Surgeon Volume and Cancer Esophagectomy, Gastrectomy, and Pancreatectomy: A Population-based Study in England.
OBJECTIVE
The aim of the study was to assess whether there is a proficiency curve-like relationship between surgeon volume and operative mortality and determine the minimum surgeon volume for optimum operative mortality.


BACKGROUND
The inverse relationship between hospital volume and operative mortality is well-established for esophageal, gastric, and pancreatic cancer. The recommended minimum surgeon volumes are however uncertain.


METHODS
We retrieved data on esophagectomies, gastrectomies, and pancreatectomies for cancer from the NHS Hospital Episodes Statistics database from April 2000 to March 2010. We defined mortality as in-hospital death within 30 days of surgery. We determined whether there was a proficiency curve relationship by inspecting surgeon volume-mortality graphs after adjusting for patient age, sex, socioeconomic, and comorbidity indices. We then statistically determined the minimum surgeon volume that produced a mortality rate insignificantly different from the optimum of the curve.


RESULTS
Sixteen thousand five hundred seventy-two esophagectomies, 12,622 gastrectomies, and 9116 pancreatectomies were examined. Surgeon volume ranged from 2 to 29 esophagectomies, from 1 to 14 gastrectomies, and from 2 to 31 pancreatectomies per surgeon per year. We demonstrated a proficiency relationship between surgeon volume and mortality in esophageal, gastric, and pancreatic cancer surgery. Each additional case of esophagectomy, gastrectomy, and pancreatectomy would reduce 30-day mortality odds by 3.4%, 7.2%, and 4.1%, respectively. However, as surgeon volume increased, mortality rate continued to improve. Therefore, we were unable to recommend minimum surgeon volume.


CONCLUSIONS
Mortality after resections for esophageal, gastric, and pancreatic cancer falls as surgeon volume rises up to 30 cases. Within this range, we did not demonstrate any statistical threshold that could be recommended as a minimum volume target.
*Department of Surgery and Cancer, Queen Elizabeth the Queen Mother Wing, St Mary's Hospital, Imperial College London, London, UK †Statistical Laboratory, Centre for Mathematical Sciences, Cambridge University, Cambridge, UK ‡Dr Foster Unit at Imperial College, Department of Primary Care and Public Health, Imperial College London, London, UK §Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.
Ravikrishna
R
Mamidanna
Zhifang
Z
Ni
Oliver
O
Anderson
Sir David
SD
Spiegelhalter
Alex
A
Bottle
Paul
P
Aylin
Omar
O
Faiz
George B
GB
Hanna
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence / Q000706:statistics & numerical data*; D016208:Databases, Factual; D004739:England; D004938:Esophageal Neoplasms / Q000401:mortality / Q000601:surgery; D016629:Esophagectomy / Q000401:mortality* / Q000706:statistics & numerical data; D005260:Female; D005743:Gastrectomy / Q000401:mortality* / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000401:mortality* / Q000706:statistics & numerical data; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000601:surgery; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D013222:State Medicine; D013274:Stomach Neoplasms / Q000401:mortality / Q000601:surgery; D066231:Surgeons / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D055815:Young Adult