Training does not affect patient outcome: a comparison of 300 elective laparoscopic colonic resections with anastomosis.
Training does not affect
patient outcome: a comparison of 300 elective laparoscopic colonic resections
SJ Dalton, A Ghosh, N Zafar, K Riyad, AR Dixon
Department of Colorectal Surgery, Frenchay Hospital, North Bristol NHS
Trust, Bristol, BS16 1LT, UK.
Key words: training, laparoscopic fellowships, laparoscopic colorectal surgery
Objective: The aim of this retrospective cohort study was to compare outcomes in
patients who underwent elective laparoscopic colonic resection with anastomosis
performed by a single surgeon or his training fellow.
Methods: A prospectively collected electronic database of all laparoscopic
procedures between January 2005 and September 2008 was used. Two groups were
compared; those operated upon by the Consultant trainer (C) and those by the
fellow (F). Fellows were either
post CCT or in their last year of training. 300 consecutive cases were
examined, 150 in each group.
Groups were matched for indication, age, ASA grade, cancer T stage and
procedure performed. Preoperative work-up, operative surgery and anaesthesia
were identical between groups.
Results: No significant difference was demonstrated in age, mean 67 (26-91) or
ASA grade. Indications for surgery
were; cancer (C) 120, (F) 126, diverticular disease (C) 22, (F) 20, Crohn’s
disease (C) 8, (F) 7. Fellow’s
median operative time was significantly longer at 126 min (95%CI 117-134)
compared to the consultant trainer - 104 min. (95%CI 98-111) (p<0.01). No significant differences in the
complication or conversion rates were demonstrated. Length of stay and the
30day readmission rates were similar.
Discussion: In this retrospective cohort study we have demonstrate that when
matched cases are compared, trainee operating time is significantly longer than
that of the consultant trainer but without any significant increase in length
of stay, complication or readmission rates. Training takes time but not at the expense of patient care.
Colorectal cancer is the third most common
malignancy in the UK1 with
open surgery remaining the mainstay of treatment2. Although Jacobs reported the first
successful laparoscopic colonic resection, a right hemicolectomy in Miami,
Florida in 19903 the
uptake of laparoscopic colorectal surgery here in the UK has been painfully
slow4, 5 with
only about 18% of ACPGBI surgeons undertaking 50% of their practice
laparoscopically4. in the 12 month period to March 2007, 8.82% of resections were performed
by this method (Nice 2006)6. Major reasoning for this delayed uptake
included early concerns about oncological safety 7,8,9 and the
recognition of the relatively long and technically demanding learning curve10-13. Large, long-term randomized control
trials of laparoscopic surgery for colorectal cancer have supported the view
that the original concerns were unfounded (MRC CLASSIC14,COST15
and Barcelona16 trials).
Systematic17, Cochrane18 reviews and meta-analysis19
concluded that laparoscopc resection was safe and associated with better
short-term outcomes and without any compromise to long-term cancer survival. NICE updated its guidance in 2006 in
favour of NHS trusts providing patients the option of laparoscopic resection as
an alternative to open surgery20. More importantly the guidance recommends that
laparoscopic surgery should only be performed by surgeons who have completed
appropriate training and who perform this procedure often enough to maintain
been written5,21,22 with regard to the leaning curve and
patient/case selection which determines the rates of conversion and clinical
outcome, and predictive models have attempted to identify suitable patients13. That said, the
main rate-limiting factor in its adoption is the shortage of surgeons suitably
skilled in this technique. In response to this and the finding that the majority of established UK
colorectal surgeons and surgeons completing training programmes are not
competent in laparoscopic colorectal surgery4,23 a number of
initiatives were introduced (industry funded fellowships and the ALS consultant
preceptorship programme). In 2008, as part of the
Cancer Reform Strategy implementation plans the DOH and the National Cancer
Action Team developed and funded a programme with an objective of training
consultant colorectal surgeons to a level of competence to perform laparoscopic
resections independently and safely. The National Cancer Director recently wrote24
to all CEOs and Medical Directors of the English acute trusts urging that they “support all your colorectal surgeons and their teams
already in training or who wish to start training, to enroll in the national
However, there has been little research looking at the quality of the
surgery carried out by “trainees” on such programmes. Here we describe our centres experience and compare the
clinical outcomes of patients who underwent elective laparoscopic colonic
resection with anastomosis performed by a single surgeon or his training
A prospectively collected electronic database of
all colorectal laparoscopic procedures between January 2005 and September 2008
was used to identify patient outcomes.
All patients undergoing elective laparoscopic resection with an
anastomosis under the care of the senior author were eligible for inclusion. Two groups were compared; those
operated upon by the consultant trainer and those operated on by the supervised
fellow. Fellows were either post
CCT or within their last six months of training. 300 consecutive cases were examined, 150 in each group. Complex diverticular and Crohn’s
fistulating disease or extended en bloc
resections were excluded from this study, as these were considered unsuitable
for the training fellow. Otherwise
there were no specific exclusion criteria.
