Der erfahrene Chirurg als unabhängiger Risikofaktor für die Morbidität nach Cholezystektomie. Eine multivariate Analyse von 710 Patienten

Zusammenfassung

Einleitung Bei komplexeren chirurgischen Eingriffen wie der Kolonresektion, herzchirurgischen Eingriffen, arteriellen Rekonstruktionen oder Leberresektionen ist der Einfluss des Chirurgen auf die postoperative Morbidität nachgewiesen. Bei Routineeingriffen wie der Cholezystektomie liegen bislang keine Erkenntnisse zum Zusammenhang von Operateur und Morbidität vor. Insbesondere Untersuchungen bei erfahrenen Chirurgen fehlen.

Methoden Es wurden 710 konsekutive Patienten, die zwischen Januar 2014 und Dezember 2018 von erfahrenen Chirurgen (über n = 300 Cholezystektomien vor Beginn der Untersuchung, über 5 Jahre nach bestandener Facharztprüfung) cholezystektomiert wurden, untersucht. In einer univariaten Analyse wurde der Einfluss von Patientenmerkmalen, Laborparametern, chirurgischen Parametern und des Operateurs auf die postoperative Morbidität analysiert. Die Variablen mit statistischer Signifikanzen wurden dann einer multivariaten logistischen Regressionsanalyse unterzogen.

Ergebnisse Die Mortalität lag bei 5 von 710 (0,7%), die Morbidität bei 58 von 710 (8,2%). 37 von 710 Patienten erlitten eine chirurgische Komplikation, 21 von 710 Patienten eine nicht chirurgische Komplikation. Hinsichtlich der Gesamtmorbidität waren in multivariater Analyse der Kreatininwert (OR 1,29; KI 1,01–1,648; p = 0,042), GOT (OR 1,0405; KI 1–1,01; p = 0,03), offene und Konversions-Cholezystektomie (OR 4,134; KI 1,587–10,768; p = 0,004) und der individuelle Chirurg (OR bis 40,675; p = 0,001) ein unabhängiger Risikofaktor. Bei Analyse der chirurgischen Komplikationen blieben offene und Konversions-Cholezystektomie (OR 8,104; KI 3,03–21,68; p < 0,001) sowie der individuelle Chirurg (OR bis 79,69; p = 0,005) ein statistisch signifikanter unabhängiger Risikofaktor.

Schlussfolgerung Der individuelle Chirurg ist auch bei einem Routineeingriff wie der Cholezystektomie ein unabhängiger Risikofaktor für die Morbidität. Dies gilt auch für erfahrene Chirurgen mit Facharztstatus und hoher Caseload. Im Hinblick auf die Patientensicherheit und Verbesserungen der Ergebnisqualität muss daher diskutiert werden, ob eine routinemäßige risikoadjustierte Messung der individuellen Ergebnisse eines jeden Chirurgen als Basis eines gezielten Qualifizierungprogramms sinnvoll ist.

Abstract

Background In sophisticated surgical procedures, e. g. colectomy, cardiac surgery, arterial reconstruction and liver resection, the individual surgeon is a major influence on postoperative morbidity. For the everyday procedure of cholecystectomy, clear data on the morbidity related to the individual surgeon are lacking.

Aims To assess the individual impact on the outcome of cholecystectomy in a cohort of experienced surgeons.

Methods The analysis covered n = 710 consecutive patients who had received cholecystecomy between January 2014 and December 2018 – performed by experienced surgeons (> n = 300 cholecystectomies before entry in the study and > 5 years after specialty registration). In a univariate analysis, the influence of patient characteristics, laboratory findings and surgical data on postoperative morbidity were investigated. Variables with statistical significance were entered into a multivariate logistic regression.

Results Mortality was 5/710 (0.7%), and morbidity was 58/710 (8.2%), including 37/710 patients with surgical morbidity and 21/710 patients with non-surgical morbidity. In a multivariable analysis the independent risk factors for overall morbidity were creatinine level (OR 1.29, CI 1.01–1.648, p = 0.042), GOT (OR 1.005, CI 1–1.01, p = 0.03), open/conversion surgery (OR 4.134, CI 1.587–10.768, p = 0.004) and the individual surgeon (OR up to 40.675, p = 0.001). In the analysis of surgical complications, open/conversion surgery (OR 8.104, CI 3.03–21.68, p < 0.001) and the individual surgeon (OR up to 79.69, p = 0.005) remained of significant influence.

