Short and Long-term Outcomes Among High-Volume vs Low-Volume Esophagectomy Surgeons at a High-Volume Center

Published:September 20, 2021DOI:
      To determine associations between surgeon volume and esophagectomy outcomes at a high-volume institution. All esophagectomies for esophageal cancer at our institution from August 2005 to August 2019 were reviewed. Cases were divided by surgeon into low, <7 cases/year, vs high volume, ≥7 cases/year, based on Leapfrog Group recommendations. Surgeons remained ‘high-volume’ after one year of ≥7 cases. Demographics, comorbidities, course of care, and long-term outcomes were compared. In total, 1029 cases were evaluated; 120 performed by low-volume surgeons vs 909 by high-volume surgeons. Never-smokers, atrial fibrillation, and clinical Stage IVa patients were associated with high-volume surgeons. Other demographics were similar. Low-volume surgeons did more open cases, 45.8% vs 14.5%, P < 0.01. Low-volume surgeons had more complications than high-volume surgeons (71.7% vs 57.6%, P < 0.01), specifically Grade II and III (59.2% vs 46.8%, P = 0.01, and 44.2% vs 27.0%, P <0.01). No differences were seen in anastomotic leak rate, 90-day mortality, recurrences, 5-year overall survival (46.7% low-volume vs 49.3% high-volume, P = 0.64), or 5-year disease-free survival (35.7% low-volume vs 42.2% high-volume, P = 0.27). In multivariable logistic regression for Grade III or higher complications, high-volume surgeons had an odds ratio of 0.56 (95% confidence interval 0.36–0.87) for complications. Our study found higher rates of open esophagectomies and complications in low-volume esophagectomy surgeons compared to high-volume surgeons at the same, high-volume institution. However, low-volume surgeons were not associated with worse survival outcomes compared to high-volume surgeons. Low-volume esophagectomy surgeons may benefit from mentoring and support to improve perioperative outcomes; these efforts are underway at our institution.

      Graphical Abstract



      OS (overall survival), DFS (disease-free survival), LRFS (locoregional-recurrence-free survival), BMI (body mass index), CAD (coronary artery disease), COPD (chronic obstructive pulmonary disease), SCC (squamous cell carcinoma), HR (hazard ratio), CI (confidence interval)
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        • Luft H.S.
        • Bunker J.P.
        • Enthoven A.C.
        Should operations be regionalized? The empirical relation between surgical volume and mortality.
        N Engl J Med. 1979; 301: 1364-1369
        • Birkmyre J.D.
        • Siewers A.E.
        • Finlayson E.V.A.
        • et al.
        Hospital volume and surgical mortality in the united states.
        N Engl J Med. 2002; 346: 1128-1137
        • Birkmyre J.D.
        • Stukel T.A.
        • Siewers A.S.
        • et al.
        Surgeon volume and operative mortality in the United States.
        N Engl J Med. 2003; 349: 2117-2127
        • Brusselaers N.
        • Mattsson F.
        • Lagergren J.
        Hospital and surgeon volume in relation to long-term survival after oesophagectomy: Systematic review and meta-analysis.
        Gut. 2014; 63: 1393-1400
        • Ely S.
        • Alabaster A.
        • Ashiku S.K.
        • Patel A.
        • Velotta J.B.
        Regionalization of thoracic surgery improves short-term cancer esophagectomy outcomes.
        J Thorac Dis. 2019; 11 (PMID:31285879, PMCID: PMC6588736): 1867-1878
        • Gottlieb-Vedi E.
        • Mackenzie H.
        • van Workum F.
        • Rosman C.
        • Lagergren P.
        • Markar S.
        • Lagergren J.
        Surgeon volume and surgeon age in relation to proficiency gain curves for prognosis following surgery for esophageal cancer.
        Ann Surg Oncol. 2019; 26 (Epub 2018 Oct 15. PMID:30324469, PMCID: PMC6341157): 497-505
      1. Leapfrog Group. Surgical Volume. Leapfrog Group website. Accessed August 4, 2020.

