The experiences surgical residents undergo in the operating room (OR) teach technique, bolster confidence, and prepare them for independent, autonomous practice. As such, educators are routinely concerned about residents’ perceptions of how and what they learn in the OR.

Concordance of a resident’s and the attending surgeon’s perception of guidance is called guiding efficiency, and it’s critical for optimal OR training experiences. However, each generation has a different learning style. Researchers at Brigham and Women’s Hospital, Boston, MA, recently published a 

 that explores the disparity in surgical residents’ and attending surgeons’ perceptions of OR guidance.

Using 8 prerecorded surgical cases, the researchers asked 2 attending surgeons and one surgical resident to observe the procedure and classify the attending surgeons’ OR guidance by type. A total of 9 attending surgeons and 8 surgical residents participated. They employed an established taxonomy for OR guidance types that designed each action as:

teaching (i.e. showing how to operate, explaining the surgeon’s thought process, or simply verbalizing information about instruments for future operation)

directing (i.e. verbally prompting the resident technique or special orientation)

assisting (i.e. facilitating OR team support or reassuring the resident’s judgment)

The researchers identified 116 OR guidance events. When both observing and attending surgeons agreed that guidance was provided and on the OR guidance type, the researchers designated that event as a concordant guidance behavior. Eight of the 116 events were thus designated, and in 73 of the 80 behaviors, observing and attending surgeons agreed on the guidance type. Then, the researchers compared these 80 events to the residents’ assessments.

In 49 of the 80 (61%) events, residents agreed with attending surgeons that guidance was provided. However, more than half the time, residents disagreed with attending surgeons concerning the OR guidance type. Residents and attending surgeons were most likely to agree on the teaching guidance (66.67%), but least likely to agree on the assisting guidance (36.84%).

The study found that when attending surgeons indicate they are “assisting,” but residents believe the surgeon is “directing,” the surgeon may overestimate the residents’ ability because the surgeon may believe the resident has made an independent decision, whereas the resident believes he or she is following direction. Having similar perceptions about the presence and the OR guidance type is critical for residents to develop autonomy.

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A new study explores the disparity in surgical residents' and their attending surgeons' perceptions operating room guidance.

Residents in the Operating Room: Discordant Opinions about Learning

Surgeons’ concerns about a controversial process to transition high-risk patients off anticoagulation may be warranted, according to a new 

Archives of Orthopaedic and Trauma Surgery

When patients who take long-term anticoagulation therapy need major surgery, anticoagulation needs to be interrupted temporarily unless the patient is high-risk. A high-risk status usually means that long-term anticoagulation must be replaced by a therapeutic dose of short-acting unfractionated or low-molecular-weight heparin (LMWH), according to most guidelines. This transition process, called 

, is used to reduce risk of venous thromboembolic events. LMWH is given by subcutaneous injection for 10 to 12 days around the time of the surgery/procedure.

Bridging is controversial. Cardiologists and internists generally believe that higher anticoagulant doses reduce risk of thromboembolic (TE) complications. Orthopedic surgeons worry that these agents elevate the risk of drainage, bleeding, or deep infection. In an aging society, patients undergoing total joint replacement are increasingly more likely to require bridging.

A team of researchers from the Netherlands attempted to resolve the bridging controversy. Using a retrospective observational design, they evaluated bleeding and TE complications in patients requiring perioperative bridging during primary unilateral total hip or knee arthroplasty (THA and TKA).

They identified all patients receiving LMWH bridging during THA or TKA according to the local protocol based on the 2012 American College of Chest Physicians’ 

In their review, 972 patients were identified as having THA or TKA, and 13 received bridging according to the guideline. Twelve bridging patients (92%) experienced bleeding complications, and the authors called this number of adverse events “alarming.” Of these, 9 patients needed active intervention, 7 of whom received blood transfusion. The blood transfusion rate was approximately 7 times higher in the bridging group than in the non-bridging group.

In the bridging group, 5 patients were re-admitted and hospital length of stay increased in all patients. Nine patients (69%) developed a hematoma and 2 patients (15%) developed a periprosthetic joint infection. Regardless, none of these patients experienced TE complication.

However, at the one-year follow-up, all patients in the bridging group had outcomes similar to those in the non-bridging group.

The authors express concern about the high complication rate in patients receiving LMWH bridging during elective TKA or THA surgery. Bleeding was the clear cause of all their complications, although the small number of patients in the bridging group is a study limitation.

They recommend a thorough discussion with patients about the risk of bleeding complications, and that surgeons have a better understanding of the comparative risks of bleeding and TE complications.

Surgeons' concerns about a controversial process to transition high-risk patients off anticoagulation may be warranted.

