Because esophagectomy is associated with high morbidity and mortality, researchers have begun to investigate whether surgical volume affects perioperative outcomes. A study at Brigham and Women’s Hospital determined that even at this high-volume center, low individual esophagectomy volume was associated with a higher perioperative complication rate.
Daniel Dolan, MD, MPH, postdoctoral research fellow of the Division of Thoracic Surgery at the Brigham, Scott J. Swanson, MD, director of Minimally Invasive Thoracic Surgery in the division, and colleagues report the findings in Seminars in Thoracic and Cardiovascular Surgery.
The team retrospectively reviewed 1,029 patients who underwent surgery for esophageal cancer at the Brigham between August 1, 2005, and August 31, 2019. High-volume surgeons operated on 909 patients and low-volume surgeons on 120.
Of 15 surgeons included in the study, two were high-volume from the beginning and seven progressed from low- to high-volume. The six others performed a high volume of procedures at partner hospitals and performed esophagectomies at the Brigham.
Postoperative complications were more common in the low-volume group:
- Overall rate—72% of patients in the low-volume group vs. 58% in the high-volume group (P=0.003)
- Grade II—59% vs. 47% (P=0.011)
- Grade III—44% vs. 27% (P<0.001)
In multivariable analysis, having esophagectomy performed by a high-volume surgeon was associated with 44% lower odds of a grade ≥III complication. Rates of grade IV and fatal complications were similar in the two groups, as were anastomotic leak rates.
Some possible explanations for the differences in complications between the low- and high-volume groups are open versus minimally invasive surgical technique, increased operative time, increased perioperative fluid administration, and overall fluid balance.
Patients of low-volume surgeons were more likely than the other group to undergo either totally open surgery (46% vs. 14%; P<0.01) or hybrid open and minimally invasive procedures (24% vs. 15%; P=0.011). In the multivariable analysis, an open approach led to 95% greater odds of a grade ≥III complication.
Even when the team considered only totally minimally-invasive cases, the overall complication rate and rates of grade II or III complications were higher in the low-volume group.
In an analysis of data from June 2015 to August 2019, both median intravenous fluid intake and fluid balance through 48 hours from surgery were similar in the low- and high-volume groups. However, operative time for both modified McKeown and Ivor–Lewis esophagectomies was significantly longer for low-volume surgeons.
Other Perioperative Outcomes
The median length of stay was somewhat longer for the low-volume group (11 days vs. 10 days, P<0.001). The two groups were similar with regard to 30-day readmission rates; mortality at 30, 60, and 90 days; and the need for adjuvant therapy.
There were no significant differences between groups in time to recurrence or rates of anastomotic recurrence, distal recurrence, or five-year overall or disease-free survival. The inpatient and outpatient teams that care for esophagectomy patients at the Brigham undoubtedly provided a “safety net” that helped achieve similar outcomes.
The Value of Mentorship
Even before these study results became available, the Brigham maintained an informal mentorship program in which low-volume esophagectomy surgeons worked with a high-volume mentor for one or two years. Now, a more formal system is being developed to provide mentorship for low-volume esophagectomy surgeons until they reach a higher volume.
No specific number of surgeries is considered the threshold for demonstrating competence. Instead, the institution will allow surgeons to gain complete independence at their own pace. In addition, surgeons of all skill levels are invited to attend tumor boards and case conferences to discuss the nuances of esophagectomy and perioperative care.