DDW 2013：住院医师经验与腹部手术转归

　　近日，在5月18日至5月21日召开的美国消化疾病周上，来自美国费城的研究人员发表题为《住院医师经验是否会影响复杂腹部手术转归？》的论文。研究指出，研究者强调在复杂腹部手术中住院医师的参与所带来的影响，证明随住院医师通过完成胰十二指肠切除术（pancreaticoduodenectomy，PD）积累经验的同时，改善病人转归。这与主治医师和医院规模与手术结果之间所表现的量-结果关系是一致的。复杂的病例提供了无与伦比的学习机会和重要的外科训练部分。住院医师最大限度的重复复杂的外科手术过程，对于病人及实习医师都是有益的。

　　对于复杂的腹部手术，术者及医院规模对手术结果的影响已被阐述。而对于住院医师的经验对其产生的影响尚不十分明确。

　　研究者回顾调查了一家大规模的临床中心2006-2012年间胰十二指肠切除术（pancreaticoduodenectomy，PD）的围手术期转归。住院医师的手术参与情况与转归被收集在一个前瞻性数据库中。用毕业后年数（post-graduate year，PGY）与完成的PD手术例数来定义住院医师的经验。

　　结果29名住院医师及4名主治外科医师共完成681例PD手术。总体的术后并发症发生率为44%。28%的病人发生PD手术特异性的相关并发症（胰瘘、胃排空延迟、胆汁漏出、脓肿形成及伤口感染），且相比于毕业后5或6年（PGY 5或6）的第一助手，毕业后4年（PGY 4）的第一助手参与的手术发生术后并发症明显增多（44% vs. 27%, p=0.016）。Logistic回归分析显示，随住院医师完成手术例数的增多，PD术后特异性并发症的发生减少（OR=0.97, p<0.01）。对于住院医师的首次手术，预测PD术后特异性并发症发生的可能性为27%；当其完成15例手术后，可降至19%（图1）。

Does Resident Experience Affect Outcomes in Complex Abdominal Surgery?
Background
For complex abdominal operations, the influence of provider and hospital volume on surgical outcomes has been described. The impact of resident experience is less well understood.
Methods
We reviewed perioperative outcomes after pancreaticoduodenectomy (PD) at a single high-volume center between 2006 and 2012. Resident participation and outcomes were collected in a prospectively maintained database. Resident experience was defined as post-graduate year (PGY) and number of PDs performed.
Results
Twenty-nine residents and four attending surgeons completed 681 PDs. The overall complication rate was 44%; PD-specific complications (defined as pancreatic fistula, delayed gastric emptying, bile leak, abscess, and wound infection) occurred in 28% and were significantly more common when the first assistant was a PGY 4 rather than a PGY 5 or 6 (44% vs. 27%, p=0.016). Logistic regression demonstrated that as residents perform more cases, PD-specific complications decrease (OR=0.97, p<0.01). For a resident's first case, the predicted probability of a PD-specific complication is 27%; this rate decreases to 19% by case 15 (Figure 1).
Conclusions
We highlight the impact of resident involvement in complex abdominal operations, demonstrating that as residents build experience with PD, patient outcomes improve. This is consistent with volume-outcome relationships for attending physicians and high-volume hospitals. Complex cases provide unparalleled learning opportunities and remain an important component of surgical training. Maximizing resident repetitive exposure to complex surgical procedures benefits both the patient and the trainee.