Bleeding Likely during Bridging Anticoagulation for Orthopedic Surgery

Though hospital stay duration was once used as a surrogate outcome for surgical recovery, the increasing popularity of short-stay surgery has eliminated that measure, making it harder for hospitals to track recovery trajectories and more difficult for surgeons to plan physical, psychological, and social postoperative courses for prospective patients.

 that appeared in the July 2014 issue of Surgery, researchers from the Montreal General Hospital in Quebec, Canada, examined recovery trajectories for short-stay surgeries, focusing on physical activity and health-related quality of life (HRQOL), as well as isolated predictors of prolonged, post-discharge recovery.

Using validated questionnaires to assess physical activity, expended calories, and HRQOL, the study authors preoperatively and postoperatively evaluated 132 patients who underwent short-stay abdominal surgery. According to the researchers, a majority of the participants were male, and the mean age was 53 years old.

More than 90% of the patients were discharged on the day of their surgery, while the remaining participants were discharged within 24 hours. In terms of procedures, 40% of the patients underwent open inguinal herniorrhaphy, 30% had laparoscopic cholecystectomy, and the rest were divided among 15 other operations.

Three weeks after their short-stay surgeries, half of the patients reported activity below their preoperative levels. Of that group, patients who were older, had a complication, and reported either low baseline physical HRQOL or high baseline physical activity were less likely to attain preoperative levels of physical activity at 3 weeks.

At 2 months post-surgery, one-third of the patients remained below preoperative measures of physical activity and physical HRQOL, and only high baseline physical activity was an

important predictor of prolonged recovery. However, social, emotional, and mental HRQOL tended to recover quickly, as most of the patients were at or close to preoperative levels 3 weeks after surgery and above baseline levels at 2 months.

Although the authors concluded that recovery trajectories for same-day surgery vary considerably, they noted that the variables can help surgeons more accurately counsel their short-stay candidates on what to expect while they heal. 

Recovery Trajectories for Short-stay Surgery Vary Considerably

For many procedures, minimally invasive surgery (MIS) is superior to open surgery because it typically involves a few small incisions, rather than one large open cut.

MIS also tends to produce improved outcomes, including fewer surgical site infections, less pain, and shorter hospital stays. However, a new 

 indicates those advantages depend largely on where a patient resides.

In the study, a surgical team from the John Hopkins School of Medicine discovered that some hospitals performed MIS less frequently than they could, due to poor division of labor and failure to direct good MIS candidates to surgeons skilled in the technique. As a result, patients assumed risks associated with open surgery more often than they should have, the authors noted.

The researchers analyzed data from the Nationwide Inpatient Sample to identify how many appendectomies, colectomies, and hysterectomies could have been performed using MIS. They also examined lung lobectomy, an operation with an unclear risk-benefit ratio for MIS.

Ideally, the projected and actual MIS rates would be similar across hospitals, but in the study, they were not. For example, the researchers found 71% of appendectomies could have been performed with MIS, but 25% of the hospitals used open operations for more than half of those procedures. When MIS was utilized, appendectomies had roughly half the complications of open appendectomies.

The hospitals that were more likely to perform MIS tended to be large urban teaching hospitals located in the Midwest, South, or West. The researchers suggested physician training might cause the regional variation, especially since physicians tend to practice close to where they trained, and surgeons rely on and prefer techniques acquired during their residencies.

For many procedures, minimally invasive surgery is superior to open surgery because it typically involves a few small incisions, rather than one large open cut.

Missed Opportunities in Minimally Invasive Surgery

When gallstones are the source of acute pancreatitis, the condition can be life threatening.

To prevent recurrent pancreatitis, consensus-based guidelines from the British Society of Gastroenterologists (BSG) and the American Gastroenterological Associations (AGA) recommend performing cholecystectomy during the primary admission to the hospital or within no more than 4 weeks of discharge. However, controversy still surrounds the timing of the surgery, since some surgeons believe performing cholecystectomy while the pancreas is inflamed increases complication rates.

, researchers in the United Kingdom specifically examined whether adherence to current BSG guidelines that advise performing cholecystectomy within 2 weeks of discharge can prevent recurrent pancreatitis with minimal surgical complications.

Over a 2-year period, the study authors followed a total of 523 patients who presented with an initial episode of gallstone pancreatitis. According to the investigators, 363 patients (69%) underwent cholecystectomy. Of those patients, 72 had their surgeries performed within the time parameters of their primary admission or within 2 weeks of discharge, while the remaining 291 underwent cholecystectomy more than 2 weeks after their primary admissions. 

Overall, 7% of the patients experienced a cholecystectomy-related complication, though more than twice as many complications occurred in those whose cholecystectomies were performed within the guideline parameters. Nevertheless, delaying cholecystectomy beyond those parameters increased the risk of readmission for recurrent pancreatitis prior to surgery.

As a result, the authors concluded that cholecystectomy performed in accordance with the BSG time parameters significantly reduces the recurrence of pancreatitis, but may increase the risk of surgical complications.

