Surgical Proficiency Gain and Survival After Esophagectomy for Cancer

Abstract

Purpose We aimed to identify the presence and length of esophagectomy proficiency gain curves in terms of short- and long-term mortality for esophageal cancer. Patients and Methods Patients who underwent esophagectomy for esophageal cancer between 1987 and 2010 with follow-up until 2014 were identified from a well-established, population-based, nationwide Swedish cohort study. Proficiency gain curves were created by using risk-adjusted cumulative sum analysis for 30-day, 90-day, 1-year, 3-year, and 5-year all-cause and disease-specific mortality measures. Similarly, the proficiency gain curves for lymph node harvest, resection margin status, and reoperation incidence were assessed as performance-contributing factors to the observed changes in long-term survival. Results Esophagectomies in 1,821 patients with esophageal cancer were conducted by 139 surgeons. The change-point in proficiency gain curve for all-cause 30-day mortality was early, at 15 cases, when mortality decreased from 7.9% to 3.1% (P < .001). Later change-points, which ranged from 35 to 59 cases, were observed for 1-, 3- and 5-year mortality rates, for which all-cause mortality decreased from 34.9% to 27.7% (P = .011), from 47.4% to 41.5% (P = .049), and from 31.4% to 19.1% (P = .009), respectively. Similar change-points were observed in disease-specific mortality at 1 and 3 years. There was a continuous increase in lymph node harvest, which did not plateau. Also, change-points were observed for resection margin with tumor involvement at 17 cases, with a reduction from 20.9% to 15.2% (P = .004), and for reoperation rate at 55 cases, with a reduction from 12.6% to 5.0% (P < .001). Conclusion The gain of proficiency in esophagectomy for cancer is associated with measurable changes in short- and long-term mortality results. These findings indicate a need for structured national training and mentorship programs for esophageal cancer surgery.

Oesophageal cancer

“…90 Even experienced surgeons who start to perform oesophagectomies have a learning curve before the survival outcome for their patients is stabilised. 88 Taken together, available scientific evidence supports centralisation of oesophagectomy.…”

“…However, the learning curve for surgeons associated with the adoption of new approaches should be taken into account. 88 …”

Minimum Volume Standards in Surgery - Are We There Yet

“…A realistic number, supported by a study with the aim of halving the mortality, is the requirement of 15 of such operations. A plateau of optimized long-term results in esophageal carcinoma was achieved only after 35-59 operations [40]: Between 1987 and 2010, 139 surgeons performed 1,821 esophagectomies. The success rate and endpoint of the study were the patients' mortality rates after 30 days as well as after 1, 2 and 5 years.…”

Surgeon proficiency and outcomes in esophagectomy: a perspective and comment on an analysis of the Swedish Cancer Registry

“…The recent publication by Markar et al in the Journal of Clinical Oncology evaluates the change in short and long term mortality as surgeons gain proficiency in performing open esophagectomy (7). In a retrospective analysis of the Swedish Cancer Registry of all patients with esophageal cancer treated with curative intent from 1987 to 2010 with follow up until November 2014, 1,821 patients were identified who underwent esophagectomy.…”