Overlapping surgery for training surgical residents generally safe

Last Updated: 2019-02-26

By Reuters Staff

NEW YORK (Reuters Health) - Overlapping surgery is not associated with worse perioperative outcomes compared with nonoverlapping surgery, a large retrospective analysis suggests.

With overlapping surgery, more than one procedure performed by the same primary surgeon is scheduled so the timing of the start of one surgery overlaps with the timing of the end of another surgery. In this situation, surgical residents may perform less complicated elements of a procedure, while the primary surgeon moves between cases to perform the critical portions of the operations.

To gauge the safety of overlapping surgery, Dr. Eric Sun of Stanford University in California and colleagues analyzed data on more than 66,000 common operations performed in adults (mean age, 59; 48% women) between 2010 and 2018, of which 12% were overlapping. The procedures included total knee or hip arthroplasty, spine surgery, coronary-artery-bypass graft (CABG) surgery and craniotomy.

Overlapping surgery was associated with increased length of surgery (204 vs. 173 minutes; P<0.001), the researchers report in the February 26 issue of JAMA.

After taking into account potential confounders, overlapping surgery was not associated with higher in-hospital mortality (adjusted rate, 1.9% vs. 1.6%; P=0.21) or risk of complications (adjusted rate, 12.8% vs. 11.8%; P=0.08).

However, overlapping surgery was tied to increased mortality (5.8% vs. 4.7%, P=0.03) and complication rates (29.2% vs. 27.0%, P=0.03) among patients at high preoperative predicted risk for mortality and complications.

The current study supports prior studies that have generally found no association between overlapping and adverse outcomes, Dr. Sun and colleagues say.

They caution that their study focused on a specific set of operations performed on adults in high-volume medical centers and results may not generalize to pediatric patients or other institutional settings.

Commenting on the study in an Editor's Note, Dr. Edward Livingston, JAMA deputy editor, says overlapping surgery is "essential for training surgical residents" and from this study appears "generally safe. However, there was a signal that outcomes (mortality and complications) might be worse for high-risk patients, a scenario that makes intuitive sense."

"This work appealed to me because it answered an important, unresolved question: Is surgery safe as practiced in academic environments that balance the needs of safe patient care with those required to train the next generation of surgeons? The answer appears to be yes," writes Dr. Livingston.

"This study," he adds, "does not address risks associated with concurrent surgery in which the attending surgeon is not present during a part of the operation considered critical. Major complications attributable to concurrent surgery have been highlighted by the news media, yet whether this practice is safe or acceptable remains unresolved and is not addressed in the current study."

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JAMA 2019.