title: A surgeon's case volume of oesophagectomy for cancer strongly influences the operative mortality rate.
abstract: OBJECTIVE
  To assess if individual case volume of oesophagectomy for cancer influences the risk of mortality and long-term survival.
  
  
  METHODS
  Between January 1994 and December 2005, 195 resections for oesophageal cancer were performed by nine surgeons in a single institution. Operative mortality, defined as in hospital death, was compared between the high-volume and low-volume surgeons. Multivariate logistic regression was used to analyze the risk factors for death between the two groups, also in the presence of covariates.
  
  
  RESULTS
  There were 140 males and 55 females with mean age of 63.4 (32-84). Two high-volume surgeons performed 61% (118) of the operations with a mean of 11 per year compared to 4 per year in the low-volume group. The patients in the two groups were matched for age (63 years vs 64; p=0.53), sex (67 vs 79% male; p=0.07). Ivor Lewis resections were performed more frequently by high-volume surgeons (95 vs 73%; p<0.001). The operative mortality rate was much lower when high case volume surgeons performed the procedure (4 vs 17%; p=0.001). The relative risk of death when low-volume surgeons performed the procedure was 4.59 (95% CI 1.57-13.46; p<0.001). In-hospital mortality was significantly associated with low-volume surgeon when controlling separately for age (OR 4.60; 95% CI 1.55, 13.60, p=0.006), tumor stage (OR 3.76; 95% CI 1.24, 11.45, p=0.02) and tumor type (OR 3.87; 95% CI 1.29, 11.60, p=0.016). Kaplan-Meier curves comparing the survival of high- and low-volume surgeons showed no statistical differences (Log rank p=0.48).
  
  
  CONCLUSIONS
  Operative mortality rate for oesophagectomy for cancer is strongly influenced by case volume and was 4.6-fold higher when performed by surgeons with low case volume. Patients with oesophageal cancer in need of an oesophagectomy may benefit from referral to a high-volume thoracic surgeon.
authors.affiliation: General Thoracic Surgery, Papworth Hospital, University of Cambridge Teaching Hospital, Cambridge, UK. mmiglior@unict.it
authors.forename: Marcello
authors.initials: M
authors.lastname: Migliore
authors.forename: Cliff K
authors.initials: CK
authors.lastname: Choong
authors.forename: Eric
authors.initials: E
authors.lastname: Lim
authors.forename: Kimberley A
authors.initials: KA
authors.lastname: Goldsmith
authors.forename: Andy
authors.initials: A
authors.lastname: Ritchie
authors.forename: Francis C
authors.initials: FC
authors.lastname: Wells
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D004938:Esophageal Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery; D016629:Esophagectomy / Q000379:methods / Q000401:mortality*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011446:Prospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D016526:Workload