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ACCOMPANYING ARTICLE See pp 1089–1095. DOI: 10.3171/2016.6.JNS16822.INCLUDE WHEN CITING Published online January 20, 2017; DOI: 10.3171/2016.9.JNS161500.

In this issue, Zygourakis and colleagues address the timely topic of patient outcomes after concurrent sur-gery.23 Concurrent, or overlapping, surgery—in which

a single attending surgeon has responsibility for more than 1 operation simultaneously—has come under close scru-tiny after newspaper coverage of several individual cases at Massachusetts General Hospital, prompting an inquiry by the US Senate Finance Committee.1,21 In response, the American College of Surgeons (ACS) has recently (April 2016) amended its Statements on Principles to address the performance of concurrent or overlapping operations (https:// www.facs.org/ about-acs/ statements/stonprin#iid). In addition, the US Center for Medicare and Medicaid Services has tacitly recognized the existence of over-lapping surgery by establishing conditions under which surgeons will be reimbursed for it (https://www.cms. gov/ Regulations-and-Guidance/ Guidance/ Transmittals/ downloads/ R2303CP.pdf).

For several reasons, overlapping surgery is a difficult issue to study. First, the terminology for operations that occur in part or in whole at the same time is confusing. The ACS now defines “concurrent or simultaneous” op-erations as those in which the “critical or key components” of the 2 operations occur at the same time, and “overlap-ping operations” as those in which the key portion of 1 operation overlaps with a noncritical portion of a second case, or when the overlapping portions of the cases are both noncritical. Because the definition of the key por-tion of an operation has usually been left to the surgeon to define, few clinical or administrative databases will contain information about which operations are concur-rent, overlapping, or have no conflict according to these definitions. Databases built to track operating room sched-uling typically do not cover these major conflicts, instead making possible still more subtle definitions of minor con-flicts: overlap of procedure time, anesthesia time, or time when the patient is awake in the operating room before induction of anesthesia or after extubation. Some of these

“conflicts,” such as 2 patients who are both in operating rooms and both awake—one before induction and the sec-ond after extubation—would seem to many surgeons to be no conflict at all. In fact, we have little way of knowing how prevalent either serious or trivial degrees of overlap between operations are in our hospitals. Anecdotally the practice appears common, although not universal.

Second, having defined the type of overlap we wish to study in relation to patient outcomes, we face the usual difficulties of comparing 2 widely accepted forms of standard surgical practice. A randomized trial of con-current surgery, while feasible in concept and probably ethical, would likely face a significant practical barrier in accruing patients. Zygourakis et al. compare outcomes after operations performed by a single academic vascular neurosurgeon, based on a nonrandomized assignment, to either overlap with the procedure time of a second case or not.23 This definition of overlap matches the broadest defi-nition of overlapping surgery as defined by the ACS State-ment on Principles, “overlapping,” but some case pairs may have been “concurrent,” i.e., overlap of 1 procedure’s key portion with a second case. For a variety of endpoints, there was no significant difference between patient out-comes after cases that did or did not overlap; operative time was about 30 minutes longer in cases that overlapped. Cases that did or did not overlap differed in several im-portant ways, generally suggesting that patients selected for overlapping surgery were lower risk: more likely to be elective, lower American Society of Anesthesiologists classification, lower severity of illness, and lower estimat-ed risk of mortality. A mixed-effects multivariate model was used to adjust for these differences, and after adjust-ment there were no detected adverse effects of overlap ex-cept for slightly longer operative time. A propensity score model, in which patients are balanced on factors predict-ing assignment to surgery with overlap, would be another appropriate way to analyze similar data.

The implied counterfactual element in this analysis—

EDITORIALConcurrent surgeryFred G. Barker II, MD

Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts

©AANS, 2017

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what “would have happened” if the surgery had been performed without overlap—was posited in this study as surgery completed by the same attending surgeon during normal elective hours. Surgeons will immediately recog-nize that this is not what really happens. More likely, to avoid overlap, these operations would need to be assigned to a different surgeon, or else performed by the index surgeon outside normal elective hours. Surgeons are not exchangeable, and in many cases a substitution would introduce a less experienced practitioner, with predict-able results. Changing attending surgeons also curtails patients’ free choice about their care. Performing elective operations after normal weekday hours, or on a weekend, is known to predispose strongly to poor outcomes. Elec-tive surgery after normal operating hours has been shown to be followed by a 3-fold higher complication rate in lapa-roscopic cholecystectomy,17 increased unplanned reop-erations (27% vs. 3%) after femoral fracture repair,19 and 2-fold higher operative mortality in nonurgent cardiac sur-gery.22 Within neurosurgery, failure to extubate after mul-tilevel spine fusions was highly correlated with time of day at the conclusion of the case, resulting in a 3-fold higher rate of postoperative pneumonia in nonextubated patients.2 The risks of weekend elective surgery have come under intense review after recent proposed work-hour policy changes in the United Kingdom. Risk-adjusted mortality rate after weekend elective surgery was 82% higher over 3 years in all English public hospitals, a result that has been replicated in the US, Canada, and other countries.4,14,20