        • Amin M.B.
        • Edge S.B.
        • Greene F.L.
        • et al.
        AJCC Cancer Staging Manual.
        8th ed. Springer, New York2017
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications: Anew proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Gottlieb-Vedi E.
        • Mackenzie H.
        • van Workum F.
        • Rosman C.
        • Lagergren P.
        • Markar S.
        • Lagergren J.
        Surgeon volume and surgeon age in relation to proficiency gain curves for prognosis following surgery for esophageal cancer.
        Ann Surg Oncol. 2019; 26 (Epub 2018 Oct 15. PMID:30324469PMCID: PMC6341157): 497-505
        • Clark J.M.
        • Cooke D.T.
        • Hashimi H.
        • Chin D.
        • Utter G.H.
        • Brown L.M.
        • Nuño M.
        Do the 2018 leapfrog group minimal hospital and surgeon volume thresholds for esophagectomy favor specific patient demographics?.
        Ann Surg. 2019; (Epub ahead of printPMID:31425294)
        • Umana-Pizano J.B.
        • Nissen A.P.
        • Sandhu H.K.
        • Miller C.C.
        • Loghin A.
        • Safi H.J.
        • Eisenberg S.B.
        • Estrera A.L.
        • Nguyen T.C.
        Acute type a dissection repair by high-volume vs low-volume surgeons at a high-volume aortic center.
        Ann Thorac Surg. 2019; 108 (Epub 2019 May 31. PMID:31158351): 1330-1336
        • Tapias L.F.
        • Mathisen D.J.
        • Wright C.D.
        • Wain J.C.
        • Gaissert H.A.
        • Muniappan A.
        • Lanuti M.
        • Donahue D.M.
        • Morse C.R.
        Outcomes with open and minimally invasive ivor lewis esophagectomy after neoadjuvant therapy.
        Ann Thorac Surg. 2016; 101 (Epub 2015 Dec 1. PMID:26652140): 1097-1103
        • Naffouje S.A.
        • Salloum R.H.
        • Khalaf Z.
        • Salti G.I.
        Outcomes of open versus minimally invasive Ivor-lewis esophagectomy for cancer: A propensity-score matched analysis of NSQIP database.
        Ann Surg Oncol. 2019; 26 (Epub 2019 Mar 29. PMID:30927192): 2001-2010
        • Valsangkar N.
        • Salfity H.V.N.
        • Timsina L.
        • Ceppa D.P.
        • Ceppa E.P.
        • Birdas T.J.
        Operative time in esophagectomy: Does it affect outcomes?.
        Surgery. 2018; 164 (Epub 2018 Aug 16. PMID:30119872): 866-871
        • Xing X.
        • Gao Y.
        • Wang H.
        • Qu S.
        • Huang C.
        • Zhang H.
        • Wang H.
        • Sun K.
        Correlation of fluid balance and postoperative pulmonary complications in patients after esophagectomy for cancer.
        J Thorac Dis. 2015; 7 (PMID:26716037, PMCID: PMC4669283): 1986-1993
        • Oh T.K.
        • Oh A.Y.
        • Hwang J.W.
        Association between perioperative fluid balance and 30-day unplanned readmission after major abdominal surgery.
        Surg Innov. 2019; 26 (Epub 2019 Mar 28. PMID:30920902): 401-407
        • Hikasa Y.
        • Suzuki S.
        • Mihara Y.
        • Tanabe S.
        • Shirakawa Y.
        • Fujiwara T.
        • Morimatsu H.
        Intraoperative fluid therapy and postoperative complications during minimally invasive esophagectomy for esophageal cancer: A single-center retrospective study.
        J Anesth. 2020; 34 (Epub 2020 Mar 30. PMID:32232660): 404-412
        • Glatz T.
        • Kulemann B.
        • Marjanovic G.
        • Bregenzer S.
        • Makowiec F.
        • Hoeppner J.
        Postoperative fluid overload is a risk factor for adverse surgical outcome in patients undergoing esophagectomy for esophageal cancer: A retrospective study in 335 patients.
        BMC Surg. 2017 13; 17 (PMID:28086855, PMCID: PMC5237209): 6
        • Wolter S.
        • Duprée A.
        • ElGammal A.
        • Runkel N.
        • Heimbucher J.
        • Izbicki J.R.
        • Mann O.
        • Busch P.
        Mentorship programs in bariatric surgery reduce perioperative complication rate at equal short-term outcome-results from the optimize trial.
        Obes Surg. 2019; 29 (PMID:30187421): 127-136
        • Rice M.K.
        • Hodges J.C.
        • Bellon J.
        • Borrebach J.
        • Al Abbas A.I.
        • Hamad A.
        • Knab L.M.
        • Moser A.J.
        • Zureikat A.H.
        • Zeh H.J.
        • Hogg M.E.
        Association of mentorship and a formal robotic proficiency skills curriculum with subsequent generations' learning curve and safety for robotic pancreaticoduodenectomy.
        JAMA Surg. 2020; 155 (PMID:32432666, PMCID: PMC7240650): 607-615