Day and night surgery: Comparing outcomes in deceased donor renal transplant with surgeons' perspectives to operate at odd hours - a prospective observational study

Ketan Mehra; Ramanitharan Manikandan; Lalgudi Narayanan Dorairajan; Kodakkattil Sreenivasan Sreerag; Rajiv Kumar

doi:10.4103/ijot.ijot_26_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 14 | Issue : 3 | Page : 224-229

Day and night surgery: Comparing outcomes in deceased donor renal transplant with surgeons' perspectives to operate at odd hours - a prospective observational study

Ketan Mehra, Ramanitharan Manikandan, Lalgudi Narayanan Dorairajan, Kodakkattil Sreenivasan Sreerag, Rajiv Kumar
Department of Urology, JIPMER, Puducherry, India

Date of Submission	03-Apr-2020
Date of Acceptance	05-Aug-2020
Date of Web Publication	30-Sep-2020

Correspondence Address:
Dr. Ramanitharan Manikandan
Department of Urology, JIPMER, Puducherry
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_26_20

Abstract

Introduction: Working in stress during night may be hazardous to the patients as well as professionals. The aim of the present study was to compare the outcomes of emergency renal transplants performed during the day with those during the night. Materials and Methods: The data of deceased transplants performed between March 2012 and June 2018 was reviewed retrospectively. Group 1 included patients operated between 8 am and 8 pm while Group 2 patients were operated between 8 pm and 8 am. The outcomes compared included cold ischemia time, vascular and urologic complications, creatinine over time period, graft survival, and mortality, if any. A custom-designed questionnaire was distributed to surgeons covering the practice of urgent renal transplant, including fatigue. Results: A total of 71 transplant recipients were included in this study. Forty (56.3%) belonged to Group 1 and 31 (43.7%) to Group 2. There were no significant differences with respect to complications, renal graft function, and patient survival between day and night time surgeries. Conclusion: Emergency renal transplants during night hours do 'not have inferior outcomes in comparison to patients operated during day time. The majority of surgeons feel less proficient in performing surgery during emergency hours and given a choice would prefer to operate during the subsequent elective operating hour.

Keywords: Emergency surgery, kidney transplant, night surgery, renal transplant

How to cite this article:
Mehra K, Manikandan R, Dorairajan LN, Sreerag KS, Kumar R. Day and night surgery: Comparing outcomes in deceased donor renal transplant with surgeons' perspectives to operate at odd hours - a prospective observational study. Indian J Transplant 2020;14:224-9

How to cite this URL:
Mehra K, Manikandan R, Dorairajan LN, Sreerag KS, Kumar R. Day and night surgery: Comparing outcomes in deceased donor renal transplant with surgeons' perspectives to operate at odd hours - a prospective observational study. Indian J Transplant [serial online] 2020 [cited 2021 May 18];14:224-9. Available from: https://www.ijtonline.in/text.asp?2020/14/3/224/296886

Introduction

Working in the night hours has always been stressful, especially for the health-care providers. The odd working hours may contribute to errors due to work-related stress leading to serious surgical flaws, thereby, increasing the risk of mortality by two-fold.^[1] Extended working hours can be hazardous to health professionals. The implications can range from increased self-injuries during surgeries to mood disorders, depression, and even increased road traffic accidents.^[2] Sleep deprivation leading to fatigue and disturbed circadian rhythm are the significant determinants which can negatively impact the surgical performance.^[3] There are various factors involved in the decision whether to operate during emergency hours such as patient comorbidities requiring optimization and hospital factors arising from the list of elective procedures performed during the day leaving operating rooms available only during emergency hours.^[4]

However, the literature reporting the outcomes concerning renal transplant surgeries, are conflicting.^{[5],[6],[7],[8]} Fechner et al., in their retrospective study, evaluated the data of 260 patients who underwent renal transplants and compared daylight and “night-time” surgeries for complications and graft survival.^[6] They observed that the incidence of complications and graft failure were higher in patients operated during night time and suggested delaying transplant till next day even at the risk of prolonged cold ischemia time (CIT). Similarly, de Boer et al. in 2018 concluded that the incidence of surgical injury and complications were significantly lower during day-time concerning deceased donor renal transplants.^[5] On the contrary, a meta-analysis by Manfredini et al. suggests that day-time or night-time surgery do not negatively impact on graft survival in deceased donor renal transplant.^[7] Recently, Sugunes et al. concluded that night-time kidney transplantation was not associated with increased adverse graft or patient-related outcomes.^[9]

The primary objective of the present study is to compare the outcomes of renal transplants performed during the day and night hours. The secondary objective is to evaluate the surgeons' ' perspectives concerning operating during odd hours in the night using a nonvalidated questionnaire.

