Non-fellowship Trained Surgeons Research Articles

The Predictors of Incidental Durotomy in Patients Undergoing Pedicle Subtraction Osteotomy for the Correction of Adult Spinal Deformity.

Background: Pedicle subtraction osteotomy (PSO) is a powerful tool for sagittal plane correction in patients with rigid adult spinal deformity (ASD); however, it is associated with high intraoperative blood loss and the increased risk of durotomy. The objective of the present study was to identify intraoperative techniques and baseline patient factors capable of predicting intraoperative durotomy. Methods: A tri-institutional database was retrospectively queried for all patients who underwent PSO for ASD. Data on baseline comorbidities, surgical history, surgeon characteristics and intraoperative maneuvers were gathered. PSO aggressiveness was defined as conventional (Schwab 3 PSO) or an extended PSO (Schwab type 4). The primary outcome of the study was the occurrence of durotomy intraoperatively. Univariable analyses were performed with Mann-Whitney U tests, Chi-squared analyses, and Fisher's exact tests. Statistical significance was defined by p < 0.05. Results: One hundred and sixteen patients were identified (mean age 61.9 ± 12.6 yr; 44.8% male), of whom 51 (44.0%) experienced intraoperative durotomy. There were no significant differences in baseline comorbidities between those who did and did not experience durotomy, with the exception that baseline weight and body mass index were higher in patients who did not suffer durotomy. Prior surgery (OR 2.73; 95% CI [1.13, 6.58]; p = 0.03) and, more specifically, prior decompression at the PSO level (OR 4.23; 95% CI [1.92, 9.34]; p < 0.001) was predictive of durotomy. A comparison of surgeon training showed no statistically significant difference in durotomy rate between fellowship and non-fellowship trained surgeons, or between orthopedic surgeons and neurosurgeons. The PSO level, PSO aggressiveness, the presence of stenosis at the PSO level, nor the surgical instrument used predicted the odds of durotomy occurrence. Those experiencing durotomy had similar hospitalization durations, rates of reoperation and rates of nonroutine discharge. Conclusions: In this large multisite series, a history of prior decompression at the PSO level was associated with a four-fold increase in intraoperative durotomy risk. Notably the use of extended (versus) standard PSO, surgical technique, nor baseline patient characteristics predicted durotomy. Durotomies occurred in 44% of patients and may prolong operative times. Additional prospective investigations are merited.

Clinical Decision Making in Open vs Arthroscopic Rotator Cuff Repair: Evidence for Preoperative Decision Making

Objective: To further understand what factors should be considered when deciding to do mini-open versus arthroscopic rotator cuff repair. Methods: A systematic literature search on the computer was done with the help of the PubMed database. Of the articles searched through, three have been chosen to specifically address topics of interest concerning the factors affecting arthroscopic vs mini-open RCR surgical approaches. Discussion: As we continue to progress down the line of factors impacting a clinician’s decision making, we begin to see how postoperative management is unchanged. Tear severity lacks sufficient evidence to base a decision on, but financial, educational, and logistical factors are proven to play a significant role in this decision. Conclusion: As of right now it seems that mini-open RCR is the most cost and time efficient method, especially amongst non-fellowship trained surgeons or ones with lower volume of shoulder scopes. However, further studies should be done to examine cost and efficiency in Sport Medicine fellowship trained orthopedic surgeons to validate these findings.