Cholecystectomy for Gallstone Pancreatitis: Does Timing Matter?

Since removing abnormal glands through parathyroidectomy (PTx) is the sole curative intervention for primary hyperparathyroidism (PHPT), a team of researchers from the Section of Endocrine Surgery at the UCLA David Geffen School of Medicine in Los Angeles recently tracked trends in the frequency and quality of PTx.

, the researchers examined data culled from the California Office of Statewide Health Planning and Development on patients who underwent PTx between 1999 and 2008. The study authors categorized hospitals by case volume — from a very low 1-4 surgeries per year, to a very high 50 or more operations per year &mdash; specifically analyzing complication rates and the percentage of cases that required reoperation.

While the database included a total 17,082 cases, the investigators noted only 990 PTx operations were completed in 1999, while 2,746 were completed in 2008 — a 177% increase in annual case volume. The researchers also reported a similar 147% increase in the per capita PTx rate over the 10-year study period.

According to the authors, PHPT patients were more than 3 times more likely to undergo PTx at a high-volume hospital, since “the proportion of cases performed by very high-volume hospitals increased from 6.4% (in 1999) to 20.5% (in 2008).” Still, the complication rates for PTx were inversely related to case volume, as very high volume hospitals reported a 3.9% rate, compared to very low volume hospitals that recorded a 5.2% rate. Overall, the complication rate for PTx declined from 8.7% in 1999 to 3.8% in 2008.

The researchers found 363 PHPT patients required reoperation, the rate of which also inversely related to hospital volume, though it “increased from 0.91% to 2.73% during the study period.” Nevertheless, the authors concluded their results augmented the evidence of progress in safety and quality across surgical care for PHPT.

“Surgery for PHPT has grown safer and more common over time, (and) high-volume centers have lower rates of complication and reoperation,” they wrote.

Since removing the abnormal glands through parathyroidectomy (PTx) is the sole curative intervention for primary hyperparathyroidism (PHPT), a team of researchers from the Section of Endocrine Surgery at the UCLA David Geffen School of Medicine in Los Angeles recently tracked trends in the frequency and quality of PTx.

Study Finds Improved Surgical Care for Primary Hyperparathyroidism

Thanks to better anesthetics, new surgical techniques, and more consistent anticoagulant use to prevent venous thromboembolism (VTE), mortality after total hip replacement surgery is rare. Nevertheless, a patient’s risk of death briefly increases following the procedure.

, a team of investigators from the Avon Orthopaedic Centre in the United Kingdom published the results of a 

 designed to identify the modifiable risk factors that decrease the risk of postoperative mortality. Their analysis included 32 studies published over the past 10 years that examined the rates of 30- or 90-day mortality following total hip replacement.

The researchers estimated the pooled incidence of mortality during the first 30 and 90 days after hip replacement to be 0.30% and 0.65%, respectively. Despite the fact that those who underwent the procedure towards the end of the 10-year study period had more comorbidities, the authors reported the patients’ risk of death decreased over time.

The authors cited several systemic improvements that contributed to their positive findings, such as multidisciplinary assessment teams, spinal anesthesia, and aggressive thromboprophylaxis. They also identified the risk factors that predicted early mortality, which included older age, male sex, and comorbid conditions, particularly cardiovascular disease (CVD).

Although pulmonary embolism (PE) was deemed the leading cause of death related to total hip replacement for many years, the authors concluded that cardiovascular complications presently cause more postoperative fatalities. 

Thanks to better anesthetics, new surgical techniques, and more consistent anticoagulant use to prevent venous thromboembolism, mortality after total hip replacement surgery is rare. Nevertheless, a patient's risk of death briefly increases following the procedure. 

Fatality Risk Falling in Total Hip Replacement

As the US Centers for Medicare and Medicaid Services (CMS) remains deeply concerned about hospital-acquired conditions (HACs) that can reasonably be prevented through the application of evidence-based guidelines, the agency does not reimburse healthcare facilities for 11 HAC categories, including surgical site infections (SSIs), urinary tract infections (UTIs), and venous thromboembolism (VTE) that are common among patients who undergo bariatric surgery.

 presented at the SAGES 2014 Annual Meeting, researchers from the Johns Hopkins University School of Medicine examined the rate of HACs in bariatric surgery patients, as well as the effects HACs have on their postoperative outcomes. Using the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) database, the investigators identified 98,553 obese adults who underwent bariatric surgery between 2005 and 2012.

Among the study population, 2,809 (2.9 %) patients developed at least one HAC. According to the researchers, SSI was the most common HAC (1.8%), followed by UTI (0.7%) and VTE (0.4%). Nevertheless, the authors reported a temporal decline in HACs, as 4.6% of patients had HACs in 2005, but that rate decreased to 2.5% in the study’s final year. They also found the presence of comorbidities and higher body mass index (BMI) increased a bariatric surgery patient’s risk of developing an HAC.

