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1.
J Surg Educ ; 79(3): 632-642, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35063391

RESUMO

OBJECTIVE: Colorectal surgery is a core component of general surgery. The volume of colorectal surgery performed by general surgery residents throughout training has not been studied. This study aims to analyze trends observed in colorectal-specific case numbers logged by general surgery residents over 16 years. DESIGN: Case number data for general surgery residents was extracted from the publicly available, annually published Accreditation Council for Graduate Medical Education (ACGME) database from 2003 to 2019. Cases were categorized as open or laparoscopic colectomy/proctectomy, colectomy with ileoanal pull-thru, abdomino-perineal resection (APR), transanal rectal tumor excision (TRE), anorectal procedure, colonoscopy, and total colorectal cases. The average case numbers per category was calculated for each year. Linear regression analyzed trends in case categories for all residents and those logged as surgeon chief and junior residents. SETTING: ACGME accredited general surgery residency programs. PARTICIPANTS: Not applicable. RESULTS: General surgery residents reported increased numbers of all, chief, and junior resident colorectal cases over the study period (124.5-173.7 cases/yr; 38.4-53.0 cases/yr; 86.4-120.6 cases/yr, all p = 0.00). Average cases for all, chief, and junior residents have increased for laparoscopic colectomy/proctectomy (4.6-26.4 cases/year; 2.7-12.9 cases/year; 2.0-13.5 cases/year, all p = 0.00), anorectal surgeries (26.7-37.7 cases/year; 5.4-9.9 cases/year; 21.3-27.8 cases/year, all p = 0.00), and colonoscopies (35.9-70.6 cases/year, p = 0.00; 6.6-14.1 cases/year, p = 0.01; 29.4-56.5 cases/year, p = 0.00). Average cases for all, chief, and junior residents have decreased for open colectomy/proctectomy (52.0-34.9 cases/year; 21.2-14.3 cases/year; 30.9-20.6 cases/year, all p = 0.00), APR (3.3-2.7 cases/year, p = 0.00; 1.8-1.3 cases/year, p = 0.00; 1.5-1.4 cases/year, p = 0.02), TRE (1.9-1.1 cases/year; 0.7-0.4 cases/year; 1.2-0.6 cases/year, all p = 0.00). Ileoanal pull-thru did not demonstrate a linear trend. CONCLUSIONS: The increase in exposure to colectomies/proctectomies, anorectal procedures and colonoscopies is encouraging, as these common colorectal operations will be encountered in general surgery practice. The observed low case numbers for TRE, APR, and ileoanal pull-thru suggest a need for specialized training.


Assuntos
Neoplasias Colorretais , Cirurgia Colorretal , Cirurgia Geral , Internato e Residência , Acreditação , Competência Clínica , Cirurgia Colorretal/educação , Educação de Pós-Graduação em Medicina , Cirurgia Geral/educação , Humanos , Estados Unidos , Carga de Trabalho
2.
Surgery ; 171(2): 267-274, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34465470

RESUMO

BACKGROUND: Routine preoperative laboratory testing is not recommended for American Society of Anesthesiologists classification 1 or 2 patients before low-risk ambulatory surgery. METHODS: The 2017 National Surgical Quality Improvement Program data set was retrospectively queried for American Society of Anesthesiologists class 1 and 2 patients who underwent low-risk, elective outpatient anorectal, breast, endocrine, gynecologic, hernia, otolaryngology, oral-maxillofacial, orthopedic, plastic/reconstructive, urologic, and vascular operations. Preoperative laboratory testing was defined as any chemistry, hematology, coagulation, or liver function studies obtained ≤30 days preoperatively. Demographics, comorbidities, and outcomes were compared between those with and without testing. The numbers needed to test to prevent serious morbidity or any complication were calculated. Laboratory testing costs were estimated using Centers for Medicare and Medicaid Services data. RESULTS: Of 111,589 patients studied, 57,590 (51.6%) received preoperative laboratory testing; 26,709 (46.4%) had at least 1 abnormal result. Factors associated with receiving preoperative laboratory testing included increasing age, female sex, non-White race/ethnicity, American Society of Anesthesiologists class 2, diabetes, dyspnea, hypertension, obesity, and steroid use. Mortality did not differ between patients with and without testing. The complication rate was 2.5% among tested patients and 1.7% among patients without tests (P < .01). The numbers needed to test was 599 for serious morbidity and 133 for any complication. An estimated $373 million annually is spent on preoperative laboratory testing in this population. CONCLUSION: Despite American Society of Anesthesiologists guidelines, a majority of American Society of Anesthesiologists class 1 and 2 patients undergo preoperative laboratory testing before elective low-risk outpatient surgery. The differences in the rates of complications between patients with and without testing is low. Preoperative testing should be used more judiciously in this population, which may lead to cost savings.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Testes Diagnósticos de Rotina/normas , Procedimentos Cirúrgicos Eletivos , Cuidados Pré-Operatórios/normas , Melhoria de Qualidade , Adulto , Redução de Custos , Testes Diagnósticos de Rotina/economia , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Cuidados Pré-Operatórios/economia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
3.
JAMA ; 311(20): 2110-20, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24867014

