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Is Supervised Independence Of Surgical Residents Associated With Compromised Clinical Outcomes In Foregut Surgical Oncology?
*Celsa Tonelli, Frederick Luchette, *Zaid Abdelsattar, Marshall Baker
Loyola University Medical Center, Maywood, IL

OBJECTIVE(S): Prior studies evaluating the association between resident independence and clinical outcome have included case mixes that cross disciplines and are heavily weighted toward less complicated procedures: cystoscopy, endoscopy, hernia repair. The association between independence and clinical outcome in foregut oncology has not been measured.METHODS: We queried the Veterans Affairs Surgical Quality Improvement Program database to identify patients undergoing complex biliary resection, esophagectomy, liver resection, pancreatectomy, gastrectomy, and small bowel resection between 2004 and 2019. The level of attending involvement was defined as the attending scrubbed with resident (AS) or the attending not scrubbed but immediately available in the operating room (ANS). Multivariable logistic regression (MVR) and propensity-score matching were used to measure the association between attending involvement and select outcomes. RESULTS: 5,604 patients met inclusion criteria. 118 (2%) underwent operations completed ANS; 5,486 (98%) AS. The majority (85%) of ANS cases were completed by PGY 5 level residents. Small bowel resections (5%) were more commonly completed ANS than biliary procedures (2%), liver resections (2%), gastrectomies (1%), pancreatectomies (1%) and esophagectomies (1%). 116 cases performed ANS were successfully 1:3 propensity score matched for age, body mass index, surgical priority, American Society of Anesthesiologist (ASA) class, year, and procedure type to 346 cases performed AS. On comparison of matched cohorts, operative times for the AS cohort were longer (4.1 + 2.64 vs 3.52 + 2.13 hours, p=0.03) but rates of Clavien Dindo III-V complication (30% vs 24%, p=0.7) and 30-day mortality were statistically identical (7% vs 5%, p=0.1). On MVR, factors associated with the occurrence of a Clavien-Dindo grade III-V complication included age (aOR 1.13; 95% CI[1.06, 1.21]), history of alcohol use (aOR 1.39; 95% CI[1.12, 1.74]), dependent functional status (aOR 1.89; 95% CI[1.47, 2.43), emergent priority (aOR 1.96; 95% CI[1.31, 2.94]), ASA class 4 (aOR 1.58; 95% CI[1.17, 2.12]), and contaminated wound class (aOR 2.01; 95% CI[1.44, 2.79]). The level of attending involvement was not associated with risk of such complication (aOR 1.18, 95% CI [0.75, 1.86]). CONCLUSIONS: Residents can be provided with increasing levels of supervised independence in foregut surgical oncology operations without compromising short term clinical outcomes.


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