Although patients who had laparoscopic gastric banding were least likely to experience an HAC (1.3%), those who underwent open gastric bypass had a 5.36-fold higher risk of developing an HAC. Consequently, bariatric surgery patients who developed an HAC had significantly higher rates of in-hospital mortality and longer lengths of stay.

Surprisingly, the presence of a resident surgeon 7—11 years post-graduation was associated with a spike in HAC risk, which the researchers attributed to longer operative times when residents are involved in procedures, greater surgical complexity in the studied cases, or less experienced staff.

“The patients most likely to develop a HAC after bariatric surgery are precisely those who stand to benefit the most from undergoing these procedures,” the authors wrote, noting that many HACs included in CMS’s payment provision are related to intrinsic factors among bariatric surgery patients. Thus, they concluded surgeons have minimal ability to impact the incidence of HACs in this patient population.

Are Hospital-acquired Conditions Inherent in Bariatric Surgery?

Out of all possible factors, trauma is the single largest cause of death among Americans aged 46 years or younger, according to a study published in the July 2014 issue of the 

For the study, researchers from the University of Arizona Health Sciences Center 

 the relationship between the aging population and trauma mortality, which they related to the rates of death from cancer and heart disease. Relying on the Web-based Injury Statistics Query and Reporting System database of the US Centers for Disease Control and Prevention (CDC), the researchers analyzed trauma deaths as unintentional injuries, suicides, and homicides over a 10-year period from 2000 to 2010.

While the US population increased by 9.7% over those 10 years, the number of trauma deaths increased by 22.8%, the investigators found. In comparison, the death rates for cancer and heart disease decreased over the study period.

Nevertheless, those aged 25 years or younger were less likely to die from trauma in 2010 than in previous years — an improvement the authors attributed to the proliferation of trauma centers. However, the risk of death from trauma increased among those aged 25 years or older, with the largest proportional increase in trauma deaths occurring among 54-year-olds.

, Gregory J. Jurkovich, MD, reiterated that the aging Baby Boomer generation’s increased risk of trauma burdens hospitals, extended care nursing facilities, and other resources. While trauma centers remain extraordinarily effective for young patients, Jurkovick noted that they might be ill equipped to properly care for elderly trauma patients.

Both articles called for increased funding for trauma research and injury-prevention strategies, as well as a shift in focus for all trauma-related healthcare activities to accommodate the needs of the aging US population.

Out of all possible factors, trauma is the single largest cause of death among Americans aged 46 years or younger.

Impact of Trauma on Aging Baby Boomers

Although hospitals routinely implement peer review processes to ensure that physicians are meeting the prevailing standards of care, the procedure has been associated with controversy since the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) first began requiring it in 1952.  

For example, in a widely publicized 1986 lawsuit, a general and vascular surgeon who left a clinic to start his own practice alleged that his former partners utilized the peer review process in a way that led to the termination of his privileges at the hospital where they were all employed. When the case was elevated to the United States Supreme Court, it was resolved with a $2.2 million award to the plaintiff, as it was clear the defendants had acted out of personal economic interest.

Many physicians deemed the case profoundly disturbing and became hesitant to participate in peer review in its aftermath. To address their concerns, Congress passed the Health Care Quality Improvement Act (HCQIA), which created reviewer immunity and established the National Practitioner Data Bank that prevents physicians who have employment-ending performance issues from simply moving to another state to practice medicine.

However, Dinesh Vyas and Ahmed E. Hozain of the Department of Surgery at Michigan State University argued in a recent 

that although the peer review process improves care quality, the HCQIA’s immunity clause likely emboldens abuses resulting in sham peer reviews, which are characterized as being “called for by either a single (physician) or group of physicians, conducted in order to lead to adverse action taken by the review committee.”

The authors also contended that powerful competitors and outspoken physicians or whistleblowers are most likely to be targeted for sham peer review, and the victims of such review have no legal recourse.

Examining possible future directions, Vyas and Hozain indicated standardization, external peer review processes, and legislative reform are needed to improve the current peer review system, and they called for physicians, professional societies, and hospital administrators to push for such enhancements.

“Immunity granted under HCQIA serves to protect hospitals and peer reviewers from litigations from appropriately sanctioned physicians. Unfortunately, HCQIA extends these immunities to sham peer reviews,” Vyas and Hozain concluded. “In the hypercompetitive and highly political United States medical system, this immunity has been abused and has led to the devastating destruction of many physicians careers. Considering Congressional and Judicial forbearance on this crisis, significant leadership by physicians, professional societies, and hospital administrators is needed in order to remedy the faults of peer review.”

Although hospitals routinely implement peer review processes to ensure that physicians are meeting the prevailing standards of care, the procedure has been associated with controversy.

July 2014