Jul 27, 1998 - Senior House Officer. K K Madhavan MS FRCSEd. Consultant Surgeon. S Paterson-Brown MS FRCSEd. Consultant Surgeon. R K Praseedom ...
Ann R Coll Surg Engl 1999; 81: 40-45
Role of the surgical trainee in upper gastrointestinal resectional surgery A M Paisley
MA FRCSEd Senior House Officer K K Madhavan MS FRCSEd Consultant Surgeon S Paterson-Brown MS FRCSEd Consultant Surgeon
R K Praseedom MS FRCSEd Specialist Registrar 0 J Garden MD FRCSGIas FRCSEd Professor of Surgery
University Department of Surgery, Royal Infirmary of Edinburgh
Key words: Training; Surgery; Gastrointestinal
The 'New Deal' set out by the Department of Health in 1991, together with the introduction of specialist 6-year training grades by Calman in 1993, has resulted in a decrease in available training time for surgeons in the UK. There is also an emerging belief that surgical procedures performed by trainees might compromise patient outcome. This study examines the level of trainee experience in a specialist gastrointestinal unit and whether operation by a trainee surgeon adversely affects patient outcome. All patients in the University Department of Surgery, Royal Infirmary, Edinburgh, undergoing oesophagogastric, hepatic or pancreatic resection between January 1994 and December 1996 were entered into the study. The early clinical outcome (in-hospital mortality and morbidity, considered in three groups: anastomotic leak, other techniquerelated complications and non-technique-related complications) was evaluated with regard to the grade of surgeon (consultant or trainee) performing the operation. Of the 222 patients undergoing major upper gastrointestinal resection during the study period, 100 (45%) were operated on by trainees. Trainees were assisted and closely supervised by consultants in all but six resections. There was no major difference in mortality rate (consultant, 4.1% vs trainee, 5%), incidence of non-technique-related complications (consultant, 6.7% vs trainee, 7.1%), anastomotic leaks (consultant, 10.7% vs trainee, 5%) or technique-related complications (consultant, 18.9% vs trainee, 15%) between the two grades of surgeon.
Correspondence to: Miss A M Paisley, University Department of Surgery, Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh EH3 9YW
In a specialist unit, the early clinical outcome of patients undergoing major upper gastrointestinal resection by supervised trainees is no worse than in those operated on by consultants. Participation of trainees in such complex procedures enhances surgical training and does not jeopardise patient care.
During recent years, the organisation of surgical training has come under review in the UK. The 'New Deal' set out by the Department of Health in 1991 has led to a marked reduction in surgical trainees' hours of work (1). This, together with the introduction by Calman in 1993 of specialist 6-year training grades (2), has resulted in a significant decrease in available training time (3) and subsequent limitation of exposure to surgical procedures (4-6). Experience for surgical trainees is also suffering owing to changing clinical practice (7). Increased subspecialisation has removed a range of procedures from the operative repertoire of younger trainees (8), and the introduction of minimal access surgery has resulted in an increasing number of procedures that were previously carried out by junior trainees now being performed by consultants (9). Furthermore, there is an emerging belief that surgical procedures performed by trainees might compromise patient outcome as a result of longer operating times, prolonged hospital stay and an increased complication rate. Minor and intermediate procedures, previously performed by trainees, are now carried out by consultants on the assumption that this will ensure minimal operating times and reduce the potential for complication (10). Patients, now better informed than in the past, increasingly expect consultant-based care and are more likely to seek compensation if complications do occur.
Role of the surgical trainee The result of these changes is likely to be a decrease in the involvement of the trainee surgeon in the overall perioperative care of patients. This will in turn lead to a significant decrease in the quality of surgical training, particularly in the more complex procedures. Although the crucial issue would appear to be the safety of patients undergoing major surgical procedures performed by trainees (8), there are little data available which address this question directly. While recent UK studies on varicose vein surgery (11), hip replacement (12) and lower limb amputation (13) have found that unsupervised trainee surgeons do have a higher rate of complications than the consultants who train them, other studies from the USA and Israel considering carotid endarterectomy (14), pancreaticoduodenectomy (15), biliary surgery (16), and thyroid surgery (17), have shown that this is not the case for supervised trainees. The University Department of Surgery, Royal Infirmary, Edinburgh, has a major subspecialty interest and tertiary referral practice in all aspects of upper gastrointestinal surgery with a large number of procedures carried out each year. In an attempt to address the potential problems associated with surgical training, we have compared the early clinical outcome of all patients in the unit undergoing major upper gastrointestinal resections with regard to the grade of surgeon performing the operation.