Elimination of surgery with overlap would have sys-tem-wide effects that should also be considered, although they are difficult to model for formal study. Inpatients would have longer wait times for surgery, increasing bed occupancy, decreasing efficiency, and causing delays for patients waiting for transfer from other facilities. Operat-ing after normal hours can cause surgeon sleep depriva-tion, increasing surgical risks for the next day’s patients,3,7 and with a higher risk over time of surgeon depression and burnout.5 Finally, overlapping surgery may in some cases facilitate surgical progress. Many of the premier surgeons of the last 50 years routinely ran multiple rooms. Pioneer-ing cardiac surgeons such as Michael DeBakey and Den-ton Cooley were known to perform up to 25 open heart operations each day, attaining unprecedented levels of surgical skill, slashing mortality rates, and throwing open fields such as valve replacement and cardiac transplanta-tion as practical realities for the entire community. Similar examples within neurosurgery will occur to every reader. Two of the iron laws of surgery—the learning curve and the volume outcome effect—predict that by placing an artificial ceiling on the operative experience of leading surgeons, we risk delaying the progress of operative neu-rosurgery in the broadest sense.

Zygourakis and colleagues documented equivalent outcomes after surgery for overlap, even against the opti-mistic comparator of an equally skilled surgeon operating without overlap during prime surgical hours, and the con-siderations outlined above suggest that for many patients the real-world alternative to surgery with overlap may be demonstrably inferior to this scenario. These findings should motivate further studies of outcomes after over-

lapping surgery. One focus of such studies will be gener-alizability. Not all types of surgery may be equally safe for overlap; not all surgeons may be equally prepared for the increased complexity of overlapping surgery. Broader study may require changing existing databases such as the ACS National Surgical Quality Improvement Program (NSQIP) and the Quality Outcomes Database (formerly N2QOD) to categorize operations at the time of surgery by degree of overlap. Importantly, hospitals and surgical coordinating committees will need to set guidelines for adequate informed consent,12,15 for which surgeons and cases are appropriate for overlap, and for adequate backup by a second attending surgeon when overlapping surgery is scheduled. Existing research on quality and informed consent when surgical trainees participate in an operation may help us in thinking through the issues surrounding overlapping surgery.6,8–11,13,16,18 The information on the safety of overlapping surgery provided by Zygourakis et al. provides a good foundation for this ongoing work.https://thejns.org/doi/abs/10.3171/2016.9.JNS161500

References 1. Abelson J, Saltzman J, Kowalczyk L, Allen S: Clash in the

name of care. Boston Globe. October 25, 2015 (http://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/) [Accessed November 15, 2016]

2. Anastasian ZH, Gaudet JG, Levitt LC, Mergeche JL, Heyer EJ, Berman MF: Factors that correlate with the decision to delay extubation after multilevel prone spine surgery. J Neu-rosurg Anesthesiol 26:167–171, 2014

3. Asfour L, Asfour V, McCormack D, Attia R: In surgeons performing cardiothoracic surgery is sleep deprivation significant in its impact on morbidity or mortality? Interact Cardiovasc Thorac Surg 19:479–487, 2014

4. Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A: Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ 346:f2424, 2013

5. Balch CM, Shanafelt TD, Dyrbye L, Sloan JA, Russell TR, Bechamps GJ, et al: Surgeon distress as calibrated by hours worked and nights on call. J Am Coll Surg 211:609–619, 2010

6. Bydon M, Abt NB, De la Garza-Ramos R, Macki M, Witham TF, Gokaslan ZL, et al: Impact of resident participation on morbidity and mortality in neurosurgical procedures: an analysis of 16,098 patients. J Neurosurg 122:955–961, 2015

7. Chu MW, Stitt LW, Fox SA, Kiaii B, Quantz M, Guo L, et al: Prospective evaluation of consultant surgeon sleep depriva-tion and outcomes in more than 4000 consecutive cardiac surgical procedures. Arch Surg 146:1080–1085, 2011

8. Kazaure HS, Roman SA, Sosa JA: The resident as surgeon: an analysis of ACS-NSQIP. J Surg Res 178:126–132, 2012

9. Kim RB, Garcia RM, Smith ZA, Dahdaleh NS: Impact of resident participation on outcomes after single-level anterior cervical diskectomy and fusion: an analysis of 3265 patients from the American College of Surgeons National Surgical Quality Improvement Program Database. Spine (Phila Pa 1976) 41:E289–E296, 2016

10. Knifed E, July J, Bernstein M: Neurosurgery patients’ feel-ings about the role of residents in their care: a qualitative case study. J Neurosurg 108:287–291, 2008

11. Knifed E, Taylor B, Bernstein M: What surgeons tell their patients about the intraoperative role of residents: a qualita-tive study. Am J Surg 196:788–794, 2008

12. Langerman A: Concurrent surgery and informed consent. JAMA Surg 151:601–602, 2016

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13. Lim S, Parsa AT, Kim BD, Rosenow JM, Kim JY: Impact of resident involvement in neurosurgery: an analysis of 8748 patients from the 2011 American College of Surgeons National Surgical Quality Improvement Program database. J Neurosurg 122:962–970, 2015