Conclusions The individual surgeon is of major influence on the outcome after an everyday procedure such as cholecystectomy in a group of experienced surgeons with specialty registration. The individual outcome of each surgeon should be measured as a basis of targeted improvement programs.

Schlüsselwörter

Abdominalchirurgie - Morbidität - Patientensicherheit - Qualitätskontrolle - Cholezystektomie - erfahrener Chirurg

Keywords

abdominal surgery - morbidity - patient safety - quality of treatment - cholecstectomy - experienced surgeon

Publication History

Received: 15 September 2021

Accepted after revision: 25 November 2021

Article published online:
02 March 2022

• Literatur

• 1 World Health Organization. Patient safety. Im Internet: https://www.who.int/patientsafety/en/
• 2 Buurma M, Kroon HM, Reimers MS. et al. Influence of individual surgeon volume on oncological outcome of colorectal cancer surgery. Int J Surg Oncol 2015; 2015: 464570
• 3 Marinello FG, Baguena G, Lucas E. et al. Anastomotic leakage after colon cancer resection: does the individual surgeon matter?. Colorectal Dis 2016; 18: 562-569
• 4 Garcia-Granero E, Navarro F, Cerdan Santacruz C. et al. Individual surgeon is an independent risk factor for leak after double-stapled colorectal anastomosis: an institutional analysis of 800 patients. Surgery 2017; 162: 1006-1016
• 5 Umminger J, Reitz M, Rojas SV. et al. Does the surgeon’s experience have an impact on outcome after total arterial revascularization with composite T-grafts? A risk factor analysis. Interact Cardiovasc Thorac Surg 2016; 23: 749-756
• 6 Tsuboi K, Omura N, Yano F. et al. Identification of risk factors for mucosal injury during laparoscopic Heller myotomy for achalasia. Surg Endosc 2016; 30: 706-714
• 7 Dubois L, Allen B, Bray-Jenkyn K. et al. Higher surgeon annual volume, but not years of experience, is associated with reduced rates of postoperative complications and reoperations after open abdominal aortic aneurysm. J Vasc Surg 2018; 67: 1717-1726.e5
• 8 Buettner S, Gani F, Amini N. et al. The relative effect of hospital and surgeon volume on failure to rescue among patients undergoing liver resection for cancer. Surgery 2016; 159: 1004-1012
• 9 Hoehn RS, Hansemann DJ, Chang AL. et al. Surgeon characteristics supersede hospital characteristics in mortality after urgent colectomy. J Gastrointest Surg 2017; 21: 23-32
• 10 World Health Organization. Disorders of gallbladder, biliary tract and pancreas (K80-K87). Im Internet: https://icd.who.int/browse10/2019/en#/K80-K87
• 11 Blohm M, Österberg J, Sandblom G. et al. The sooner, the better? The importance of optimal timing of cholecystectomy in acute cholecystitis: data from the National Swedish Registry for Gallstone Surgery, GallRiks. J Gastrointest Surg 2017; 21: 33-40
• 12 Gutt CN, Encke J, Köninger J. et al. Acute cholecystitis. Early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NTC00447304). Ann Surg 2013; 258: 385-393
• 13 Bundesinstitut für Arzneimittel und Medizinprodukte. ICD-10-GM Version 2019. Im Internet: https://www.dimdi.de/dynamic/.downloads/klassifikationen/icd-10-gm/vorgaenger/icd10gm2019.zip
• 14 Bassi C, Dervinis C, Butturini G J. et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138: 8-13
• 15 Koch M, Garden J, Padbury R. et al. Bile leak after hepatobiliary and pancreatic surgery: a definition and grading of severity by the international study group of liver surgery. Surgery 2011; 149: 680-688
• 16 Grat M, Lewandowski Z, Patkowski W. et al. Individual surgeon experience yields bimodal effects on patient outcomes after deceased-donor liver transplant: results of a quantile regression for survival data. Exp Clin Transplant 2018; 16: 425-433