Patients and methods During a 3-year period, from January 1994 to December 1996, details of all patients in the University Department of Surgery, Royal Infirmary, Edinburgh, undergoing elective or emergency oesophagogastric, hepatic or pancreatic resection, for either benign or malignant disease, were collected prospectively. Owing to the small number, solitary bile duct excisions were excluded, as was all nonresectional surgery and other lesser upper gastrointestinal resections such as cholecystectomy and splenectomy. Patient characteristics and details of the operation, including procedure performed, grade and name of first surgeon and assistant were all recorded using the Lothian Surgical Audit data system. Patients were followed up daily until discharge from hospital or death and major complications recorded. The data obtained were then compared to determine whether the grade of surgeon performing the operation made any difference to the early clinical outcome. This study did not consider long-term follow-up, with no information being collected on disease recurrence or long-term survival. Mortality was defined as in-hospital death, irrespective of the time from resection. Morbidity was considered in three groups: anastomotic leaks; technique-related complications; and non-technique-related complications. Postoperative anastomotic leaks were diagnosed by the persistent presence of significant quantities of amylaserich, biliary or enteric fluid in the abdominal drains, associated with a clinical deterioration in patient condition; all cases were confirmed by contrast radiology.
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Technique-related complications included non-anastomotic leaks, for example from the duodenal stump after a gastrectomy, bile leak from the liver edge after hepatic resection or from the pancreatic stump after distal pancreatectomy; persistent ileus, defined as persistent vomiting or high nasogastric output in the absence of mechanical gastric outlet obstruction as indicated by contrast radiology; intra-abdominal collection requiring drainage, postoperative haemorrhage, acute liver failure, small bowel perforation, hepatic abscess and omental prolapse. Non-technique-related complications were defined as those not directly related to the surgical procedure which prolonged hospital stay, and included myocardial infarction, major chest infection, pulmonary embolus, cerebrovascular accident, persistent ascitic drainage and wound infection confirmed by culture and requiring debridement or drainage. More minor complications such as pulmonary atelectasis, urinary tract infection, minor superficial wound infection, which did not prolong time to discharge, were excluded. The surgery was regarded as being performed by the trainee if they carried out the resection and anastomoses. Consultants were able to advise the trainee on procedure and help with certain difficult components of the operation. The trainee was considered to be consultant supervised if the consultant was scrubbed in theatre and actively assisting in the procedure. The four consultants involved in the study work as a team, each participating in the postoperative care of each other's patients and we therefore consider the postoperative management of all the patients to be uniform. No attempt was made to randomise the patient groups and the decision to allow a trainee to proceed with an operation was dependent on individual patient details, experience of the trainee and familiarity of the trainee to the consultant. As such, the two groups are highly selected and statistical comparison inappropriate.
Results Patients In all, 222 patients (114 males, 108 females), with an average age of 57.5 years (range 11-81 years), underwent major upper gastrointestinal resections in the 3-year study period. Of the resections, 164 (74%) were carried out for malignant disease and 58 (26%) for benign conditions. Of the patients, 122 (55%) were operated on by consultants and 100 (45%) by trainees. The age, sex distribution, proportion of malignant and benign disease and percentage of emergency procedures were similar in both consultant and trainee groups (Table I).
Operative details Trainee experience Of the 222 resections, 70 (31.5%) were oesophagogastric, 73 (32.9%) were hepatic and 79 (35.6%) were pancreatic.
42
A M Paisley
et
al.
Table I. Patient demographics of 222 major resections Consultant
Trainee
1:1 Male: Female 1.13:1 Mean 55.3 years 60.3 years Range 11-88 years 18-81 years 92:30 72:28 Pathology Malignant: Benign 118:4 98:2 Urgency Elective: Emergency
Sex Age
Table II. Type of resection performed according to grade of surgeon
Oesophagectomy Total gastrectomy Partial gastrectomy
Consultant
Trainee
Total
10 7 7 24 (34.3%) 22
7 12 27 46 (65.7%) 18
17 19 34 70
The distribution of the various operative procedures between consultant and trainee groups is shown in Table II. Trainees performed 46 (65.7%) of the oesophagogastric resections, 28 (38.4%) of the hepatic and 26 (32.9%) of the pancreatic resections. Four consultants performed 122 resections and 11 trainees, of specialist registrar level and above, performed 100 resections. The trainees were assisted and closely supervised by consultants in all but six of the 100 resections. These unsupervised procedures included four polyagastrectomies and two distal gastrectomies Roux-en-Y. All but one of these cases were routine procedures and reflected increasing experience of the trainee. A slightly greater proportion of the more complex resections was carried out by consultants. This is also reflected in the operating times for each procedure, shown in minutes from incision to closure in Table III. Overall, there was very little difference in operating time between surgeon grades.
