Source: Cochrane DD, Kestle JRW. The influence of surgical Cochrane DD, Kestle JRW. The influence of surgical operative experience on the duration of first ventriculoperitoneal shunt function and infection. Pediatr Neurosurg. 2003;38:295–301.In recent years there have been remarkable efforts to quantify the outcomes of frequently performed surgical procedures. These efforts have been driven by various professional, economic, and political forces, and they first addressed surgical enterprises that account for large health care expenditures, for instance, coronary artery surgery.1 Analytical eyes have now cast their gaze on the tiny field of pediatric neurosurgery and its most routine procedure, cerebrospinal fluid (CSF) shunt insertion.The Canadian provincial health plans issue all subscribers —essentially the entire population of Canada —a unique health care number that allows tracking of all insured medical services by patient as well as by provider and facility. Data from inpatient services in most provinces find their way to a repository at the Canadian Institute for Health Information. The previous experiences of institutions and of individual surgeons with CSF shunt surgery can be culled from the repository, as well as various demographic and clinical data. With suitable protections of privacy, confidentiality, and security, these data can be accessed for academic research and health administrative analysis.The authors from Vancouver, British Columbia, Canada and Salt Lake City, Utah, studied 3,794 first CSF shunt insertions in patients under 19 years of age performed by 181 surgeons for treatment of hydrocephalus over a 12-year period beginning in 1989. The outcomes studied were infection and reoperation for complications. Survival of the shunts without one or the other adverse outcome was analyzed with lifetable methodologies. Shunts inserted by surgeons with greater than the median experience had better survival than shunts inserted by surgeons with lesser experience. The 6-month risks of shunt failure were 31% and 38%, respectively, and although this gap diminished at later points in time, the difference between the 2 survival curves was highly significant (P=.001). The more experienced surgeons had an infection rate of 7%, while the less experienced surgeons had a rate of 9.4%, also a highly significant difference (P=.006). In a proportional hazards model, surgeon experience and surgeon infection rate retained significance as determinants of shunt survival, along with patient-specific factors such as age and etiology.Most surgeons endorse the general proposition that surgical experience makes a difference in patient outcomes, but they are likely to disagree about how much experience makes how much of a difference. One might gain some perspective by considering the design of 2 randomized, controlled, multicenter shunt insertion trials conducted (by these authors) in the 1990s.2,3 The trials were both powered at β = 0.8 to detect a clinically significant reduction in the risk of shunt failure at 1 year between the experimental and control arms. In both trials a “clinically significant” reduction was defined as 50%, typically from 0.4 to 0.2. From this perspective, the effect of surgeon experience on shunt survival in the current report may appear marginal.The American Academy of Pediatrics has gone on record as supporting referral of children with surgical conditions, including infantile hydrocephalus, to pediatric surgical subspecialists at regional pediatric centers.4 There are many practical justifications for this position but, until recently, substantiation of this position by actual outcomes data has not been possible. Clearly, a parent, a referring physician, or a health systems planner may wish to weigh surgeon experience in their respective deliberations, but other factors, particularly access to care, will have weight as well.It may be somewhat draining to think that without an experienced pediatric neurosurgeon, the risk of complications for a child requiring shunt placement is increased. Yet, more careful reading of this study will show that the findings are not as conclusive as the authors purport. For example, information regarding whether one specific neurosurgeon was the reason for the good or bad results versus many different neurosurgeons is not available in this data set. In addition, the involvement of trainees in these cases could not be determined. Thus, the limitations of this study will, hopefully, reduce the pressure on less experienced, yet fully boarded pediatric neurosurgeons who undertake this very common neurosurgical procedure.
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Jan 1, 2022
Mubarak Ali Algahtany + 2