• 17 Goka EA, Phillips P, Poku E. et al. The relationship between hospital or Surgeon volume and outcomes in lower limb vascular surgery in the United Kingdom and Europe. Ann Vasc Surg 2017; 45: 271-286
• 18 Donkervoort SC, Dijksman LM, Versluis GV. et al. Surgeon’s volume is not associated with complication outcome after laparoscopic cholecystectomy. Dig Dis Sci 2014; 59: 39-45
• 19 Csikesz NG, Singla A, Murphy MM. et al. Surgeon volume metrics in laparoscopic cholecystectomy. Dig Dis Sci 2010; 55: 2398-2405
• 20 Giger UF, Michel JM, Opitz I. et al. Risk factors for perioperative complications in patients undergoing laparoscopic cholecystectomy: Analysis of 22 953 consecutive cases from the Swiss Association of Laparoscopic and Thoracoscopic Surgery database. J Am Coll Surg 2006; 203: 723-728
• 21 Murphy MM, Ng SC, Simons JP. et al. Predictors of major complications after laparoscopic cholecystectomy: surgeon, hospital, or patient?. J Am Coll Surg 2010; 211: 73-80
• 22 Verban OA, Greenberg CC, Schram J. et al. Surgical skill in bariatric surgery. Does skill in one procedure predict outcome for another?. Surgery 2016; 160: 1172-1181
• 23 Lee KT, Chang WT, Huang HC. et al. Influence of surgeon volume on clinical and economic outcomes of laparoscopic cholecystectomy. Dig Surg 2004; 21: 406-412
• 24 Shi HY, LeeKTChiu CC. et al. The volume outcome relationship in laparoscopic cholecystectomy: a population-based study using propensity score matching. Surg Endosc 2013; 27: 3139-3145
• 25 Abelson JS, Spiegel JD, Afaneh C. et al. Evaluating cumulative and annual surgeon volume in laparoscopic cholecystectomy. Surgery 2017; 161: 611-617
• 26 Israelson LA. The surgeon as a risk factor for complications of midline incisions. Eur J Surg 1998; 164: 353-359
• 27 Tam SF, Au JT, Sako W. et al. How sick are dialysis patients undergoing cholecystectomy? Analysis of 92.672 patients from the American College of Surgeons National Surgical Quality Improvement Programm Database. Am J Surg 2015; 210: 864-870
• 28 Yule S, Flin R, Paterson-Brown S. et al. Non-techniqual skills for surgeons in the operating room: a review of the literature. Surgery 2006; 139: 140-149
• 29 Mathias AP, Vogel P, Knauff M. Different Cognitive Styles Can Affect Performance in Laparoscopic Surgery Skill Training. Surg Endosc 2020; 34: 4866-4873
• 30 McDermid E, Young CJ, Moug SJ. et al. Heuristics and bias in rectal surgery. Int J Colorectal Dis 2017; 32: 1109-1115
• 31 Dekker SWA, Hugh TB. Laparoscopic bile duct injury: understanding the psychology and heuristics of the error. ANZ J Surg 2008; 78: 1109-1114
• 32 Vogel P, Vogel DHV. Cognition errors in the treatment course of patients with anastomotic failure after colorectal resection. Patient Saf Surg 2019; 13: 4
• 33 Zilbert NR, Murnaghan ML, Gallinger S. et al. Taking a chance or playing it safe: reframing risk assessment within the surgeon’s comfort zone. Ann Surg 2015; 262: 253-259
• 34 Way LW, Sewart L, Gantert W. et al. Causes and prevention of laparoscopic bile duct injuries. Analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 2003; 237: 460-469
• 35 Brunt LM, Deziel DJ, Telem DA. et al. Safe cholecystectomy multi-society practice guideline and state of the art consensus conference on prevention of bile duct injury during cholecystectomy. Ann Surg 2020; 272: 3-23
• 36 Espin S, Lingard L, Baker GR. et al. Persistance of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room. Qual Saf Health Care 2006; 15: 165-170
• 37 Burt C, Madahu R, Leonard M. et al. The learning curve for laparoscopic cholecystectomy. J Laparoendosc Surg 1994; 4: 419-427