title: A Challenge between Trainee Education and Patient Safety: Does Fellow Participation Impact Postoperative Outcomes Following Bariatric Surgery?
abstract: Surgical training may potentially influence patient care. A safe, high-quality bariatric and metabolic surgery practice requires dedicated and specialized training commonly acquired during a fellowship. This study evaluates the impact of fellow participation on early postoperative outcomes in bariatric surgery.
  
  
  
  From the American College of Surgeons (ACS-NSQIP) database, we identified all obese patients who had undergone primary laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) between 2010 and 2012. Logistic regression was used to prognosticate the surgical fellow (PGY-6, 7, or 8) participation in bariatric surgeries on perioperative outcomes, as compared to surgeries with no trainee participation.
  
  
  
  The study cohort consisted of 10,838 patients (8819 LRYGB, 2019 LSG, 32 % fellow participation). Fellows participated in higher-risk surgeries. Fellow involvement was associated with increased operative time in LRYGB (difference 42.4 ± 1.2 min, p < 0.001) and in LSG (difference 38.8 ± 2.5 min, p < 0.001). Multivariate regression revealed that fellow involvement in LSG did not significantly alter postoperative adverse events. Conversely, in the LRYGB group, fellow participation was independently associated with higher rates of overall complications (OR = 1.37, 95 % CI 1.16-1.63), serious complications (OR = 1.23, 95 % CI 1.00-1.52), surgical complications (OR = 1.42; 95 % CI 1.17-1.73), and reoperation (OR = 1.43, 95 % CI 1.10-1.87). On adjusted analysis, while readmission was higher with fellow involvement in both procedures, mortality rates were comparable.
  
  
  
  Fellow involvement resulted in a clinically appreciable increase in operative times. Fellow participation in the operating room was also independently associated with worse early postoperative outcomes following LRYGB, but was not the case for LSG. Promoting proficiency in surgical simulation laboratories and a gradual participation of fellows from LSG to LRYGB during fellowship may be associated with a reduction in postoperative complications.
authors.affiliation: Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA. aminiaa@ccf.org.
authors.forename: Ali
authors.initials: A
authors.lastname: Aminian
authors.affiliation: Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
authors.forename: Rizwan M
authors.initials: RM
authors.lastname: Chaudhry
authors.affiliation: Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
authors.forename: Zhamak
authors.initials: Z
authors.lastname: Khorgami
authors.affiliation: Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
authors.forename: Amin
authors.initials: A
authors.lastname: Andalib
authors.affiliation: Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
authors.forename: Toms
authors.initials: T
authors.lastname: Augustin
authors.affiliation: Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
authors.forename: John
authors.initials: J
authors.lastname: Rodriguez
authors.affiliation: Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Kroh
authors.affiliation: Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
authors.forename: Philip R
authors.initials: PR
authors.lastname: Schauer
authors.affiliation: Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
authors.forename: Stacy A
authors.initials: SA
authors.lastname: Brethauer
mesh_terms: D000328:Adult; D050110:Bariatric Surgery / Q000193:education* / Q000379:methods; D019985:Benchmarking; D016208:Databases, Factual; D005257:Fellowships and Scholarships; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000193:education* / Q000379:methods; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D061646:Operative Time; D061214:Patient Safety; D011183:Postoperative Complications / Q000517:prevention & control; D014481:United States
keywords: Bariatric surgery; Fellow; Fellowship; Gastric bypass; NSQIP; Sleeve gastrectomy; Trainee
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