Analysis of operative outcomes for hysterectomy as treatment for endometrial cancer when performed by surgical trainees: An ACS-NSQIP study (407)

Abstract

<b>Objectives:</b> Endometrial cancer is the most common gynecologic malignancy in the United States. Hysterectomy remains the primary treatment for endometrial cancer, with the most common complications in the early postoperative period being urinary retention and deep venous thrombosis. The literature has identified that these complication rates differ by the volume of the hospital and the experience of the surgeon. This has led to a common perception that the involvement of physicians-in-training could be detrimental to patient health. More than 90% of hysterectomies for endometrial cancer are performed by gynecologist oncologists, where generalist gynecologists typically perform cases with less complex diseases. More complex procedures often occur at large academic centers and include trainees in surgery. A broad survey showed that only 40% of incoming gynecology oncology fellows felt comfortable performing a hysterectomy independently, indicating a robust need for more tailored residency training (Urban et al., 2019). This study aimed to identify the operative outcomes of surgical management of endometrial cancer stratified by trainee involvement. <b>Methods:</b> The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for all hysterectomies done between 2005 and 2016, identified by using the appropriate CPT codes. Cases were stratified for treating endometrial cancer by identifying ICD-9 code 182.0 as postoperative diagnosis and further stratified by training year as coded by NSQIP: PGY-Junior, PGY-Senior, PGY-Fellow, PGY-Attending for a total of 2,039 cases. Univariate analysis, independent t-test, ANOVA, and multivariate logistic regression were applied where applicable to analyze significance. SPSS version 25.0 was used, and significance was set at p<0.05. <b>Results:</b> Operative time was increased for cases performed by residents and fellows compared to attendings (Junior 179.55±76.3 minutes vs Senior 174.55±73.5 minutes vs Fellow 187.9±84.7 minutes vs Attending 126.82±65.5 minutes, p<0.001). Cases involving trainees also had an increase in anesthesia duration compared to cases with attendings as primary surgeons. There was no significant difference identified in the length of hospital stay between the groups. Re-admission rates and re-operation rates were relatively similar among the cohorts, while fellow cases had an increased rate of unplanned re-admission compared to the other groups (unplanned re-admission rates: Junior 1.3% vs Senior 1.1% vs Fellow 3.3% vs Attending 0.8%, p=0.013). There was no difference in medical or surgical complication rates amongst the cohorts. <b>Conclusions:</b> Including trainees in surgical procedures increases operative and anesthesia time but does not increase the complication rate. Increases in operative and anesthesia time can be partially explained by additional time invested by attendings to teach trainees. Time devoted by attending physicians during surgical cases is invaluable in developing confident and skilled surgeons. The data set revealed higher re-admissions in the cases involving fellows. This difference may be due to a higher level of autonomy given by attendings to fellows in the operating room. Further studies should be conducted to help elucidate the specific role of the trainee in this environment in order to help bridge the gap that currently exists between residency training and conducting independent hysterectomies for endometrial cancer.