A surgeon's case volume of oesophagectomy for cancer strongly influences the operative mortality rate

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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.