A propensity score matching analysis: Impact of senior resident versus fellow participation on outcomes of complex surgical oncology

Optimal management of intra-abdominal and intra-thoracic tumors, including gastric, esophageal, pancreatic and hepatic malignancies, requires multidisciplinary treatment and extensive integration of evolving knowledge across medical and surgical specialties. Surgical fellowship is an opportunity for trainees to develop the technical prowess necessary for advanced cancer resections, build a holistic understanding of multidisciplinary treatment modalities, and gain necessary experience in delivering multifaceted care to oncologic patients [1]. Historically hepato-pancreato-biliary (HPB), transplant and thoracic fellowships have been integral in training surgeons to treat oncologic disease.

Unofficial fellowships in complex surgical oncology have been documented as early as 1947, under the oversight of the James Ewing Society that is now known as the Society of Surgical Oncology (SSO) [2,3]. Formal recognition of Complex General Surgical Oncology (CGSO) as a subspecialty was granted by the American Board of Surgery and American Board of Medical Specialties (ABMS) in 2011 [4]. To date, there are 36 Accreditation Council for Graduate Medical Education (ACGME) accredited programs [5].

As the number of fellowship programs and positions continue to increase, there has been variable concern that co-existing fellowship programs may degrade resident operative experiences and clinical training, especially as operative training in complex HPB among general surgery residents is limited at baseline [6]. Principally, this concern is derived from the possibility that fellow participation will be prioritized given potential positive effects for patient safety and perioperative outcomes. Multiple studies have investigated the impact of resident and fellow participation, versus attending only involvement, on perioperative outcomes, with the results largely demonstrating that resident and fellow participation is safe and does not adversely affect clinical outcomes [[7], [8], [9], [10], [11], [12], [13], [14]]. Data on the differential impact of residents versus fellows on perioperative outcomes is less robust; however, in minimally invasive, breast and endocrine surgery, trainee level, specifically senior resident versus fellow, did not translate to adverse outcomes [9,[13], [14], [15]].

In complex surgical oncology, an analysis of data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) assessing the impact of resident participation demonstrated that resident participation was associated with significantly higher 30-day postoperative complications, but lower 30-day mortality and improved rescue rate after complications [16]. While these findings may relate to differences in the complexity and acuity of patients at academic and non-academic institutions, the data expose a potential detriment of resident participation in complex surgical oncology. However, the differential impact of resident versus fellow participation on outcomes of complex surgical oncology is not known. Utilizing the ACS-NSQIP database, this study sought to investigate the impact of resident versus fellow participation on outcomes following complex surgical oncology cases.

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