背景:手术技巧,获得的智慧的总结,深思熟虑的实践和经验,与改善患者预后有关。对病理和手术技术的分级指导是外科培训的基石。阑尾切除术是外科手术学员独立执行的首批程序之一。我们假设,考虑到外科的嵌入式训练精神,再加上实现培训师对独立能力的认可所需的陡峭学习曲线,阑尾切除术治疗急性阑尾炎后的“真实世界”临床结果是操作者不可知的。分级自主的原则与他们可以独立管理的临床条件相匹配,复杂性的增加驱动着对护理技术方面的投入或假设,因此,无法检测到操作员经验对结果的影响。
方法:本研究是SnapAppy国际有时限的前瞻性观察队列研究的亚组分析(ClinicalTrials.gov试验#NCT04365491),包括在2020-2021年3个月期间接受阑尾炎阑尾切除术的所有年龄≥15岁的连续患者.特定于患者和外科医生的变量,以及术后90天的结果,被收集。根据手术医生的经验对患者进行分组(仅限受训者,直接参加监督的实习生,仅出席)。使用泊松和分位数回归模型(针对患者相关的混杂因素进行校正)评估手术经验与术后并发症或住院时间(hLOS)之间的关系。分别,校正了患者相关的混杂因素。感兴趣的主要结果是90天内的任何并发症。
结果:共纳入来自14个国家71个中心的4,347名患者。受训者手术的患者年龄较小(中位数(IQR)33[24-46]vs38[26-55]岁,p<0.001),ASA分类较低(ASA≥3:6.6%对11.6%,p<0.001),与主治医生相比,合并症较少。此外,受训者单独手术治疗阑尾穿孔患者较少(AAST严重程度≥3级:8.7%vs15.6%,p<0.001)。回归分析显示,操作员经验与并发症之间没有关联(受训者与参加的IRR1.0395CI0.83-1.28;受监督的受训者与参加的IRR1.1395CI0.89-1.42)或hLOS。
结论:在毕业自主性背景下,病例复杂性与操作者经验的联系是外科培训的中心原则。要么下意识地,或者通过设计,受训者手术的病人更年轻,更健康,患有早期疾病。至少在某种程度上,这些解释了为什么阑尾切除术后的临床结局不会因手术外科医生的经验而有所不同.
BACKGROUND: Surgical skill, a summation of acquired wisdom, deliberate practice and experience, has been linked to improved patient outcomes. Graded mentored exposure to pathologies and operative techniques is a cornerstone of surgical training. Appendectomy is one of the first procedures surgical trainees perform independently. We hypothesize that, given the embedded training ethos in surgery, coupled with the steep learning curve required to achieve trainer-recognition of independent competency, \'real-world\' clinical outcomes following appendectomy for the treatment of acute appendicitis are operator agnostic. The principle of graded autonomy matches trainees with clinical conditions that they can manage independently, and increased complexity drives attending input or assumption of the technical aspects of care, and therefore, one cannot detect an impact of operator experience on outcomes.
METHODS: This study is a subgroup analysis of the SnapAppy international time-bound prospective observational cohort study (ClinicalTrials.gov Trial #NCT04365491), including all consecutive patients aged ≥ 15 who underwent appendectomy for appendicitis during a three-month period in 2020-2021. Patient- and surgeon-specific variables, as well as 90-day postoperative outcomes, were collected. Patients were grouped based on operating surgeon experience (trainee only, trainee with direct attending supervision, attending only). Poisson and quantile regression models were used to (adjusted for patient-associated confounders) assess the relationship between surgical experience and postoperative complications or hospital length of stay (hLOS), respectively, adjusted for patient-associated confounders. The primary outcome of interest was any complications within 90 days.
RESULTS: A total of 4,347 patients from 71 centers in 14 countries were included. Patients operated on by trainees were younger (Median (IQR) 33 [24-46] vs 38 [26-55] years, p < 0.001), had lower ASA classifications (ASA ≥ 3: 6.6% vs 11.6%, p < 0.001) and fewer comorbidities compared to those operated on by attendings. Additionally, trainees operated alone on fewer patients with appendiceal perforation (AAST severity grade ≥ 3: 8.7% vs 15.6%, p < 0.001). Regression analyses revealed no association between operator experience and complications (IRR 1.03 95%CI 0.83-1.28 for trainee vs attending; IRR 1.13 95%CI 0.89-1.42 for supervised trainee vs attending) or hLOS.
CONCLUSIONS: The linkage of
case complexity with operator experience within the context of graduated autonomy is a central tenet of surgical training. Either subconsciously, or by design, patients operated on by trainees were younger, fitter and with earlier stage disease. At least in part, these explain why clinical outcomes following appendectomy do not differ depending on the experience of the operating surgeon.