Letters about Published Papers

Reply

To the Editor,

Re: Outcome of after-hours elective surgery: Setting, skill and timing may explain the outcome. Published July 2019, 27(2) Jnl of Orthopaedic Surgery. DOI: 10.1177/2309499019861264

Dear Editor

Thank you for the keen interest in our research. We are aware about the large cohort post hoc analysis study done by Cortegiani et al., ¹ which included 9861 patients from 146 hospitals across 29 countries. They found that intraoperative adverse events and postoperative pulmonary complications occurred more often in patients undergoing night-time surgery. Our study investigated a specific subset of adolescent idiopathic scoliosis (AIS) patients who had planned elective posterior spinal fusion (PSF) surgeries and not emergency surgeries. ² Moreover, our patients had surgeries done by a dedicated spine team involving the same surgeons, anaesthetist, radiographers, nurses and assistants. Therefore, the aim of our study and the patient population of our study were not similar to the study done by Cortegiani et al.

Regarding your statement ‘the vast majority of patients in the “after-hours” group underwent surgery between 17:00 and 19:00’, we had answered this in the limitations section of the manuscript: ‘This study did not have any patients who had surgery starting time after 23:00 h and thus may only represent the earlier phase of after-hours and not the later phase of after-hours. The negative effects of surgeon fatigue, lack of availability of support staffs, and other logistical facilities and resources factors in after-hours surgeries may be more prominent in the later phase of after-hours and not in the earlier phase of after-hours’.

We do agree with the commentator’s opinion that the good outcome of after-hours surgeries in our study was related to these factors: (1) similar PSF surgeries in young healthy patients, (2) similar pathology of AIS, (3) surgeries that were done by dedicated ‘skilled’ surgical team and (4) surgeries done in the earlier phase of the after-hours. We concur with the commentator’s conclusion that the results of this study should not be generalized to the whole concept of ‘after-hours’ in all types of surgeries and also not to other centres that may not have appropriate skill or expertise.

Chee Kidd Chiu¹, Chris Yin Wei Chan¹ , Josephine Rebecca Chandren¹, Jun Yin Ong¹, Shweh Fern Loo¹, Mohd Shahnaz Hasan² and Mun Keong Kwan^{1 1}Department of Orthopaedic Surgery, National Orthopaedic Centre of Excellence for Research and Learning, University of Malaya, Kuala Lumpur, Malaysia ²Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia Corresponding author: [e-mail]