The study’s primary endpoints were duration of
surgery and complication rates; secondary endpoints were length of stay and
readmission rates. Groups were
matched for indication of surgery, patient age, ASA grade, cancer T stage and
operative procedure performed. Matching was performed from the complete
prospectively collected database with the researcher performing the matching
blinded to the final outcome data.
Instat prism software® was used to test
normality of data and to perform analysis. Differences between percentages in
contingency tables were evaluated by the Pearson ?2 test or Fisher’s exact
probability test. Differences
between means of normally distributed variables were assessed by the t test;
the Mann Whitney test was used for non-normal data. The sample size of 150 patients per group gives an 80% power
to detect a significant difference of 0.05 between groups. The patients’ data were held on a
Microsoft Excel database (Microsoft ® Corporation, Redmond, Washington, USA).
Patients received a phosphate enema on the morning
of surgery. Volatile agents
provided anaesthesia; epidurals were never used, with peri/postoperative
analgesia provided by a combination of short acting opiods, intravenous
paracetamol and a pre-operatively placed transabdominalis plane block (TAP
block), supplemented by an oral opiate25. Catheters were removed in theatre and patients were actively
mobilised and allowed diet as tolerated.
Patients for left-sided resection were positioned
in the dorsi-lithotomy position, hips extended in 30 degrees of Trendelenburg. Patients for right-sided resections
were placed supine. A medial or
lateral approach was used as the anatomy/pathology dictated; dissection was
performed using harmonic scalpel (Ethicon
Endosurgery, Bracknell, UK) and pedicles ligated with either Hem-o-Lok
clips (Teleflex Medical, High Wycombe, UK)
or vascular linear staplers (Ethicon
Endosurgery, Bracknell, UK). Three
ports were used for most resections. Drains were not used routinely.
300 consecutive elective none-complicated
colorectal resections with anastomosis were performed over the four-year study
period: 150 in each cohort. The
demographics of the two groups were well matched; the mean age was 66.9, (range
26-91). There were 78 men in the Fellows’ group and 62 in the Consultant
group. The mean ASA was 2.20 in
the Fellows’ group and 2.29 in the Consultant group (Table 1). Mean BMI was 26.4 for the Fellows’
group (range14-39) and 26.7 (range 16-55) in the Consultant group. Indications for surgery included:
cancer (Fellow) 126, (Consultant) 120, diverticular disease (F) 20, (C) 22,
Crohn’s disease (F) 7, (C) 8. The
cancer T-stages were T1 (12), T2 (21), T3 (56) and T4 (17) for the patients
operated upon by the supervised Fellows and T1 (10), T2 (22), T3 (64), T4 (12)
for the Consultant operated group.
The average nodal yields for cancer was 15.4 in the Fellows’ cohort and
16 in those operated upon by the Consultant.
The training Fellows’ group comprised 55
right/extended right hemicolectomies, 60 high anterior resections and 31 TME
resections (18 with covering ileostomies); in the Consultant group there were
55 right/extended right hemicolectomies, 55 high anterior resections, 40 TME
resections (22 with covering ileostomies). A conversion was defined as “an unplanned additional or
extended incision”; there were three conversions (2%) in the Fellows group and
none in the Consultant group.
There was no significant difference in the 30-day
mortality between the groups with four deaths (2.6%) occurring in the
Consultant cohort - septic complications following anastomotic leaks (2) and
myocardial infarctions (2); three patients (2%) died in the Fellows’ group
(complications following an anastomotic leak and an “off screen” enterotomy and
a case of Clost. Difficile colitis with
acute renal failure). There was no
significant difference in the complication rates between groups. Six leaks (4%) - clinical and
radiological were seen in the Fellows’ group and four (2.6%) in the Consultant
group. The Fellows median
operative time was significantly longer at 126 min. (95%CI 117-134) compared to
the Consultant group; 104 min. (95%CI 98-111) (p<0.01). The length of postoperative hospital
stay was similar between groups with a mean length of stay of 4.6 days (95%CI
2.2-5.6) for the Fellows’ group and 4.46 days (95%CI 2.0-5.9) for the
Consultant operated group.
There was no difference in the rate of
post-operative complications between groups. 26 (17%) complications developed
in the Fellows’ group: anastomotic leak (6), “off screen enterotomy” (3),
ureteric injury (1), abscess (1), ileus (4), wound infection (3), Clost. Diff (1), AF (2), PE (1),
cerebral oedema (1), retention of urine (1), headache (2), UTI (1), perforated
DU (1). The Consultant operated
group contained 34 (22%) complications: anastomotic leak (3), “off screen
enterotomy” (1), ileus (9), wound infection (3), myocardial infarct (2), AF
(4), Clost. Diff (1), abscess (2),
retention urine (5) and anastomotic bleed (2). Major surgical injuries/errors were more common on the
Fellows’ group (4) than when the Consultant trainer operated (1).
