Comments on “Head and Neck Reconstruction: Does Surgical Specialty Affect Complication Rates?”
Comments on “Head and Neck Reconstruction: Does Surgical Specialty Affect Complication Rates?”
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对“头颈重建：外科专业会影响并发症发生率吗？”的评论
DOI：
10.1055/s-0039-3400272
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发表时间：
2019
影响因子：
2.1
通讯作者：
Ashit Patel
中科院分区：
文献类型：
--
作者：
James J. Drinane;Ashit Patel
我们感谢并承认Bur等人对我们最近发表的文章“头颈部重建：外科专业是否影响并发症发生率？”“1首先，我们要强调的是，患者安全在我们所做的一切中都是至关重要的，本出版物的目的是确定是否有可能在美国外科医师学会国家外科质量改进计划（美国外科医师学会(ACS)-NSQIP）数据库中，该专业影响头颈部重建的结果。这样做的原因可能是为了找出可以通过加强临床团队和基础科学研究人员的合作来解决的差异。我们的假设是外科专业不会影响结果。我们的观点是，重要的是程序的执行，而不是个人的专业，以获得优质和安全的护理。我们相信，有许多不同背景的优秀显微外科医生（骨科、泌尿外科、耳鼻喉科和整形外科）都在进行创新手术，如果我们想继续改善对患者的护理，我们需要更多的合作，并随时分享想法。我们同意Bur等人的担忧，即NSQIP中包含的“外科医生专业（SURG-SPEC）”变量仅记录了NSQIP中反映的一次初级手术的记录外科医生。2然而，对于包括多名外科医生的病例存在误解，导致该变量的报告不统一。如果每个外科医生都进行了额外的手术暂停，那么该病例将被记录为单独的主要手术。然而，如果病例是并发的，并且没有额外的超时执行，那么只有执行指定的主要手术的外科医生将记录他/她的专业。我们用合理的方法进行了这项研究。我们在补充表中纳入了现行程序术语（CPT）代码15757，作为纳入研究的CPT代码的第一个代码为了排除头颈部外的游离组织转移病例，我们通过使用国际疾病分类第9和第10号（ICD-9和ICD-10）代码来确定所有头颈部癌症病例。在此之后，我们确定了进行游离组织移植的病例。同时发生的病例中，当涉及两个或多个手术团队时，仅报告了其中一位外科医生的外科专业，因此我们排除了他们，以防止将游离皮瓣归因于给定专业的错误。我们选择不研究重建缺陷的位置，以获得最大可能的样本量。此外，根据伤口分类来比较缺陷是没有意义的，因为所有涉及上、下气消化道和眶部的缺陷都不是无菌的体腔，而是清洁污染的手术区域我们也同意，大型数据库是强大的工具，必须负责任地使用，以产生有意义的研究。在数据科学家的帮助下，我们对数据进行了合理的统计分析。事后修正在统计学界是有争议的为了简化报告，所有p<0.05的变量都具有小于0.001的小p值，如果进行Bonferroni校正，则校正后的α将降至0.0488，从而不会改变我们的结论。值得注意的是，我们的数据清楚地反映了一种趋势，即在耳鼻喉科完成手术的病例中，有统计学意义的更高的意外返回手术室，而在耳鼻喉科治疗的患者中，再入院率的趋势不显著。医学研究人员有责任理解统计分析并正确设计分析，因为多达78%的外科出版物包含重大的统计错误当检查患者基线特征的差异时，我们注意到差异是显著的。然而，在我们检查了术前功能分级和美国麻醉学会分级（ASA）评分的分布后，发现这些组是分布的
We appreciate and acknowledge the concerns voiced by Bur et al regarding our recently published article “Head and Neck Reconstruction: Does Surgical Specialty Affect Complication Rates?”1 First and foremost, we want to stress that patient safety is paramount in all that we do and that the aim of this publication was to determine if it was possible that the specialty affected outcomes for head and neck reconstruction in the American College of Surgeons National Surgical Quality Improvement Program (American College of Surgeons (ACS)-NSQIP) database. The reason for this is to possibly identify differences that could be resolved with increased collaboration of clinical teams and basic science researchers. Our hypothesis was that surgical specialty would not affect outcomes. We are of the opinion that it is the execution of a procedure that matters, not an individual’s specialty that garners excellent and safe delivery of care. We believe that there are exceptional microsurgeons of many diverse backgrounds (orthopedics, urology, otolaryngology, and plastic surgery) all performing innovative surgery and that if we want to continue to improve the care delivered to our patients, we need to collaborate more and share ideas readily. We agree with the concerns by Bur et al that the “surgeon specialty (SURG-SPEC)” variable contained in NSQIP only records the surgeon of record for a primary procedure as reflected in NSQIP.2 However, there are misconceptions regarding cases including multiple surgeons that lead to nonuniform reporting of this variable. If additional surgical timeouts are performed for each surgeon, then the case will be recorded as a separate primary procedure. However, if cases are concurrent and no additional timeout is performed, then only the surgeon, performing the designated primary procedure, will have his/her specialty recorded. We conducted this study with sound methodology. We did include current procedural terminology (CPT) code 15757 in the supplemental table as the first code of included CPT codes, included in the study.1 To exclude cases of freetissue transfer outside of the head and neck, we identified all head and neck cancer cases by using both the International Classification of Disease 9th and 10th (ICD-9 and ICD-10) codes to identify cases. After this, we identified caseswhere a free tissue transfer was performed. Concurrent cases report only one of the involved surgeons as the surgeon specialty for a case involving two or more surgical teams, thus we excluded them to prevent errors in attributing a free flap to a given specialty. We choose not to study the site of the defect reconstructed to enable the largest possible sample size. Furthermore, comparing the defects based upon wound classification is meaningless, as all defects involving the upper and lower aerodigestive tract and orbit are not sterile body cavities but rather clean-contaminated operative fields.3 We too agree that large databases are powerful tools that must be used responsibly to generate meaningful research. With the help of our data scientist, we conducted a sound statistical analysis of the data. The post hoc corrections are controversial amongst the statistical community.4 To simplify reporting, all variables with a p<0.05 had small p-values that were under 0.001 and if a Bonferroni’s correction was performed, the corrected α would have fallen to 0.0488 resulting no changes to our conclusions. It should be noted, that our data clearly reflected a trend to a statistically significant higher unplanned return to the operating room in cases completed by otolaryngology and a nonsignificant trend to higher readmission rates for patients treated by otolaryngologists. It is incumbent upon medical researchers to understand statistical analysis and properly design an analysis because as many as 78% surgical publications contain significant statistical errors.4,5 When examining the differences in patients’ baseline characteristics, we noted differences that were significant. However, after we examined the distribution of preoperative functional class, and American Society of Anesthesiology class (ASA) scores, the groups were found to be distributed