Back to back surgeries safe: Second scoliosis surgery of the day as effective as first

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Vishal Sarwahi presenting his talk “Back to back scoliosis surgeries: is patient safety and outcomes compromised?” at IMAST 2018

Scoliosis correction is an extensive surgery, and operating on multiple patients in one day can be exhausting for the surgical team. However, recent research finds that the second surgery of the day has similar outcomes and complication rates compared to the first surgery. Additionally, the second surgery had similar results to single day scoliosis surgeries.

This is the conclusion reached by Vishal Sarwahi and colleagues (New York, USA), presented by Sarwahi at the 25th International Meeting on Advanced Spine Techniques (IMAST; 11–14 July, Los Angeles, USA). The investigators conducted an ambispective review of 251 scoliosis surgeries between 2011–2017.

Sarwahi told the IMAST audience, “During the summer months, surgeons often book multiple adolescent idiopathic scoliosis surgeries on the same day. However, a later operative start time and lack of a consistent surgical team, especially for the second case, has been shown to increase surgical complications and adverse patient outcomes.” Additionally, other specialties have reported differences in outcome between the first and second surgery of the day: cardiac cases after 3pm have been shown to increase mortality risk by two, and liver transplants starting after 3pm were not only longer, but had twice the mortality risk of a morning operation.

Therefore, the study investigators set out to determine if they could detect a difference in the number of complication rates between the first and second surgery of the day for scoliosis corrections.

They found that multiple scoliosis surgeries in one day can be performed safely without compromising radiographic or perioperative outcomes. When comparing the first scoliosis surgeries of the day with the second, the investigators found that surgical time, estimated blood loss, and postoperative Cobb angle were all similar. The first surgery of the day typically lasted for 224 minutes, compared to 214 minutes for the second surgery. Estimated blood loss was 400ml for the first surgery of the day, compared to an average of 350ml in the day’s second surgery. Where the preoperative Cobb angle for patients undergoing the first or second surgery of the day was similar (51.5 vs. 46.7, respectively), the postoperative Cobb angle was also alike for both groups: 17.9 vs. 16.3 (p=0.428).

When comparing the second surgery of the day to operations where the case was the only scoliosis surgery of the day, the operative time was significantly shorter for the second surgery, at 214 minutes compared with 267 minutes (p=0.001). However, similar complication rates were observed: 4.3% for the day’s second surgery, and 8.3% for the only surgery of the day (p=1.0).

Another factor the investigators took into consideration was whether or not the same surgeons were performing the two operations in the day, or if it made a difference to the surgical outcome if the operating team was new in the afternoon. Lack of a consistent team has previously been shown to be linked with an increase in complications for some surgeries. However, when Sarwahi and colleagues investigated this factor for scoliosis surgeries, they found that changes in the operating team for the second case does not appear to impact safety, efficiency or outcomes.

Sarwahi and colleagues split the 251 scoliosis surgeries they were analysing into four groups. These were as follows:

  • Group one: patients were the first scoliosis surgery of the day
  • Group two: the second scoliosis surgery of the day
  • Group three: the only scoliosis surgery of the day
  • Group four: surgeries performed by surgeons who perform only one scoliosis surgery of the day

In order to measure the impact of a consistent team, the study investigators compared the surgical outcomes and complications rates between patients in groups two and four: the patient cohort who were the second surgery of the day for the operating surgeon vs. those patients treated by a surgeon performing their first case. Group four were lacking a consistent surgical team. Group two had a significantly shorter surgical time; 214 minutes compared with 307 minutes in group four. Estimated blood loss and complications rates were also lower in group two—350ml vs. 600ml (p=0.02), and 4.3% vs. 11.8% (p=0.473).

Sarwahi and colleagues also compared adolescent idiopathic scoliosis cases in groups three and four; early and late start cases. At IMAST, Sarwahi explained, “This is the most interesting finding: there were no significant differences between the two groups. The Cobb angle, kyphosis, postoperative Cobb correction, blood loss, levels fused… all were similar. The anaesthesia times were almost identical, as was the length of stay and the perioperative complications. So, interestingly, despite the late start, and despite the lack of variegated surgical time, there was no significant differences in the outcomes.”

Concluding, Sarwahi summarises, “The start time of standard posterior spinal fusion does not appear to impact patient outcomes, safety or length of stay. Lack of a consistent surgical team and anaestheologist also does not increase length of surgery, blood loss or complications. In addition, surgeon fatigue was not witnessed, as the clinical outcomes and operative time for second surgery were similar to the first case.”

Sarwahi and colleagues were nominees for the Whitecloud Award for Best Clinical Paper at IMAST 2018.

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