Self-Appraised Readiness of Senior and Graduating General Surgery Residents to Perform Thoracic Surgery

General surgeons perform up to 50% of noncardiac thoracic surgery (TS). Although data show consistent TS case volume during general surgery (GS) residency it is unknown whether this operative trend will persist given potentially limited subspecialty exposure. We sought to determine if certain aspects of residency programs and resident characteristics were associated with trainees' perceived comfort in performing certain basic TS procedures. An anonymous survey was distributed to GS residents regarding program characteristics, presence of a TS residency, and intent to pursue thoracic surgical training, and estimated case volumes of individual procedures. Comfort levels for performing video-assisted thoracoscopic surgical (VATS) procedures, open lobectomy, elective thoracotomy, and sternotomy were attained through a 5-point Likert-type scale. This survey was administered at 50 training programs with responses recorded via an online form. Fourth- and fifth-year GS residents in the United States. Of 272 respondents 58% were fourth-year residents, 62% of residents trained at university-affiliated programs, and 64% reported a TS residency program at their institution and 16% stated intent to pursue TS. Fifth-year residents performed significantly more cases than fourth-year residents despite no difference in median comfort levels. Residents intending to pursue TS performed significantly more cases and were more comfortable performing a thoracotomy, sternotomy, VATS wedge resection/biopsy, and VATS decortication/pleurodesis (p = 0.044, <0.001, 0.045, 0.025). No characteristics were associated with comfort performing a lobectomy via thoracoscopic or open (thoracotomy) approaches. Most senior or graduating GS residents state they are comfortable performing certain thoracic procedures with those pursuing additional thoracic surgical training more comfortable overall. No characteristics were associated with comfort performing a lobectomy. These findings may advise residency curriculum design to ensure continued thoracic surgical exposure and recommend against non-fellowship trained surgeons performing a pulmonary lobectomy.

MP25-19 SURVEY ON THE CONTEMPORARY MANAGEMENT OF INTRAOPERATIVE URETHRAL INJURIES DURING PENILE PROSTHESIS IMPLANTATION

You have accessJournal of UrologySexual Function/Dysfunction: Surgical Therapy I1 Apr 2017MP25-19 SURVEY ON THE CONTEMPORARY MANAGEMENT OF INTRAOPERATIVE URETHRAL INJURIES DURING PENILE PROSTHESIS IMPLANTATION Stephanie J. Sexton, Michael A. Granieri, and Aaron C. Lentz Stephanie J. SextonStephanie J. Sexton More articles by this author , Michael A. GranieriMichael A. Granieri More articles by this author , and Aaron C. LentzAaron C. Lentz More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.769AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Intraoperative urethral injury is an uncommon event during the placement of an inflatable penile prosthesis (IPP) with an estimated incidence of up to 3%. The conventional teaching is to perform primary repair, place a transurethral catheter, and abort the procedure. Recently, alternative management strategies have been proposed with continuation of the implant following urethral injury. The objective of this study is to evaluate surgeon management of urethral injury during IPP and determine if fellowship training influences practice. METHODS An online survey was sent to the society listservs of the Genitourinary Reconstructive Surgeons (GURS) and The Sexual Medicine Society of North America (SMSNA). Physicians were queried on their fellowship training, experience with IPP and urethroplasty, IPP surgical approach, and management of urethral injuries during IPP implantation. The response data was analyzed using SAS 9.4 (SAS Institute Inc., Cary, NC). Chi-squared test and Fisher's exact test were used to determine associations between variables. RESULTS There were a total of 131 survey responses. Of the responders, 41.2% were GURS fellowship trained, 19.1% were SMSNA trained, 30.5% were non-fellowship trained, and 9.2% trained in other fellowships. 25.4% of participants perform >50 IPPs per year, while 37.7% perform 20-50 and 36.9% perform fewer than 20 per year. Urethral injury during IPP implantation was uncommon, with 26.2% reporting 0 injuries, 58.5% reporting 1-3 injuries, and 15.4% reporting >3 career injuries. Injuries were most commonly encountered during corporal dilation (71.1%), compared to corporal exposure (12.5%), or penile straightening maneuvers (7.0%). There was no statistically significant difference with aborting or continuing implantation among GURS, SMSNA, and/or non-fellowship trained surgeons. Of all responders, 55% abort the procedure after distal urethral injury, while 45% continue the procedure with unilateral or bilateral insertion of cylinders. For those who chose to abort the procedure, the next implant was attempted in <6 weeks in 9.3%, 6-12 weeks in 45.7%, and >12 weeks in 41.1%. Patient factors that increased likelihood of aborting procedure in the case of urethral injury included immunosuppression, spinal cord injury, and clean intermittent catheterization-dependence. CONCLUSIONS Urethral injury during IPP implantation is a rare but established risk of the procedure. Fellowship training does not appear to have an effect on intraoperative management of this injury. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e318 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Stephanie J. Sexton More articles by this author Michael A. Granieri More articles by this author Aaron C. Lentz More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Trends in Primary and Revision Hip Arthroplasty Among Orthopedic Surgeons Who Take the American Board of Orthopedics Part II Examination