Materials and Methods

The study was performed by retrospectively reviewing the data of 71 emergency deceased donor renal transplants which were performed at a tertiary center in South India, between March 2012 and June 2018. Patients were divided into two groups depending on the time of commencement of surgery: Group 1: Surgery started between 8 am and 8 pm and Group 2: Surgery between 8 pm and 8 am.

The outcomes compared were warm ischemia time (WIT), CIT, delayed graft function (DGF), slow graft function (SGF), vascular complications, urologic complications, creatinine after 1 year of transplant, creatinine at the last follow-up visit, patient survival and graft survival. WIT was defined as time between taking the allograft out of ice for anastomosis till reperfusion, CIT was defined as time between the start of cold perfusion and revascularization of the kidney in the recipient. SGF was defined as creatinine >3 mg/dL on postoperative day 5, without the need for further dialysis.^[10] DGF was defined as institution of dialysis within the 1^st week after renal transplant.^[10] Graft loss was defined as the need for maintenance dialysis posttransplant. Mortality, if any, deemed to be directly attributable to surgical cause were also recorded. Every recipient surgeon's team had an experienced surgeon along with a resident for surgical assistance. All surgical procedures were performed by expert surgeons with more than 10 years of experience. An anonymous, self-filling and confidential custom-made questionnaire [Appendix 1] was distributed to surgeons in the department of Urology covering aspects related to the practice of urgent renal transplant and fatigue [Table 1].

Table 1: Data depicting surgeons' perspective

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Ethics statement

The study procedure followed was in accordance with the ethical standards on human experimentation and adhered to ethical guidelines of Declaration of Helsinki. The study got approval from the Institutional Ethics Committee, JIPMER, Puducherry with approval number JIP/IEC/SC/2/303/2018.

Statistical analysis

Statistical analysis was performed using IBM SPSS Statistics 48 for Windows, version 19. Armonk, NY: IBM Corp. All 49 continuous variables were expressed as medians and range 50 and the groups were compared using Mann–Whitney U-test. All categorical variables were expressed as percentages and 51 compared between the groups using the Fisher's exact test. 52 A P < 0.05 was considered statistically significant.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Results

The donor characteristics such as age, gender, and body mass index were all comparable in both the groups with no significant difference [Table 2]. The data of 71 patients who underwent deceased donor transplants were included in the analysis. Group 1 included 40 (56.3%) patients and Group 2 had 31 (43.7%) patients. In Group 1 and Group 2, the median age of patients was 35 years (range 20–54) and 32 years (range 17–57), respectively. There were 27 (67.5%) and 21 (67.7%) males and 13 (32.5%) and 10 (32.3%) females in Group 1 and 2, respectively. There were 2 (4.9%) vascular complications and 1 (2.4%) urologic complication in Group 1 whereas, Group 2 had neither vascular nor urologic complication (P = 0.228 and 0.397, respectively).

Table 2: Demographic and outcome measures

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Group 1 and Group 2 each had 3 grafts lost (7.5% and 9.7%, P = 0.534) and 5 patients died (12.5 and 16.1%, P = 0.734). In Group 1 and 2, DGF was 2 (5%) and 3 (9.7%) (P = 0.647), SGF was 3 (7.5%) and 1 (3.2%) (P = 0.627), and median CIT was 180 (60–720) min and 210 (90–720) min (P = 0.353), respectively. The median creatinine level at 1-year follow-up in Group 1 and Group 2 was 1.4 (0.8–7.7) mg/dL and 1.3 (0.8–4.5) mg/dL, respectively (P = 0.546) and the median creatinine values at last follow-up were 2 (1–10) mg/dL and 1 (1.1–6) mg/dL, respectively (P = 0.045).

Twelve surgeons were requested to complete the questionnaire to assess the working patterns and exhaustion, if any at the end of the deceased donor transplants. Among the surgeons, 4 were consultants and 8 were residents who were involved in the transplants. On evaluating surgeons reported questionnaire 100% rated night time as a period of lesser ability [Table 1]. Moreover, the majority (93.7%) reported sleep deprivation during the emergency transplants and slept lesser then the usual sleep duration. On measuring fatigue on a scale of “none,”” little tired,” “tired,” “very tired,” and “exhausted,” 11/12 (93.7%) surgeons felt either “very tired” or “exhausted” after emergency renal transplant.