RESUMO

IMPORTANCE: Surgery in older patients often poses risks of death, complications, and functional decline. Prior to surgery, evaluations of health-related priorities, realistic assessments of surgical risks, and individualized optimization strategies are essential. OBJECTIVE: To review surgical decision making for older adult patients by 2 measures: defining treatment goals for elderly patients and reviewing the evidence relating risk factors to adverse outcomes. Assessment and optimization strategies for older surgical patients are proposed. EVIDENCE ACQUISITION: A review of studies relating geriatric conditions such as functional and cognitive impairment, malnutrition, facility residence, and frailty to postoperative mortality and complications (including delirium, discharge to an institution, and functional decline). Medline, EMBASE, and Web of Science databases were searched for articles published between January 1, 2000, and December 31, 2013, that included patients older than 60 years. RESULTS: This review identified 54 studies of older patients; 28 that examined preoperative clinical features associated with mortality (n = 1,422,433 patients) and 26 that examined factors associated with surgical complications (n = 136,083 patients). There was substantial heterogeneity in study methods, measures, and outcomes. The absolute risk and risk ratios relating preoperative clinical conditions to mortality varied widely: 10% to 40% for cognitive impairment (adjusted hazard ratio [HR], 1.26 [95% CI, 1.06-1.49] to 5.77 [95% CI, 1.55-21.55]), 10% to 17% for malnutrition (adjusted odds ratio [OR], 0.88 [95% CI, 0.78-1.01] to 59.2 [95% CI, 3.6-982.9]), and 11% to 41% for institutionalization (adjusted OR, 1.5 [95% CI, 1.02-2.21] to 3.27 [95% CI, 2.81-3.81]).) Risk ratios for functional dependence relating to mortality ranged from an adjusted HR of 1.02 (95% CI, 0.99-1.04) to an adjusted OR of 18.7 (95% CI, 1.6-215.3) and for frailty relating to mortality, ranged from an adjusted HR of 1.10 (95% CI, 1.04-1.16) to an adjusted OR of 11.7 (95% CI not reported) (P < .001). Preoperative cognitive impairment (adjusted OR, 2.2; 95% CI, 1.4-2.7) was associated with postoperative delirium (adjusted OR, 17.0; 95% CI, 1.2-239.8; P < .05). Frailty was associated with a 3- to 13-fold increased risk of discharge to a facility (adjusted OR, 3.16 [95% CI, 1.0-9.99] to 13.02 [95% CI, 5.14-32.98]). CONCLUSIONS AND RELEVANCE: Geriatric conditions may be associated with adverse surgical outcomes. A comprehensive evaluation of treatment goals and communication of realistic risk estimates are essential to guide individualized decision making.