BackgroundA certified list of all operative cases performed within a 6-month period is a required prerequisite for surgeons taking the American Board of Orthopaedic Surgery Part II oral examination. Using the American Board of Orthopaedic Surgery secure Internet database database containing these cases, this study (1) assessed changing trends for primary and revision total hip arthroplasty (THA) and (2) compared practices and early postoperative complications between 2 groups of examinees, those with and without adult reconstruction fellowship training. MethodsSecure Internet database was searched for all 2003-2013 procedures with a Current Procedural Terminology code for THA, hip resurfacing, hemiarthroplasty, revision hip arthroplasty, conversion to THA, or removal of hip implant (Girdlestone, static, or dynamic spacer). ResultsAdult reconstruction fellowship-trained surgeons performed 60% of the more than 33,000 surgeries identified (average 28.1) and nonfellowship-trained surgeons performed 40% (average 5.2) (P < .001). Fellowship-trained surgeons performed significantly more revision surgeries for infection (71% vs 29%)(P < .001). High-volume surgeons had significantly fewer complications in both primary (11.1% vs 19.6%) and revision surgeries (29% vs 35.5%) (P < .001). Those who passed the Part II examination reported higher rates of complications (21.5% vs 19.9%). ConclusionIn early practice, primary and revision hip arthroplasties are often performed by surgeons without adult reconstruction fellowship training. Complications are less frequently reported by surgeons with larger volumes of joint replacement surgery who perform either primary or more complex cases. Primary hip arthroplasty is increasingly performed by surgeons early in practice who have completed an adult reconstructive fellowship after residency training. This trend is even more pronounced for more complex cases such as revision or management of infection.

Impact of Robotic Fellowship Experience on Perioperative Outcomes of Robotic-Assisted Laparoscopic Partial Nephrectomy

Background: We analyzed differences in patient selection and perioperative outcomes between robotic-fellowship trained and non-fellowship trained surgeons in their initial experience with robotic-assisted laparoscopic partial nephrectomy. Methods: Data through surgeon case 10 was analyzed. Forty patients were identified from two fellowship trained surgeons (n = 20) and two non-fellowship trained surgeons (n = 20). Results: Fellowship trained surgeons performed surgery on masses of higher nephrometry score (8.0 vs. 6.0, p = 0.007) and more posterior location (60 vs. 25%, p = 0.03). Retroperitoneal approach was more common (50 vs. 0%, p = 0.0003). Fellowship trained surgeons trended toward shorter warm ischemia time (25.5 vs. 31.0 min, p = 0.08). There was no significant difference in perioperative complications (35 vs. 35%, p = 0.45) or final positive margin rates (0 vs. 15%, p = 0.23). Conclusion: Fellowship experience may allow for treating more challenging and posterior tumors in initial practice and significantly more comfort performing retroperitoneal robotic-assisted laparoscopic partial nephrectomy.

Association between Fellowship Training, Surgical Volume, and Laparoscopic Suturing Techniques among Members of the American Association of Gynecologic Laparoscopists.