Discussion

In the present study, night-time surgeries had no significant difference concerning graft failures, patient mortalities, DGF, or SGF as compared to the day-time operations. The CIT was 30 min higher for the night-time surgeries than the day-time surgeries. This may reflect the fatigue of surgeons at night time, but the creatinine values at 1 year follow-up was similar for both the groups. The creatinine, at last, follow-up, was higher in the day-time surgery patients with a statistical significance. However, there were no vascular or urological complications in the night-time surgeries as compared to day-time surgeries in which such complications were reported. The plausible hypothesis for this finding can be multifactorial. First, Zheng et al. hypothesized that this difference may be due to surgeons working with more concentration in a quiet environment with lesser interruptions during night time, leading to better outcomes.^[11] Many researchers have alluded to the above hypothesis that there is a direct correlation between interruptions and surgical errors.^[10],[11] Second, Amirian et al. reported that during night time, there is an increase in sympathetic activity with elevated heart rate and decreased variability, which may impart more vigilance to the operating surgeon.^[12]

However, even after demonstrating marginally better results of night-time surgeries, working during night hours may not be the choice for the surgeons as it causes fatigue and exhaustion as is evident from the surgeons' reply to our questionnaire. In addition, there is an increased risk of metabolic syndrome and certain malignancies when consistently working during night hours due to the disturbed circadian rhythm.^{[13],[14],[15]}

The effect of timing of surgery on the patients' outcomes has been studied in different realms of surgical specialties such as colorectal, orthopedic, and organ transplantations.^{[5],[16],[17]} There have been conflicting results in various studies regarding the timing and the outcomes of surgeries. Fernandes et al. compared the surgical outcomes in the setting of acute colorectal diseases during night time and day time. They concluded that urgent night time surgeries are not associated with increased post-operative risk compared with surgeries during the day time.^[16] Similarly, Rashid et al. observed that there was no difference in the complication rates among patients operated during day and night time concerning surgical treatment of hip fractures.^[17] Moreover, George et al. reported that with respect to thoracic organ transplants, there was no significant association between operative time of day and survival even after 1 year.^[18]

Griffith and Mahadevan in their meta-analysis of sleep deprivation on human performance suggested that sleep deprivation and disturbed circadian rhythm causes fatigue which adversely affects human performance.^[3] The impact of fatigue has been proven in the form of less vigilance and decreased psychomotor activity in professionals such as police officers and commercial vehicle drivers.^[19],[20] There have been studies in the field of medicine extrapolating the same results. Landrigan et al. performed a study according to which interns who worked infrequent shifts of 24 h or more than that, had more chance of making serious medical errors than when they worked in shorter shifts.^[21] In certain specialties such as gastrointestinal surgeries and orthopedic trauma in which night surgeries are routinely performed to prevent deterioration of the patient's condition, however, reported contrary results.^[16],[17] There are only a few published studies on renal transplantation, which explored the impact of working hours on the allograft function and surgical complications.^{[6],[22],[23],[24],[25]}

Seow et al. studied the outcomes of 322 deceased donor recipients and concluded that time factor did not affect the immediate and late graft outcomes.^[23].

Kienzl-Wagner et al. retrospectively analyzed 873 deceased donor kidney transplants.^[24] They compared patient or graft survival, DGF, acute rejection rate, and surgical complications. There was no difference in 1 and 5 years of patient and graft survival between the two transplant groups. There were 31.1% DGF in day-time surgeries versus 37.6% in night-time procedures. (P = 0.06) Acute allograft rejection rates were higher in day-time (22.6%) compared to night-time renal transplants (18.3%), however, not statistically significant (P = 0.15). Besides, the night-time surgeries had comparable rates of surgical complications (22.4%) to day-time procedures (22.1%). Hence, they concluded that night-time renal transplants did not lead to higher surgical complication rates nor reduced 5-year graft survival when compared to day-time procedures.

