Quantifying the learning curve for pulmonary thromboendarterectomy.

BACKGROUND: Pulmonary thromboendarterectomy (PTE) is an effective treatment for chronic thromboembolic pulmonary hypertension (CTEPH), but is a technically challenging operation for cardiothoracic surgeons. Starting a new program allows an opportunity to define a learning curve for PTE. METHODS: A retrospective case review was performed of 134 consecutive PTEs performed from 1998 to 2016 at a single institution. Outcomes were compared using either a two-tailed t-test for continuous variables or a chi-squared test for categorical variables according to experience of the program by terciles (T). RESULTS: The 30-day mortality was 3.7%. The mean length of hospital stay, length of ICU stay, and duration on a ventilator were 12.6 days, 4.6 days, and 2.0 days, respectively. The mean decrease in systolic pulmonary artery pressure (sPAP) was 41.3 mmHg. Patients with Jamieson type 2 disease had a greater change in mean sPAP than those with type 3 disease (p = 0.039). The mean cardiopulmonary bypass time was 180 min (T1-198 min, T3-159 min, p = <0.001), and the mean circulatory arrest time was 37 min (T1-44 min, T3-31 min, p < 0.001). Plotting circulatory arrest times as a running sum compared to the mean demonstrated 2 inflection points, the first at 22 cases and the second at 95 cases. CONCLUSIONS: PTE is a challenging procedure to learn, and good outcomes are a result of a multi-disciplinary effort to optimize case selection, operative performance, and postoperative care. Approximately 20 cases are needed to become proficient in PTE, and nearly 100 cases are required for more efficient clearing of obstructed pulmonary arteries.

Carotid endarterectomy in a general surgical training program.

Concern regarding the quality of surgical treatment performed within resident training programs and the need for direct, active involvement of the attending surgeon have been issues of interest to surgeons and the public. To provide specialized training in the diagnosis and treatment of vascular disease, vascular surgical fellowships have been established. In institutions with established vascular fellowships, one may question whether general surgical residents or vascular surgical fellows should perform carotid endarterectomies. The majority of carotid reconstructive procedures are performed at our institution by the chief general surgical resident under direct supervision. We elected to review our experience with surgical treatment of the carotid artery in an effort to examine the safety of this practice. The record of all patients who underwent carotid endarterectomy or reconstruction from April 1980 to July 1984 were reviewed. One hundred and twenty-nine patients who underwent 153 reconstructions of the carotid artery constituted the study group. The indication for operation was symptomatic carotid atheromatous disease in 96 and asymptomatic disease in 57. Ninety-three per cent of the procedures were performed by the chief general surgical resident under the supervision of one attending surgeon. Although the incidence of associated systemic problems (hypertension, diabetes and coronary artery disease) was significant in the study group, postoperative cardiovascular and cranial nerve and central neurologic deficits were 1.3 per cent, respectively, with no operative mortality. At our institution, the performance of carotid endarterectomy under close supervision provides an excellent context in which the resident in training may learn precise and careful dissection of the tissue and arterial repair. The need for formal vascular surgical fellowships to develop proficiency in judgment, technique and management of vascular disease is not questioned. However, as a learning experience for the general surgical resident, we believe this practice is both safe and effective, and a high standard of patient care is not compromised.