Study Objective. To compare surgical volume and techniques including laparoscopic suturing among members of the American Association of Gynecologic Laparoscopists (AAGL) according to fellowship training status. Design. A web-based survey was designed using Qualtrics and sent to AAGL members. Results. Minimally invasive gynecologic surgery (FMIGS) trained surgeons were more likely to perform more than 8 major conventional laparoscopic cases per month (63% versus 38%, P < 0.001, OR [95% CI] = 2.78 [1.54–5.06]) and were more likely to perform laparoscopic suturing during these cases (32% versus 16%, P < 0.004, OR [95% CI] = 2.44 [1.25–4.71]). The non-fellowship trained (NFT) surgeons in private practice were less likely to perform over 8 conventional laparoscopic cases (34% versus 51%, P = 0.03, OR [95% CI] = 0.50 [0.25–0.99]) and laparoscopic suturing during these cases (13% versus 27%, P = 0.01, OR [95% CI] = 0.39 [0.17–0.92]) compared to NFT surgeons in academic practice. Conclusion. The surgical volume and utilization of laparoscopic suturing of FMIGS trained surgeons are significantly increased compared to NFT surgeons. Academic practice setting had a positive impact on surgical volume of NFT surgeons but not on FMIGS trained surgeons.

Advanced laparoscopic fellowship training decreases conversion rates during laparoscopic cholecystectomy for acute biliary diseases: A retrospective cohort study

Introduction: Acute biliary pathology is a risk factor for conversion to open surgery and increased surgical morbidity during laparoscopic cholecystectomy (LC). The purpose of our study was to examine the impact of an advanced laparoscopic fellowship-trained surgeon on risks of conversion, surgical morbidity, and postoperative complications in this patient population. Methods: Of 1382 patients who underwent an LC from January 2008 to August 2011, 592 patients were diagnosed with an acute biliary process and were included in the study. Patients were divided into two groups; those operated on by an advanced laparoscopic fellowship-trained surgeon (N = 237), and those operated on by a non-laparoscopic fellowship-trained surgeon (N = 355). The primary end-points were conversion rates and surgical morbidity. The secondary end-point was operative time. Results: Fellowship-trained surgeons were more likely to perform IOC (57%) versus non-fellowship trained surgeons (20%) (p < 0.0001). The conversion rate for the fellowship-trained group was significantly lower than for the non-fellowship trained group (1.7% vs 8.5%, p = 0.0004). The intraoperative and postoperative complication rates for the fellowship-trained group were not significantly different. The operative time was slightly longer in the non-fellowship trained group compared to the fellowship-trained group (104 min vs 111 min, p = 0.04). Discussion: Our data demonstrate that advanced laparoscopic fellowship training decreases conversion rates of laparoscopic cholecystectomy for acute biliary pathology. Moreover, given the lower conversion rates, patients may have experienced shorter hospitalizations. Conclusions: Formal advanced laparoscopic fellowship training may decrease length of stay among patients presenting with acute biliary pathology who undergo laparoscopic cholecystectomy.

The impact of fellowship training on pathological outcomes following radical prostatectomy: a population based analysis.

BackgroundRadical prostatectomy (RP) is a common treatment for prostate cancer (PCa). Morbidity, mortality and pathological outcomes may be superior in academic institutions. One explanation may be the involvement of oncology fellowship trained urologists within academic institutions. The literature examining pathological outcomes often lacks individual surgeon data. The objective of this study was to compare pathological outcomes following RP between fellowship trained and non-fellowship trained urologists.MethodsPopulation-based, retrospective chart review of men diagnosed with PCa between 2003 and 2008, the majority treated with open approach RP (>99%). Pathological outcomes were compared between oncology fellowship trained academic (FTA), non-fellowship trained academic (NFTA) and non-academic (NA) urologists. Relationships with pathological outcomes were examined utilizing multivariable logistic regression.Results83.1% of eligible patients were included in our analysis resulting in 1075 patients. In multivariable analysis, surgeon group was an independent predictor of positive surgical margin (PSM) (p < 0.0001). NFTA and NA urologists were more likely to have PSM compared to FTA urologists (OR 2.50; 95% CI: 1.44 - 4.35 and OR 2.10; 95% CI: 1.53 - 2.88, respectively). However, the proportion of PSM between NFTA and NA urologists was not significant (p = 0.492). In addition, pathological stage (p = 0.0004), Gleason sum (p < 0.0001), and surgeon volume (p = 0.017) were associated with PSM. Limitations include retrospective design and lack of clinical and functional outcomes.ConclusionsUro-oncology fellowship trained surgeons had significantly lower rates of PSM than non-fellowship trained surgeons in this population based cohort. This study demonstrates the importance of surgeon-related variables on pathological outcomes and highlights the value of additional urologic oncology fellowship training.

