Collin R Creange, MD, Bradley Schwack, MD, Marina Kurian, MD, George Fielding, MD, Christine Ren-Fielding, MD. New York University Medical Center
Introduction: The impact of resident involvement on outcomes after bariatric procedures is not well understood. Prior studies have demonstrated increased complication rates with resident involvement in Roux-en-y gastric bypass (RYGB). These studies did not include data for laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric band (LAGB). At our institution, attending surgeons operate with both residents and physician assistants (PA) interchangeably, thus controlling for surgeon variability. Our objective was to demonstrate that resident involvement in complex bariatric surgeries does not increase complication rates when residents and PA’s work with the same attending surgeons.
Methods and Procedures: Patients undergoing bariatric procedures at our institution between 3/2012 and 3/2015 were identified using the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) database. All patients under 18 years of age were excluded. Cases were stratified into four different categories- RYGB, LSG, LAGB, and LAGB revision (replacement, removal, or port revision). Data included patient demographics, comorbidities, length of stay, and 30-day complications. The primary outcomes of the study were operative time and 30-day overall complication rate. Secondary outcomes included length of stay, major complications and reoperation rates.
Results: There were 2741 bariatric surgeries performed from 2012-2015. Of those, 2067 had resident involvement and 674 had PA involvement. 30-day complication rates for all surgery types, with and without residents, were 5.3% and 6.1%, respectively (p = .45). Complication rates for LSG (p= .716), LAGB (p= .694), LAGB revision (p= .493), and RYGB (p= .126) were also not significant. Operative duration for all surgery types was longer with residents (77.0 vs 60.6 min, p < .0001). Operative duration was longer with resident involvement for LSG (101.1 vs 76.6 min, p < .0001), LAGB (51.6 vs 42.4 min, p <.0001), and LAGB revision (63.0 vs 51.6 min, p = .007). After risk adjustment, OR time for RYGB was significantly longer as well (134.3 min vs 119.3 min, p = .038). Length of stay was also found to be significantly increased in the resident group (1.23 vs 1.09 days, p = .0007).
Conclusion: Resident involvement as first assistant in the OR does not increase complication rates in bariatric surgery. Operative times and length of stay are prolonged, as shown in other studies, but no difference was seen in complication rates for cases involving a resident and cases involving a dedicated operative PA. Teaching advanced bariatric surgery techniques to residents is both safe and essential to their education.