Performing concurrent operations in academic vascular neurosurgery does not affect patient outcomes

Abstract

OBJECTIVE Concurrent surgeries, also known as "running two rooms" or simultaneous/overlapping operations, have recently come under intense scrutiny. The goal of this study was to evaluate the operative time and outcomes of concurrent versus nonconcurrent vascular neurosurgical procedures. METHODS The authors retrospectively reviewed 1219 procedures performed by 1 vascular neurosurgeon from 2012 to 2015 at the University of California, San Francisco. Data were collected on patient age, sex, severity of illness, risk of mortality, American Society of Anesthesiologists (ASA) status, procedure type, admission type, insurance, transfer source, procedure time, presence of resident or fellow in operating room (OR), number of co-surgeons, estimated blood loss (EBL), concurrent vs nonconcurrent case, severe sepsis, acute respiratory failure, postoperative stroke causing neurological deficit, unplanned return to OR, 30-day mortality, and 30-day unplanned readmission. For aneurysm clipping cases, data were also obtained on intraoperative aneurysm rupture and postoperative residual aneurysm. Chi-square and t-tests were performed to compare concurrent versus nonconcurrent cases, and then mixed-effects models were created to adjust for different procedure types, patient demographics, and clinical indicators between the 2 groups. RESULTS There was a significant difference in procedure type for concurrent (n = 828) versus nonconcurrent (n = 391) cases. Concurrent cases were more likely to be routine/elective admissions (53% vs 35%, p < 0.001) and physician referrals (59% vs 38%, p < 0.001). This difference in patient/case type was also reflected in the lower severity of illness, risk of death, and ASA class in the concurrent versus nonconcurrent cases (p < 0.01). Concurrent cases had significantly longer procedural times (243 vs 213 minutes) and more unplanned 30-day readmissions (5.7% vs 3.1%), but shorter mean length of hospital stay (11.2 vs 13.7 days), higher rates of discharge to home (66% vs 51%), lower 30-day mortality rates (3.1% vs 6.1%), lower rates of acute respiratory failure (4.3% vs 8.2%), and decreased 30-day unplanned returns to the OR (3.3% vs 6.9%; all p < 0.05). Rates of severe sepsis, postoperative stroke, intraoperative aneurysm rupture, and postoperative aneurysm residual were equivalent between the concurrent and nonconcurrent groups (all p values nonsignificant). Mixed-effects models showed that after controlling for procedure type, patient demographics, and clinical indicators, there was no significant difference in acute respiratory failure, severe sepsis, 30-day readmission, postoperative stroke, EBL, length of stay, discharge status, or intraoperative aneurysm rupture between concurrent and nonconcurrent cases. Unplanned return to the OR and 30-day mortality were significantly lower in concurrent cases (odds ratio 0.55, 95% confidence interval 0.31-0.98, p = 0.0431, and odds ratio 0.81, p < 0.001, respectively), but concurrent cases had significantly longer procedure durations (odds ratio 21.73; p < 0...

Analysis of overlapping surgery in patients undergoing microsurgical aneurysm clipping: acute and long-term outcomes from the Barrow Ruptured Aneurysm Trial

“…Although this study was matched case by case in a statistical model, relative case numbers within each specialty were small, and no conclusions can be made about specific case types from this analysis. Zygourakis et al 23 published their single-center, single-provider experience with 1219 vascular neurosurgery cases at the University of California, San Francisco, with results similar to those of earlier studies-variations in case complexity were present between overlapping and nonoverlapping cases, but no evidence of worse outcomes with overlapping surgery was identified in a multivariate analysis. We sought to evaluate the practice of overlapping surgery in a more homogeneous cohort of patients undergoing microsurgical clipping of an acutely ruptured aneurysm with data from a prospective, randomized trial.…”

“…In teaching institutions, overlapping cases are also associated with more resident involvement and graduated autonomy for surgeons in training, which many believe represents an invaluable learning opportunity. 4,9,23 However, recent reports questioning the safety of overlapping surgery have required surgeons and institutions to address this strategy to ensure that the best possible care is being offered to patients. 16,21 Few studies have been performed on this subject to date, and recent changes in practice have been driven by anecdotal reports of surgical complications in overlapping or concurrent cases.…”

“…1,21 Concerns about patient safety have led to nationwide changes in surgical scheduling regulations; however, limited data examining this practice exist. No studies published to date have found any evidence of worse outcomes with overlapping surgery; 5,9,11,23 however, these studies examined heterogeneous populations of patients undergoing a variety of neurosurgical procedures.…”

Hemorrhage associated with ventriculoperitoneal shunt placement in aneurysmal subarachnoid hemorrhage patients on a regimen of dual antiplatelet therapy: a retrospective analysis

“…Lastly, in a number of recent studies, resident involvement in neurosurgical care has not been found to impact patient outcomes. 3,11,17 We aimed to qualitatively assess the number of VP shunt-associated hemorrhagic complications with respect to chief resident coverage periods to assess safety of resident involvement for this patient subset.…”

Editorial. Neurosurgery program building at its best: Dr. Charles Wilson (1929–2018)

“…On 2 or 3 days each week, Dr. Wilson would perform up to 8 major cases each day, by virtue of his operating in 3 different rooms each day. Overlapping or simultaneous surgery has become an important topic in the recent neurosurgical literature, 2,3,8 but it is probably fair to say that Dr. Wilson was one of the earliest proponents and masters of this approach to neurosurgical cases.…”