Brunschot et al. reviewed the data of 4519 renal transplantation from the Dutch Organ Transplant Registry.^[25] Among them, 1480 transplants were performed during the night hours. They observed that graft loss within 10 days after surgery without signs of acute or hyperacute rejection was more in the day-time surgery group (2.6%) than in night time (1%) which was statistically significant (P<.001). The vascular complications reported were almost double in day surgeries (1.6%) than night surgeries (P = 0.03). Urological complications were similar in both the groups. However, the WIT was virtually identical in both the groups. CIT was 40 min shorter in day surgery group as compared to the night surgery group. The possible explanation for the difference in day and night time surgeries was attributed to postponing recipients with a more miserable physical condition to the next morning. The strength of this study was its large sample size, and it was multicentric. The limitations of this study were that it was retrospective and transplants were performed by different surgeons with different level of expertise. The outcomes of other studies comparing renal transplantation during day time and night time have shown in [Table 3].

Table 3: Comparison of different studies' outcomes

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On the contrary, Fechner et al. reported more graft failure and vascular complications when surgeries were performed during night hours.^[6] The reoperation rate was also significantly higher in night-time operations (16.8%) versus day-time surgeries (6.4%). Similar to our study, Sugunes et al. compared the outcomes of renal transplant performed during day-time to that performed during night-time.^[9] It was a retrospective analysis of 215 end-stage renal disease patients who received allograft from the cadaveric donors. 132 (61%) recipients were operated between 8 am to 8 pm, and 83 (39%) recipients between 8 pm and 8 am. The primary outcomes, such as patient and graft survival, were evaluated at 3 months and 1 year of follow-up. Secondary outcomes analyzed were acute rejection, DGF, and post-operative complications. This study reported a significantly higher risk of death in the day-time surgery group (P = 0.017). However, there was no difference in the long-term graft survival rate in the two groups. The mean CIT was significantly higher in the night-time group (12.4 ± 5.3 h) as compared to day time (10.7 ± 3.6 h). The intraoperative complication rate was 1.2% and 3.8% during night-time and day-time surgery, respectively, but the difference was statistically insignificant. The incidence of post-operative complications was 56% in day-time and 49% in the night-time group (P = 0.34). They concluded that night-time surgery was not associated with increased risk of adverse events as compared to day-time cadaveric renal transplantation.

Limitations of the study

There are some limitations to our study. First, it was a retrospective analysis with a smaller sample size as compared to other studies reported in the literature. Second, all surgeries were performed by four different consultants with different skills. Third, etiology of renal failure in the recipients could also act as the confounding factor, which was not included in the analysis. Moreover, the questionnaire used by us in this study was a nonvalidated one.

Conclusion

Emergency renal transplants performed during night hours did not demonstrate inferior outcomes in comparison to patients operated during day time. Although renal transplantation can be performed during night hours, minimizing the cold ischemic time, working during night is exhaustive and may be detrimental for the surgeons' health. If given an option, the majority of surgeons would like to defer the emergency transplant to day time as it may be less exhaustive for them. There is a need to perform well designed, prospective, multicentric studies to establish whether scheduling the renal transplants to the next elective operating day will not be detrimental to the graft outcomes. Besides, research should be undertaken to determine the factors which may negatively impact the health of the surgeons working during night hours regularly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Appendix 1: Surgeon questionnaire

What is your name?_________________________________________________
What is your age in years? ___________________________________________
Qualification (please tick)

Consultant ◻
Resident ◻

How many emergency renal transplant you have assisted/done?____________________

How much hours you sleep in 24 h? _____________________________________

How much hours you sleep when there is an emergency renal transplant (Transplant starting between 6 pm and 6 am)? ____________________________________________

Which is a period of lesser ability for you?

Night time ◻
Daytime ◻

What is your Fatigue level at night time during emergency renal transplant?

None ◻
Little tired ◻
Tired ◻
Very tired ◻
Exhausted ◻

From your perspective, do you feel like "Postpone urgent surgery" so that you can work more efficiently at day time?

