title: Outcomes for trainees vs experienced surgeons undertaking laparoscopic antireflux surgery - is equipoise achieved?
abstract: BACKGROUND
  There is a learning curve associated with laparoscopic antireflux surgery which has an impact on patient outcomes. It is unclear, however, whether this can be eliminated by supervision of early cases by experienced surgeons. The aim of this study was to evaluate the impact of training under supervision on outcomes for laparoscopic fundoplication.
  
  
  METHODS
  Patients undergoing primary laparoscopic antireflux surgery from 1995 to 2009 were identified from a prospective database. Patients were classified according to whether they were operated on by an experienced consultant or supervised trainee, and sub-categorised according to the presence of a very large hiatus hernia. A standardised questionnaire was used to assess outcomes for heartburn, dysphagia and satisfaction at 1 and 5 years follow-up. Outcomes for the study groups were compared.
  
  
  RESULTS
  One thousand seven hundred and ten patients underwent surgery; 1,112 were operated on by consultants and 598 by trainees. The peri-operative complication rate was not different between the groups, although in patients operated on by trainees, there were increased rates of endoscopic dilatation (9 vs. 5 % p = 0.014) and re-operation (9 vs. 6 %, p = 0.031), and a lower satisfaction rate (76 vs. 82 %, p = 0.044) within 5 years of surgery. All other outcomes were similar for trainees vs. consultants.
  
  
  CONCLUSIONS
  The learning curve for laparoscopic fundoplication had a small, but statistically significant, impact on patient outcomes, with slightly lesser outcomes when surgery was undertaken by trainees, even when supervised by experienced surgeons. Although the differences were not large, they raise questions about equipoise and highlight ethical dilemmas with teaching new generations of surgeons.
authors: Department of Surgery and the Royal Adelaide Hospital, University of Adelaide, Level 5, Eleanor Harrald Building, Royal Adelaide Hospital, 5000 Adelaide, South Australia, Australia. clrnbrown@doctors.org.uk
authors: Claire N
authors: CN
authors: Brown
authors: Lorelle T
authors: LT
authors: Smith
authors: David I
authors: DI
authors: Watson
authors: Peter G
authors: PG
authors: Devitt
authors: Sarah K
authors: SK
authors: Thompson
authors: Glyn G
authors: GG
authors: Jamieson
mesh_terms: D002983:Clinical Competence; D005260:Female; D018662:Fundoplication / Q000193:education* / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006551:Hernia, Hiatal / Q000601:surgery; D006801:Humans; D010535:Laparoscopy / Q000193:education*; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome
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