Subspecialization may improve an esophageal atresia service but has not addressed declining trainee experience.
J Pediatr Surg
; 47(7): 1363-8, 2012 Jul.
Article
en En
| MEDLINE
| ID: mdl-22813798
ABSTRACT
BACKGROUND:
Subspecialization defined pediatric surgery using Alder Hey innovations in neonatal surgical units (Rickham) and anesthesia (Jackson-Rees). In neonatal surgery, United Kingdom subspecialization for cloacal extrophy and biliary atresia acknowledges their dependence on multidisciplinary management and the desirability of caseload for training. We phased in regional subspecialization for esophageal atresia (EA) repair and replacement surgery while trainee numbers increased nationally to reduce hours. We examined EA outcomes and training during subspecialization.METHODS:
We analyzed EA cases (1999-2009) treated at Alder Hey Children's Hospital in two 5-year cohorts, the first early phase of incomplete subspecialization and the later near-total or "comprehensive" subspecialization phase. These periods approximated those before and after trainee numbers rose sharply to reduce working hours.RESULTS:
Of 119 cases, 60 in the early cohort shared similar characteristics with the 59 in the later cohort. Near-complete subspecialization was achieved in the second 5 years with 97% of cases performed under a surgeon with an EA specialty interest; in the earlier cohort, 25% of surgeries were undertaken by surgeons without EA subspecialty interest. With near-complete subspecialization, pediatric intensive care unit stay fell from 5 (4-11) to 4 (2-7) days (median (IQR); P = .005), and approaches such as the Bianchi axillary repair and Bax single-stage jejunal interposition were introduced; hospital stay went from 25 (12-63) to 17 (13-28) days (P = .27), and deaths, from 6 to 3 children (P = .49). Mortality was 7.6% (9/119) compared with 14% (19/134) in our previous institutional series (χ(2) = 2.8, P = .09), and neonatal mortality fell from 6% to 0 (P = .008). Near doubling of trainee numbers accompanied an approximately 3-fold fall in repairs per trainee over the study.CONCLUSION:
Near-complete subspecialization for EA coincided with reduced pediatric intensive care unit stay, successful introduction of cosmetic axillary approaches, and extension of our replacement service to offer all interposition types. It has not reversed the steep decline in trainee experience of EA that has been associated with the greater numbers of trainees that have been employed to reduce working hours.
Texto completo:
1
Bases de datos:
MEDLINE
Asunto principal:
Especialización
/
Especialidades Quirúrgicas
/
Esofagostomía
/
Atresia Esofágica
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Esofagoplastia
/
Neonatología
Tipo de estudio:
Etiology_studies
/
Evaluation_studies
/
Incidence_studies
/
Observational_studies
/
Risk_factors_studies
Límite:
Female
/
Humans
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Male
/
Newborn
País/Región como asunto:
Europa
Idioma:
En
Revista:
J Pediatr Surg
Año:
2012
Tipo del documento:
Article
País de afiliación:
Reino Unido