Overlapping Surgery

ACS: American College of Surgeons After publication of an investigative report by the Boston Globe in late 2015,1 the practice of overlapping surgery became highly controversial within the surgical community and was the subject of significant discourse across the field. Policies at numerous institutions were abruptly changed before investigation of the practice could be completed. The American Association of Neurological Surgeons and the Congress of Neurological Surgeons issued a joint statement regarding the practice in rapid succession,2 and a US Senate sub-committee hearing was held regarding the topic.3 More recently, discussion of the confusing terminology regarding overlapping surgery, peer-reviewed discussion of the topic, and surveying of patients regarding the practice have been completed.4,5 Changes to the policies regarding the use of overlapping surgery continue to have an effect on surgical training, access to surgical resources, and public perception of the surgeon–patient relationship. It depends on surgeons, and not policy makers or public misperception, to guide better patient care. OVERLAPPING SURGERY DEFINED One of the most fundamental issues tackled early on in the debate surrounding overlapping surgery was the formal definition of the practice itself. The original Boston Globe investigation utilized a number of names for the act of supervising more than 1 operative case at a time—the most common being “concurrent surgery.”1 What the original article failed to reconcile was the idea that not all portions of every surgery are necessarily created equal and that a case where the so-called “critical portion” of 1 operation overlapped with another was vastly different from 1 where only tasks such as sterile field preparation or exposure occurred simultaneously. This nuance was quickly picked up by observers in the surgical fields, and formal titles were applied in early 2016 by the American College of Surgeons (ACS).6 Cases where critical aspects of 1 case occurred at the same time as another were deemed “concurrent surgery,” and it was generally agreed that this was inappropriate. Cases where only noncritical aspects happened simultaneously were dubbed “overlapping surgery,” and these were deemed to be appropriate under the right set of circumstances. These definitions have been adopted broadly and have enabled a significant improvement in the clarity of the discourse surrounding the topic. A remaining challenge that is significantly harder to overcome is the precise definition of what constitutes the critical portion of a particular operation. Such a definition, likely informed by several variables including the specific patient, surgeon, and circumstance under which each operation is performed, may indeed be impossible to formalize. All research into the field of overlapping surgery is limited by this difficulty, and to date no generally agreed-upon solution to this problem exists. Despite this, it is believed that the vast majority of cases performed in academic medical centers today that have overlap fall into the category of “overlapping surgery,” not “concurrent surgery.”6 PATIENT PERCEPTION OF OVERLAPPING SURGERY The attention brought to the topic of overlapping surgery has highlighted a disconnection between the surgical community's utilization of the practice and the public's understanding of this use. A study by Kent et al5 suggested that only a small minority of patients were aware that their surgery might overlap with another, and the vast majority thought that it was important that the possibility of surgeries overlapping needed to be discussed prior to the operation. A more recent article by Edgington et al4 assessing patient and family member comfort with overlapping and concurrent surgery concluded that a large proportion of patients had concerns regarding either practice. To help address this gap in understanding between surgeons and patients, the need for discussion prior to surgery about the possibility of surgical overlap has been incorporated into the guidelines of both the ACS3 and individual surgical subspecialty societies.2 One positive aspect of debate regarding overlapping surgery has been the increased discussion of what defines medical professionalism as well as more open informed consent between surgeons and patients. SAFETY OF OVERLAPPING SURGERY During the early days of the most recent overlapping surgery debate, there were few published data available on the safety of the practice. Since that time, several studies have been published comparing the complication profiles of patients undergoing overlapping and nonoverlapping procedures in a wide variety of subspecialties.7-13 Only 1 of these studies has suggested any increase in complication rates when comparing overlapping and nonoverlapping procedures. The only study that has found a higher rate of adverse events in overlapping surgical cases was recently published by Ravi et al.13 The authors performed a population-based cohort analysis of a large set of patients from a healthcare system–wide administrative database in Ontario. Two procedures were chosen—hip fracture repair and total hip arthroplasty—and overlapping surgery cases were matched with those that did not overlap. The authors found a significantly higher 1-yr adverse event rate for hip fracture repairs performed in an overlapping manner. Although the design of this study was excellent and the follow-up was robust, the authors highlighted several important limitations to the study. The first is the fact that it is impossible to ascertain which surgeries in this cohort were “overlapping” and which were “concurrent,” an appropriate criticism of any publication on the topic to date. The second was the rarity of performing multiple surgeries at once in the cohort—fewer than 3% of hip fracture operations overlapped—suggesting that the centers where such operations were undertaken may have lacked sufficient expertise in the logistics needed to successfully coordinate multiple cases simultaneously. A third weakness, highlighted in the invited commentary for the publication, is the fact that only approximately 70% of overlapping operations in the study were performed in the academic setting,14 raising the question of whether or not qualified assistants were available for such cases. In contrast, all previous publications on the topic have been out of major academic medical centers with robust residency and fellowship programs. Finally, a significant limitation not brought up in any of the discourse on the paper to date is the fact that the median number of years in practice of orthopedic surgeons in the analyzed cohort was 0 (with a range of 0-4 yr).13 This contrasts with our institutional guidelines restricting overlapping surgery scheduling to surgeons with at least 5 yr of postfellowship experience (with an average practice experience of over a decade). This further calls into question whether the paper raises concerns about overlapping surgery as a whole or simply overlapping surgery performed in hospitals unfamiliar with the practice by surgeons who are not prepared to do so. Such concerns are far from purely academic in nature. The topic of overlapping surgery has been the subject of a US Senate investigation,3 and numerous centers have altered their policies as a result of public pressure.11 Because of the controversial nature of the topic, media response to articles such as the Ontario study are frequently sensational—the Boston Globe article highlighting the paper's findings quoted a surgeon who compared studying overlapping surgery to blindfolding a child before they walk across the highway. In fact, according to most studies, the use of overlapping surgery has a benign effect on surgical outcomes, and there may be other unrecognized effects of the limitations on its use. For example, data are still limited on the possible negative effects of overlapping surgery bans on healthcare and healthcare accessibility. Our group recently published a study examining the influence on both resident education and patient waiting times for complex neurosurgical procedures after a significant restriction on overlapping surgery at our institution.15 Our findings suggest that the policy change did not result in any improvements in patient complication rates but did significantly reduce the exposure of residents to such cases and increase waiting times for operations. Further data will be necessary to determine whether the limitations are significantly affecting healthcare in a negative direction. CONCLUSION A discussion of the use of overlapping surgery brings to light a number of aspects in the modern surgical treatment of patients. More than simply a discussion of a closed chapter in medicine, the intersection of events affecting overlapping surgery (eg, physician–patient relationships, reimbursement, public policy, and access to medical resources) will likely continue to play a role in shaping patient care. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

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