Assuntos
Avaliação Geriátrica , Período Pré-Operatório , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisões , Idoso Fragilizado , Humanos , Consentimento Livre e Esclarecido , Razão de Chances , Medição de Risco , Procedimentos Cirúrgicos Operatórios/mortalidade
4.
World J Surg ; 38(6): 1398-404, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24407941

RESUMO

BACKGROUND: Little is known about the breadth and quality of nonobstetric surgical care delivered by nonphysician clinicians (NPCs) in low-resource settings. We aimed to document the scope of NPC surgical practice and characterize outcomes after major surgery performed by nonphysicians in Tanzania. METHODS: A retrospective records review of major surgical procedures (MSPs) performed in 2012 was conducted at seven hospitals in Pwani Region, Tanzania. Patient and procedure characteristics and level of surgical care provider were documented for each procedure. Rates of postoperative morbidity and mortality after nonobstetric MSPs performed by NPCs and physicians were compared using multivariate logistic regression. RESULTS: There were 6.5 surgical care providers per 100,000 population performing a mean rate of 461 procedures per 100,000 population during the study period. Of these cases, 1,698 (34.7 %) were nonobstetric MSPs. NPCs performed 55.8 % of nonobstetric MSPs followed by surgical specialists (28.7 %) and medical officers (15.5 %). The most common nonobstetric MSPs performed by NPCs were elective groin hernia repair, prostatectomy, exploratory laparotomy, and hydrocelectomy. Postoperative mortality was 1.7 % and 1.5 % in cases done by NPCs and physicians respectively. There was no significant difference in outcomes after procedures performed by NPCs compared with physicians. CONCLUSIONS: Surgical output is low and the workforce is limited in Tanzania. NPCs performed the majority of major surgical procedures during the study period. Outcomes after nonobstetric major surgical procedures done by NPCs and physicians were similar. Task-shifting of surgical care to nonphysicians may be a safe and sustainable way to address the global surgical workforce crisis.


Assuntos
Recursos em Saúde/economia , Enfermeiros Clínicos/organização & administração , Qualidade da Assistência à Saúde , Procedimentos Cirúrgicos Operatórios/métodos , Acreditação , Competência Clínica , Bases de Dados Factuais , Países em Desenvolvimento , Feminino , Hospitais Gerais , Humanos , Modelos Logísticos , Masculino , Análise Multivariada , Pobreza , Estudos Retrospectivos , Medição de Risco , Procedimentos Cirúrgicos Operatórios/economia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Tanzânia , Resultado do Tratamento
6.
World J Surg ; 37(3): 498-503, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23224074

RESUMO

BACKGROUND: Surgical conditions represent an immense yet underrecognized source of disease burden globally. Characterizing the burden of surgical disease has been defined as a priority research agenda in global surgery. Little is known about the epidemiology of inguinal hernia, a common easily treatable surgical condition, in resource-poor settings. METHODS: Using data from the National Health and Nutrition Examination Survey prospective cohort study of inguinal hernia, we created a method to estimate hernia epidemiology in Ghana. We calculated inguinal hernia incidence and prevalence using Ghanaian demographic data and projected hernia prevalence under three surgical rate and hernia incidence scenarios. Disability adjusted life-years (DALYs) associated with inguinal hernia along with costs for surgical repair were estimated. RESULTS: According to this approach, the prevalence of inguinal hernia in the Ghanaian general population is 3.15% (range 2.79-3.50%). Symptomatic hernias number 530,082 (range 469,501-588,980). The annual incidence of symptomatic hernias is 210 (range 186-233) per 100,000 population. At the estimated Ghanaian hernia repair rate of 30 per 100,000, a backlog of 1 million hernias in need of repair develop over 10 years. The cost of repairing all symptomatic hernias in Ghana is estimated at US $53 million, and US $106 million would be required to eliminate hernias over a 10-year period. Nearly 5 million DALYs would be averted with the repair of prevalent cases of symptomatic hernia in Ghana. CONCLUSIONS: Data generated by our method indicate the extent to which Ghana lacks the surgical capacity to address its significant inguinal hernia disease burden. This approach provides a simple framework for calculating inguinal hernia epidemiology in resource-poor settings that may be used for advocacy and program planning in multiple country contexts.


Assuntos
Efeitos Psicossociais da Doença , Saúde Global/economia , Hérnia Inguinal/epidemiologia , Hérnia Inguinal/cirurgia , Herniorrafia/economia , Estudos Transversais , Bases de Dados Factuais , Países em Desenvolvimento , Feminino , Custos de Cuidados de Saúde , Recursos em Saúde , Necessidades e Demandas de Serviços de Saúde , Hérnia Inguinal/economia , Herniorrafia/estatística & dados numéricos , Humanos , Masculino , Pobreza , Prevalência , Medição de Risco , Uganda
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