Yes ◻
No ◻

References

1.	Available from: http://www.sciencedaily.com/releases/ 2007/09/070924092553.htm. [Last accessed on 2020 Apr 02].
2.	Rodriguez-Jareño MC, Demou E, Vargas-Prada S, Sanati KA, Skerjanc A, Reis PG, et al. European working time directive and doctors' health: A systematic review of the available epidemiological evidence. BMJ Open 2014;4:e004916.
3.	Griffith CD, Mahadevan S. The influence of fatigue on human performance: Meta-analysis of sleep deprivation effect on performance measures. 2007 IEEE 8^th Human Factors and Power Plants and HPRCT 13^th Annual Meeting, Monterey, CA, USA, 2007, pp. 291-296
4.	Novack V, Jotkowitz A, Etzion O, Porath A. Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey. Int J Qual Health Care 2007;19:170-6.
5.	de Boer JD, Van der Bogt KEA, Putter H, Ooms-de Vries KM, Haase-Kromwijk BJ, Pol RA, et al. Surgical quality in organ procurement during day and night: An analysis of quality forms. BMJ Open 2018;8:e022182.
6.	Fechner G, Pezold C, Hauser S, Gerhardt T, Müller SC. Kidney's nightshift, kidney's nightmare? Comparison of daylight and night-time kidney transplantation: Impact on complications and graft survival. Transplant Proc 2008;40:1341-4.
7.	Manfredini R, Gallerani M, De Giorgi A, Tiseo R, Lamberti N, Manfredini F, et al. Renal transplantation and outcome: Does time of surgery matter? Prog Transplant 2016;26:397-8.
8.	Humar A, Ramcharan T, Kandaswamy R, Gillingham K, Payne WD, Matas AJ. Risk factors for slow graft function after kidney transplants: A multivariate analysis. Clin Transplant 2002;16:425-9.
9.	Sugunes H, Bichmann A, Biernath N, Peters R, Budde K, Liefeldt L et al. Analysis of the effects of day-time vs. night-time surgery on renal transplant patient outcomes. J Clin Med 2019;8:1051.
10.	Rivera-Rodriguez AJ, Karsh BT. Interruptions and distractions in healthcare: Review and reappraisal. Qual Saf Health Care 2010;19:304-12.
11.	Zheng B, Panton ON, Al-Tayeb TA. Operative length independently affected by surgical team size: Data from 2 Canadian hospitals. Can J Surg 2012;55:371-6.
12.	Amirian I, Toftegård Andersen L, Rosenberg J, Gögenur I. Decreased heart rate variability in surgeons during night shifts. Can J Surg 2014;57:300-4.
13.	He C, Anand ST, Ebell MH, Vena JE, Robb SW. Circadian disrupting exposures and breast cancer risk: A meta-analysis. Int Arch Occup Environ Health 2015;88:533-47.
14.	Ramin C, Devore EE, Wang W, Pierre-Paul J, Wegrzyn LR, Schernhammer ES. Night shift work at specific age ranges and chronic disease risk factors. Occup Environ Med 2015;72:100-7.
15.	Wang F, Zhang L, Zhang Y, Zhang B, He Y, Xie S, et al. Meta-analysis on night shift work and risk of metabolic syndrome. Obes Rev 2014;15:709-20.
16.	Fernandes S, Carvalho AF, Rodrigues AJ, Costa P, Sanz M, Goulart A, et al. Day and night surgery: Is there any influence in the patient post-operative period of urgent colorectal intervention? Int J Colorectal Dis 2016;31:525-33.
17.	Rashid RH, Zubairi AJ, Slote MU, Noordin S. Hip fracture surgery: Does time of the day matter? A case-controlled study. Int J Surg 2013;11:923-5.
18.	George TJ, Arnaoutakis GJ, Merlo CA, Kemp CD, Baumgartner WA, Conte JV, et al. Association of operative time of day with outcomes after thoracic organ transplant. JAMA 2011;305:2193-9.
19.	Waggoner LB, Grant DA, Van Dongen HP, Belenky G, Vila B. A combined field and laboratory design for assessing the impact of night shift work on police officer operational performance. Sleep 2012;35:1575-7.
20.	Hanowski RJ, Hickman J, Fumero MC, Olson RL, Dingus TA. The sleep of commercial vehicle drivers under the 2003 hours-of-service regulations. Accid Anal Prev 2007;39:1140-5.
21.	Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004;351:1838-48.
22.	Shaw TM, Lonze BE, Feyssa EL, Segev DL, May N, Parsikia A, et al. Operative start times and complications after kidney transplantation. Clin Transplant 2012;26:E177-83.
23.	Seow YY, Alkari B, Dyer P, Riad H. Cold ischemia time, surgeon, time of day, and surgical complications. Transplantation 2004;77:1386-9.
24.	Kienzl-Wagner K, Schneiderbauer S, Bösmüller C, Schneeberger S, Pratschke J, et al. Nighttime procedures are not associated with adverse outcomes in kidney transplantation. Transpl Int 2013;26:879-85.
25.	Brunschot DM, Hoitsma AJ, van der Jagt MF, d'Ancona FC, Donders RA, van Laarhoven CJ, et al. Night-time kidney transplantation is associated with less pure technical graft failure. World J Urol 2016;34:955-61.