. A four-level ordinal scale adjusted for case complexity. Hierarchical logistic regression models were constructed controlling for institution, sepsis, case complexity, pre-op transfusion and trauma or emergency general surgery to assess the impact of experience on morbidity and mortality.Patients: Adult patients who required emergency general surgery operationsInterventions: NoneMain Outcome Measures: mortality, complications, length of stay, blood loss and unplanned return to the operating room.
Results: Of 740 surgeries, later mid-career surgeons operated on older patients, with more physiologic compromise but similar outcomes (table). After adjustment mortality (table), complications, post-op transfusion, organ space surgical site infection, and length of stay were not different between groups. Body cavity closure and ostomy after colectomy were similar between groups. Unplanned returned to the operating room declined with experience then increased in older surgeons though not significantly.
Conclusions: Experienced surgeons may be more willing to operate on physiologically compromised patients without impact on mortality. Differences in unplanned return to the operating room cannot be ruled out.
| Surgeon experience | <6 years | 6-10 years | 11-30 years | >30 years | p |
| n (%) | 353 (46.3) | 272 (35.7) | 84 (11.0) | 53 (6.9) | |
| Age (SD) | 48.8 (19.7) | 47.8 (19.6) | 56.8 (20.5) | 47.6 (19.0) | 0.003 |
| Functional status n (%) | |||||
| Independent | 336 (95.2) | 265 (97.4) | 78 (92.8) | 42 (91.3) | 0.200 |
| Partially dependent | 11 (3.1) | 7 (2.6) | 5 (5.6) | 3 (6.5) | |
| Totally dependent | 6 (1.7) | 0 (0) | 1 (1.2) | 1 (2.2) | |
| Ventilator dependence n(%) | 44 (12.3) | 29 (10.3) | 13 (15.3) | 4 (8.7) | 0.547 |
| Ascites n (%) | 18 (5.0) | 11 (3.9) | 8 (9.4) | 0 (0) | 0.078 |
| Acute renal failure n (%) | 57 (15.9) | 23 (8.1) | 16 (18.8) | 9 (19.6) | 0.007 |
| Sepsis n (%) | |||||
| SIRS | 98 (27.3) | 66 (23.4) | 7 (8.3) | 20 (43.5) | <0.001 |
| Sepsis | 36 (10.0) | 34 (12.1) | 6 (7.1) | 1 (2.2) | |
| Septic shock | 39 (10.8) | 17 (6.0) | 13 (15.5) | 2(4.4) | |
| Hemorrhagic shock n (%) | 68 (18.9) | 53 (18.8) | 14 (16.5) | 9 (19.6) | 0.957 |
| Case complexity n (%) | |||||
| I – least complex | 30 (8.4) | 18 (6.4) | 5 (5.9) | 5 (10.8) | 0.552 |
| II | 143 (39.8) | 114 (40.4) | 31 (36.5) | 20 (43.5) | |
| III | 156 (43.5) | 133 (47.2) | 46 (54.1) | 17 (36.9) | |
| IV – most complex | 30 (8.4) | 17 (6.0) | 3 (3.5) | 4 (8.7) | |
| Emergency Surgery Score | 3.7 (2.5) | 3.4 (2.5) | 4.2 (3.1) | 3.5 (2.5) | 0.067 |
| Body cavity closed n (%) | 248 (72.3) | 200 (72.2) | 59 (72.0) | 30 (76.9) | 0.938 |
| Ostomy created n(%) | 30 (10.9) | 33 (12.0) | 10 (12.2) | 0 (0) | 0.105 |
| Mortality n(%) | 31 (9.0) | 26 (9.6) | 11 (13.3) | 3 (7.1) | 0.638 |
| Adjusted OR (95% CI) for mortality | Reference | 1.26 (0.66-2.40) | 1.15 (0.48-2.76) | 1.08 (0.28-4.20) | |
| Total complications n (%) | 1[0-2] | 0 [0-1] | 0 [0-2] | 0 [0-2] | 0.310 |
| Organ Space SSI n (%) | 38 (11.1) | 20 (7.4) | 9 (10.8) | 2 (4.8) | 0.289 |
| Wound Dehiscence n (%) | 6 (1.8) | 10 (1.4) | 2 (2.4) | 1 (2.4) | 0.518 |
| Post-op PRBCs (median) | 0 | 0 | 0 | 0 | 0.198 |
| Unplanned return to the operating room (OR) n (%) | 53 (15.5) | 28 (10.3) | 5 (6.0) | 7 (16.7) | 0.051 |
| Adjusted OR (95% CI) for return to the OR | Reference | 0.73 (0.42-1.28) | 0.40 (0.14-1.13) | 0.87 (0.33-2.29) | |
| Length of Stay | 8.0 | 8.0 | 10.0 | 6.0 | 0.021 |
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