Overlapping surgery is a common practice in many hospitals to utilise hospital resources effectively, promote timely access to care and provide opportunities to educate surgical trainees. Nonetheless, overlapping surgeries – in this instance, hip surgeries – was found to be associated with a 90% increased risk, according to a study conducted by researchers at the Sunnybrook Health Sciences Centre in Toronto, Canada.

In this first population-based study, led by hip surgeon Dr Bheeshma Ravi, the team looked at population-based cohorts of 38,008 hip fracture procedures between 2009 and 2014 and 52,869 hip replacement surgeries between 2009 and 2015 – across more than 75 hospitals in Ontario.

The study, published in JAMA Internal Medicine on 4 December, reported that 2.5% of hip fracture procedures and 3% of hip replacement operations were performed by a primary surgeon who also oversaw another procedure – and the two usually overlapped for 30 minutes or more. In some cases, they overlapped for as long as three hours and for each additional 10 minutes, the risk of complications increased by 7%.

A 90% increase in complications a year after the surgery was performed, was also reported. Complications include infections, repeat surgery and dislocation. The complication risk also almost doubled from 6.4% to 10.4% when a patient underwent, specifically, hip fracture overlapping surgeries.

“If your surgeon is in multiple places, there’s an increased risk of having a complication,” says Ravi. “I think that just makes sense.”

An unwanted attention in 2015

The concept of overlapping surgeries first became of point of contention in 2015 when a report by Globe Spotlight Team – a team of investigative journalists for the Boston Globe newspaper – revealed a dispute at America’s Massachusetts General Hospital over the safety of overseeing multiple surgeries.

In the dispute, several of the hospital’s top orthopaedic surgeons often scheduled two operations that overlapped for hours. Many of their colleagues pointed out that the patients were not informed and felt that the practice also put patients in danger.

While hospital managers claimed that no patients were harmed, the hospital now faces a barrage of lawsuits, and many doctors have since left.

The issue of double-booked surgery has simmered since a 2015 Globe Spotlight Team report revealed a dispute at Massachusetts General Hospital over the safety of those procedures. Photo credit: Pat Greenhouse/Boston Globe
The issue of double-booked surgery has simmered since a 2015 Globe Spotlight Team report revealed a dispute at Massachusetts General Hospital over the safety of those procedures. Photo credit: Pat Greenhouse/Boston Globe

Since then, a vast majority of studies were carried out, but have found no significant difference in complication rates when operations run simultaneously – although many had limitations such as not capturing the primary surgeon’s actual time in the OR, or defining which parts of the operation were critical.

Last year, a cohort study found that overlapping surgeries were safe, providing the same outcome as for patients of non-overlapping surgeries. Conducted at the Mayo Clinic in America, the researchers compared the outcomes of 10,614 overlapping surgeries with 16,111 non-overlapping operations, with data from the University HealthSystem Consortium – an alliance of academic medical centres.

Reportedly, there was no increase in postoperative complications or death post-surgery. Published in the Annals of Surgery, the study also compared 10,000 overlapping and non-overlapping surgeries conducted by the same surgeon – which also found no difference in outcome.

Effectiveness of overlapping surgeries: “too early to tell”

But, for Dr James Rickert, an orthopaedic surgeon and president of the Society for Patient Centred Orthopaedics, “this study [the JAMA study] shuts the door on the idea that simultaneous surgery is as safe as solo surgery, when the doctor’s just concentrating on you. The size, the numbers, the multiple institutions, and the long-term follow-up dwarf any of those other studies.”

Additionally, previous studies have only focused on individual hospitals or outpatient clinics whereas this study examined multiple hospitals amounting to tens of thousands of patients. The study is also the only one explore the outcome of the operations after a year – as opposed to just a few weeks.

“This seems to be the first study to show an adverse effect from the practice of overlapping surgery,” Dr Alan L. Zhang, an orthopedic surgeon at the University of California San Francisco, wrote in an opinion piece accompanying the study. “The increased length of follow-up is an important factor to consider for complications, which adds value to the results of the current study.”

However, lead author Ravi admits, “it is important to note that the occurrence of overlapping surgery, for these procedures, was low.” Hip surgery patients are also far more at risk of complications because they are usually elderly.

Also, given that 70% of the overlapping procedures were conducted in teaching hospitals, the likelihood of surgeons going wrong whilst teaching how not to perform the operation, is low.

It is clear there is no consensus on the practice but as Dr L.D. Britt, a past president of the American College of Surgeons and current head of surgery at Eastern Virginia Medical School explains, “attempting to validate concurrent operations by documenting safe outcomes is tantamount to my blindfolding my daughter and having her walk across a busy six-lane highway. Just because she might reach the other side safely does not dictate a best practice.” MIMS

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