Right hepatectomy Extended right hepatectomy Left hepatectomy Left lobectomy Segmentectomy
Postoperative details Mortality and morbidity There were ten deaths in the series, five in the consultant group and five in the trainee group, giving mortality rates of 4.1% and 5% respectively. The underlying surgical complications which eventually led to death are shown in Table IV. One death in each group followed emergency
these deaths occurred as a result of anastomotic leak, two after technique-related complications and one after a nontechnique-related complication. Of the five deaths in the trainee group, three occurred after oesophagogastric resection and two after hepatic resection. Three of these deaths followed technique-related complications and two were non-technique-related. The incidence of anastomotic leak, technique-related and non-technique-related complications after the three resection types are shown for both grades of surgeon in Table V.
surgery. Of the five deaths in the consultant group, three after oesophagogastric resection, one after hepatic resection and one after pancreatic resection. Two of
Pancreaticoduodenectomy Distal pancreatectomy Total pancreatectomy
Total
40 12 8 9 4 73
(61.6%)
2 1 6 1 28 (38.4%)
34
20
54
16
6
22
3 53
0 26
3 79
10 7 3 3 45
(67.1%)
(32.9%)
122 (55%)
100 (45%)
222
Table III. Operation time, from incision to closure, of major resections according to grade of surgeon Trainee
Consultant
Oesophagectomy Total gastrectomy Partial gastrectomy Right hepatectomy Extended right hepatectomy Left hepatectomy Left lobectomy Segmentectomy Pancreaticoduodenectomy Distal pancreatectomy Total pancreatectomy
Range (min)
Mean
(min)
n
Range (min)
Mean
n 10 7 7 22
215-360 184-350 100-245 125-355
283 249 163 224
7 12 27 18
165-355 160-241 95-225 105-440
263 213 118 239
10 7 3 3
160-359 225-375 130-300 182-230
253 277 222 202
2 1 6 1
200-205 180 120-265 105
203 180 179 105
34 16 3
215-485 105-505 270-365
319 213 328
20 6 0
275-655 60-405
353 224
(min)
Role of the surgical trainee
43
Table IV. Mortality in 222 major resections according to grade of surgeon Complication leading to death
Consultant
Trainee
Total
1 1 1 3 (6.5%)
6 (8.6%)
(2.2%)
1 1 2 (7.1%)
3 (4.1%)
1
0
1
Oesophagogastric Intrathoracic anastomotic leak Gastroenteric anastomotic leak Duodenal stump leak Pneumonia Myocardial infarction
1 1 1 3 (12.5%)
Hepatic Postoperative haemorrhage Acute liver failure
1 -
1
Pancreatic Portal vein thrombosis
(1.9%) Total
5
10
(4.1%)
(5%)
(4.5%)
Table V. Complications arising from 222 major resections according to grade of surgeon
2 (8.3%) 5 (20.8%)
1 (2.2%) 3 (4.3%) 4 (8.6%) 9 (12.9%)
3 (12.5%)
5 (10.9%) 8 (11.4%)
1 (2.2%) 11 (24.4%)
1 (5.9%) 8 (28.6%) 19 (26.0%)
3 (6.7%)
2 (7.1%) 5 (6.8%)
The overall morbidity and mortality between consultant resections (n = 122) and trainee resections (n = 100) are shown in Fig. 1. There was no difference in mortality rate (consultant, 4.1% vs trainee, 5%) or incidence of nontechnique-related complications (consultant, 6.7% vs trainee, 7.1%) between the two grades of surgeon. However, the consultants did appear to have a higher incidence of anastomotic leaks (consultant, 10.7% vs trainee, 5%) and technique-related complications (consultant, 18.9% vs trainee, 15%) than the trainees, possibly reflecting the increased difficulty of those procedures performed by consultants. As already stated, both consultant and trainee groups were highly selected and hence statistical comparison was considered inappropriate.
10 (18.9%) 7 (13.2%)
4 (15.4%) 14 (17.7%) 3 (11.5%) 1 (12.7%)
Discussion
2 (3.8%)
2 (2.5%)
Consultant
Oesophagogastric Anastomotic leak Technique related Non-technique related Hepatic Anastomotic leak Technique related Non-technique related Pancreatic Anastomotic leak Technique related Non-technique related ? Pli
(1.3%)
5
Trainee
Total
This study has demonstrated that, even with increasing surgical subspecialisation and the reduced training period
-0--
m Consultant El Trainee
20
10
A nastorAtic Lak-
Tcdrniquc RdIaIedComplicutons Ntmn-ecaiique-ReIAWe C-omplienau'on
Figure 1. Overall morbidity and mortality.