Finally, readmission rates were not significantly
different between groups. The
Fellows’ group had six readmissions; adhesional small bowel obstruction (1),
anastomotic leak (1), faecal impaction (1), wound complications (2) and one
with diarrhoea and new onset AF.
There were 10 readmissions in the Consultant cohort: urinary retention
post TME (4), delayed anastomotic leak at day 30 (1), wound infection (2),
Norwalk virus (1), pancreatitis/hypercalcaemia (1) and one for
reassurance. Two readmitted
patients died; one from each group.
Surgical training has traditionally been an
apprenticeship and when available training in laparoscopic surgery has followed
this well trodden path. However, laparoscopic surgery also requires additional
cognitive and motor skills, with the requirement of long periods of continuous
concentration, image interpretation and adjustment to the loss of a degree of
tactile feedback and altered anatomical view26. Whilst
data suggests that laparoscopic surgery can be complemented by focused
simulator training27, the role of such training for a senior trainee
or training consultant is limited. The relatively long and technically
demanding learning curve of laparoscopic colorectal surgery is established11,12,13
and the central role of a preceptor in this training is recognised28. Estimations of the number of cases
required before embarking on safe independent practice range from 20-6029.
Whether patients are at risk from increased
complications or a greater length of stay when operated upon by surgeons during
this learning curve is not known. Lordan et
al have suggested22 that the change from open to laparoscopic
dissection is safe even during the initial learning curve. Their series however is small and
includes only 77 laparoscopic cases with 32 conversions. Renwick et al demonstrated no difference for
open colorectal resection when closely supervised trainees were compared with
their consultant trainer; patient groups were not matched and were operated
upon in different hospitals30. Evidence
from other specialities suggests that preceptoring of trainees does not result
in increased patient risk; Skrecas et al demonstrated that a mentoring program allows safe
introduction of laparoscopic radical prostatectomy31. There is little data however,
supporting the safety of such a program for laparoscopic colorectal surgery.
combination of the emergence of new technology and patients’ intuitive belief
that a minimally invasive procedure offers significant advantages has meant
that training programs have had to work hard to prepare surgical trainees for performing
these operations. To date, we do not have a standard requirement for either
volume let alone the diversity and potential for laparoscopic colorectal
practice. Our results suggest that this learning curve does not result in patient
harm when an experienced trainer is involved. This is important as with the
growing need for trained laparoscopic colorectal surgeons the preceptorship of
trainees and established consultants is set to increase. All of our fellows exceeded the “ideal” case
volume suggested by a survey of US MIS fellows31 and have, like their Ethicon Endosurgery funded Fellowship counterparts
achieved competency upon completion of their six-month post. All as newly appointed consultants, now
provide a comprehensive laparoscopic colorectal service. Hopefully the hard won lessons that followed the
introduction of laparoscopic cholecystectomy in the UK are taken on board and
acted upon. “Off screen”
enterotomy (not seen on “playback”) with potential for adverse outcome can and
do occur, even when the operator/trainer is experienced; approx 1/1000
(trainer) versus 1:50 trainee.
Their mechanism of causation remains debalable.
This paper does have its flaws; a single trainer is
compared to a number of laparoscopic fellows with the data grouped to allow
analysis. Though this heterogeneity weakens the study, it reflects current
practice and allows for a meaningful comparison. The possible selection bias generated by the easier cases
being performed by the laparoscopic fellows or by the trainer completing cases
where the trainee failed to progress has been considered; however, cases were
only included in the Fellows group if the whole operation was completed by the
fellow and cases were matched to avoid a selection bias. The significance of a
shorter operative time for the trainer is debateable. Chen et al have
shown that operating time is a poor surrogate for the learning curve in
laparoscopic colorectal resections34 and argued that case difficulty
increases as experience increases and therefore operative time in a case series
yields little information. In our
study cases were matched and so the shorter operative time of the preceptor
compared to the trainee is a true, although not a particularly surprising
finding. Though the time
differences were significant the actual increase in operative time was small
and hence the clinical effect on the patients is likely to be minimal. However, the accumulative effect of a
supervised trainee performing three consecutive resections is significant and
would if sufficient beds were available have a financial and target implication
to the hospital trust.
In this review of a prospectively collected
database we demonstrate that when matched cases are compared trainee-operating
time is significantly longer than that of the preceptor however no significant
increase in complication rate, length of stay or readmission rate is
demonstrated. Training and preceptorship takes time but not at the expense of
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Table 1. ASA grades of two
No of patients
No of patients