Does Specialized Surgical Training Increase Lymph Node Yield in Colon Cancer?

Most colon cancer resections do not meet the 12-lymph node minimum recommended in 2001 National Cancer Institute (NCI) panel guidelines. Previous reports suggest surgical training influences lymph node recovery. We hypothesized that recent trends show improved results for lymphadenectomy regardless of specialty. The cancer registry database at a large community hospital with an academic surgical oncology training program was queried to identify resections performed for colon cancer before (1995 to 2000) and after (2001 to 2006) NCI guideline publication. There were no changes in pathology procedures between 374 early and 411 later procedures. The later period brought increases in mean total lymph nodes (15.4 vs 10.4, P < 0.0001), total positive nodes (1.8 vs 1.2, P = 0.005), and the percentage of procedures yielding 12 or more nodes (overall: 65.9 vs 36.0%, P < 0.0001; Stage II and III disease: 73.0 vs 41.4%, P < 0.003). In addition, mean nodal yield increased (P < 0.0001) for fellowship-trained surgeons (16.7 vs 11.2) and nonfellowship-trained surgeons (14.9 vs 10.2). Single-registry data show that since 2001, most colon resections exceed minimum recommendations for lymph node recovery regardless of surgical training. The increased rate of adequate lymphadenectomy for Stage II and III disease is encouraging because this patient population will benefit most by accurate staging of colon cancer.

Postoperative bracing after spine surgery for degenerative conditions: a questionnaire study

Background context A variety of orthoses are routinely applied after spinal procedures but there are limited data regarding their efficacy, especially with the increasing use of internal fixation. At this time, the proper indications for postoperative bracing are not well established. Purpose To assess the postoperative bracing patterns of spine surgeons. Study design/setting Questionnaire study. Patient sample Spine surgeons attending the “Disorders of the Spine” conference (January 2008, Whistler, Canada). Outcome measures Frequencies of bracing after specific surgical procedures. Methods A single-page questionnaire was distributed to all spine surgeons attending the “Disorders of the Spine” conference (January 2008). The questionnaire focused on whether surgeons typically immobilize patients after specific spinal procedures, the type of orthosis used, the duration of treatment, and the rationale for bracing. Results Ninety-eight of 118 surgeons completed the survey (response rate: 83%). The frequency of bracing was similar between academic and private as well as orthopedic and neurosurgical practices. The difference in the bracing tendencies of fellowship and non-fellowship trained surgeons was found to be statistically significant (61% vs. 46%, p<.0001). The duration of clinical experience did not appear to influence the propensity of surgeons to use orthoses. Bracing was employed more regularly after cervical spine procedures than surgeries involving the lumbar spine (63% vs. 49%, p<.0001). In the anterior cervical spine, orthoses were used more often as the complexity of the procedure increased from single to multilevel constructs (55% vs. 76%, p<.0001). The frequencies of bracing were not significantly different between noninstrumented and instrumented lumbar fusions. In most cases, bracing was continued for a total of 3-8 weeks and the restriction of patient activity was the most common reason cited by surgeons who use orthoses. Conclusions Although most of the respondents brace their patients postoperatively, there is an obvious lack of consensus regarding the most appropriate type, duration, and indications for immobilization. Further prospective, clinical studies may play a helpful role in evaluating the efficacy of postoperative bracing protocols.