14. McIsaac DI, Bryson GL, van Walraven C: Elective, major noncardiac surgery on the weekend: a population-based co-hort study of 30-day mortality. Med Care 52:557–564, 2014

15. Mello MM, Livingston EH: Managing the risks of concur-rent surgeries. JAMA 315:1563–1564, 2016

16. Morgan MK, Assaad NN, Davidson AS: How does the participation of a resident surgeon in procedures for small intracranial aneurysms impact patient outcome? J Neuro-surg 106:961–964, 2007

17. Phatak UR, Chan WM, Lew DF, Escamilla RJ, Ko TC, Wray CJ, et al: Is nighttime the right time? Risk of complications after laparoscopic cholecystectomy at night. J Am Coll Surg 219:718–724, 2014

18. Porta CR, Sebesta JA, Brown TA, Steele SR, Martin MJ: Training surgeons and the informed consent process: routine disclosure of trainee participation and its effect on patient willingness and consent rates. Arch Surg 147:57–62, 2012

19. Ricci WM, Gallagher B, Brandt A, Schwappach J, Tucker M, Leighton R: Is after-hours orthopaedic surgery associated with adverse outcomes? A prospective comparative study. J Bone Joint Surg Am 91:2067–2072, 2009

20. Ruiz M, Bottle A, Aylin PP: The Global Comparators proj-ect: international comparison of 30-day in-hospital mortality by day of the week. BMJ Qual Saf 24:492–504, 2015

21. Twedt S: Senate committee looks at policies on surgeons performing more than one surgery at once. Pittsburgh Post-Gazette. March 28, 2016 (http://www.post-gazette.com/business/healthcare-business/2016/03/28/Senate-committtee-looks-at-hospital-policies-regarding-concurrent-surgeries/stories/201603270074) [Accessed November 15, 2016]

22. Yount KW, Lau CL, Yarboro LT, Ghanta RK, Kron IL, Kern JA, et al: Late operating room start times impact mortality and cost for nonemergent cardiac surgery. Ann Thorac Surg 100:1653–1659, 2015

23. Zygourakis CC, Lee J, Barba J, Lobo E, Lawton MT: Performing concurrent operations in academic vascular neurosurgery does not affect patient outcomes. J Neu-rosurg [epub ahead of print January 20, 2017. DOI: 10.3171/2016.6.JNS16822]

DisclosuresThe author reports no conflict of interest.

ResponseCorinna C. Zygourakis, MD,1,2 and Michael T. Lawton, MD1

1Department of Neurological Surgery, University of California, San Francisco, California2Center for Healthcare Value, University of California, San Francisco, California

We thank Dr. Barker for his thoughtful comments on our paper. Differentiating concurrent from overlapping surgeries, as he notes, depends on the definition of the “critical portion of the case.” This definition is vague, not clearly recorded in the medical record, and may reclas-sify an overlapping case to a concurrent one. In our study, the vast majority of our surgeries were overlapping, but we were unable to differentiate those cases that might have been considered concurrent with simultaneous criti-

cal portions of 2 cases. Nonetheless, the study shows that “running two rooms” can be performed safely and that the general public’s concerns can be answered scientifically with data. The study shows that overlapping surgery must be performed with careful patient selection and case pair-ings, assistance from residents and fellows, attending-level backup, and patient awareness through informed consent.

Dr. Barker highlights harmful repercussions of banning overlapping surgery, namely after-hours operations with less experienced operating room teams and tired surgeons. Overlapping surgery enables neurosurgeons to treat pa-tients expeditiously and allows patients to be treated by ex-pert subspecialists with high-volume practices. This is an important point, because of the direct relationship between surgeon volume and patient outcomes. Concentrating case volume in specialized centers with dedicated surgeons fosters technical excellence, and overlapping surgery is an important method of achieving this. Subspecialty surgeons who amass vast experience, as Dr. Barker points out with the examples of DeBakey and Cooley in cardiac surgery, are positioned to make surgical advances and pioneering work. Among the 15 faculty neurosurgeons operating at our main hospital, we found a positive correlation between the percentage of overlapping surgeries in their practice and publications (Fig. 1), which substantiates the impact of case volume on surgical expertise and progress.

Another important byproduct of overlapping surgery is that it creates unique learning opportunities for residents and fellows. Trainees learn through observation, observed operation, and unobserved operation. With the first meth-od, the resident observes and assists the instructor, who then safely and quickly completes the surgery. With the second method, the instructor observes and coaches the resident, which may slow the surgery but still ensures safe-ty and educational value. With the third method, the resi-dent operates independently, which is a coveted learning opportunity for him or her, while the instructor works in a second room and maximizes productivity. Autonomy is critical in training the next generation of young neurosur-geons to develop their manual dexterity, make intraopera-tive decisions on their own, and confront pathology first-hand. Learning requires a combination of these 3 methods, and overlapping surgery fosters this independent learning.

FIG. 1. Comparison of publications per year post-residency for neurosurgery attendings at the University of California, San Francisco, Parnassus hospital (n = 15) and percentage of overlapping surgeries performed. Figure is available in color online only.

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