title: Surgical Proficiency Gain and Survival After Esophagectomy for Cancer.
abstract: 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 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.
  
  
  
  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).
  
  
  
  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.
authors.affiliation: Sheraz R. Markar, Hugh Mackenzie, and George B. Hanna, Imperial College London; Jesper Lagergren, King's College London, London, United Kingdom; and Sheraz R. Markar, Pernilla Lagergren, and Jesper Lagergren, Karolinska Institutet, Sweden.
authors.forename: Sheraz R
authors.initials: SR
authors.lastname: Markar
authors.affiliation: Sheraz R. Markar, Hugh Mackenzie, and George B. Hanna, Imperial College London; Jesper Lagergren, King's College London, London, United Kingdom; and Sheraz R. Markar, Pernilla Lagergren, and Jesper Lagergren, Karolinska Institutet, Sweden.
authors.forename: Hugh
authors.initials: H
authors.lastname: Mackenzie
authors.affiliation: Sheraz R. Markar, Hugh Mackenzie, and George B. Hanna, Imperial College London; Jesper Lagergren, King's College London, London, United Kingdom; and Sheraz R. Markar, Pernilla Lagergren, and Jesper Lagergren, Karolinska Institutet, Sweden.
authors.forename: Pernilla
authors.initials: P
authors.lastname: Lagergren
authors.affiliation: Sheraz R. Markar, Hugh Mackenzie, and George B. Hanna, Imperial College London; Jesper Lagergren, King's College London, London, United Kingdom; and Sheraz R. Markar, Pernilla Lagergren, and Jesper Lagergren, Karolinska Institutet, Sweden.
authors.forename: George B
authors.initials: GB
authors.lastname: Hanna
authors.affiliation: Sheraz R. Markar, Hugh Mackenzie, and George B. Hanna, Imperial College London; Jesper Lagergren, King's College London, London, United Kingdom; and Sheraz R. Markar, Pernilla Lagergren, and Jesper Lagergren, Karolinska Institutet, Sweden. jesper.lagergren@ki.se.
authors.forename: Jesper
authors.initials: J
authors.lastname: Lagergren
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D004938:Esophageal Neoplasms / Q000401:mortality* / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods / Q000401:mortality* / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D012042:Registries; D013548:Sweden / Q000453:epidemiology; D055815:Young Adult