44
A M Paisley et al.
available for the trainee surgeon, early clinical outcome in patients undergoing major upper gastrointestinal resections is similar, irrespective of whether a consultant or a supervised trainee performs the procedure. The morbidity and mortality rates obtained in this study lie within the range reported in the literature for oesophagogastric (18,19), hepatic (20) and pancreatic (21) resections. Of the 222 major upper gastrointestinal resections performed in our unit over the 3-year study period, 100 (45%) were carried out by trainees. The proportion of trainee resections in the oesophagogastric group (65.7%) was approximately twice that found in the hepatic and pancreatic groups (35% and 33%, respectively). This can be explained by the large number of the less complex partial gastrectomies undertaken by trainees (trainees, 79.4% vs consultants, 20.6%). While 45°% of resections were carried out 'skin-to-skin' by trainees, certain components of the consultant operations were also performed by trainees. For example, the senior house officer often removes the gallbladder and performs the gastroenterostomy during a pancreaticoduodenectomy, while the junior registrars might undertake the biliary anastomosis. Therefore, specialist training for the trainee extends into those procedures primarily undertaken by the consultant. There is little doubt that our study contains a selection bias, with the trainees performing the more straightforward resections. Some of the consultant-related resections were initiated by trainees, but owing to technical difficulty were taken over by the supervising consultant. A more informative analysis would be obtained if patients were randomised preoperatively to be operated on by either consultant or trainee, with trainee resections being carried out from start to finish by trainees. This approach, while providing more accurate information on a trainee's ability, might be considered unethical. This study is therefore an attempt to evaluate this difficult area in a more realistic and pragmatic way. It is widely believed that the development of postoperative complications is inversely proportional to the experience of the surgeon. Specialist surgeons have also been shown to achieve better results in their area of interest than the generalist undertaking the occasional operation in that field (22-25). However, when determining patient outcome, the perioperative management, often multidisciplinary, provided in specialist units is of equal importance to the experience of the specialist consultant surgeon. Furthermore, the specialist consultant, as is the case in this study, can act as an assistant supervisor rather than prime operator. Our findings are supported by two other studies from North America which demonstrated that outcome after carotid endarterectomy (14) and pancreaticoduodenectomy (15) undertaken by supervised trainees compared favourably with published results. Two other studies have compared the results of consultants with the supervised trainees in the surgical treatment of gallstones (16) and thyroidectomy (17). No difference was observed. In contrast, a detrimental effect on patient outcome after trainee surgery has recently been found by UK
studies into varicose vein surgery (11), total hip replacements (12), and lower limb amputations (13). The trainees were unsupervised in all three studies; indeed, in the first paper, operations performed by consultant-supervised trainees were classed as consultant operations. Furthermore, in all but the amputation study, the characteristics of consultant and trainee groups were not described. It is therefore clear that the level of trainee supervision is the critical factor, and provided the trainee is adequately supervised by a consultant experienced in the procedure in question, patient outcome is not jeopardised. In our study, trainees were assisted and closely supervised by consultants in all but six of the 100 operations. In the past it has been assumed that provided trainees were sharing in the provision of a service then training was being received. However, supervision, adequate training and feedback are essential (26), and experience in the absence of proper instruction and feedback results in confidence but not competence (27). Many published studies have concluded that too little emphasis is placed on supervised operating (28-31). The Confidential Enquiry into Peri-Operative Deaths (CEPOD) of 1987 found that between 30% and 50% of deaths in three English regions (South West, North and North East Thames) had received no consultant input to their management at any stage, with surgical trainees in some hospitals practising as independent 'pseudo consultants'. Lack of consultant supervision in orthopaedic surgery was cited as a major deficiency in emergency hip operations, with only 19% of cases being performed by consultants. The enquiry concluded that regarding juniors as a subconsultant service grade must be avoided (32). The successor to CEPOD, the National Confidential Enquiry into Peri-Operative Deaths in 1990, found the same deficiencies (33), and in 1992, the Committee of Postgraduate Medical Deans (COPMED), identified lack of proper supervision by consultant teachers as one of several weaknesses in the UK system of higher surgical training (34). Adequate trainee supervision in the operating theatre is therefore essential, not only for the safety of patients, but also for adequate training, and a good example of this has recently been well-described by the cardiothoracic unit at Papworth, Cambridge (35).
Conclusion We can conclude from this study that not only is the early clinical outcome in patients undergoing major upper gastrointestinal resections by supervised trainees similar to that in those operated on by consultants, there is also very little difference in operating time. Therefore, there is no longer any excuse for trainees to be denied the supervised training they so obviously require in the surgical specialties. Postoperative surgical results depend on a number of factors, which include specialist multidisciplinary care and surgical expertise. From this study it is clear that, in many cases, the latter can be as effectively provided by a consultant
Role of the surgical trainee supervising rather than performing the operation. Undoubtedly, provision of adequate consultant supervision will require review of job plans, working practice and on-call commitment, but failure to do so will not only jeopardise the next generation of surgeons but could now be considered grounds for withdrawal of trainee posts. We are grateful to Professor Sir David Carter for his support during this study, in addition to the consultant anaesthetists, theatre staff and ward nurses who participated in the multidisciplinary care of the patients studied.
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