The volume of operations a surgeon performs affects both short- and long-term patient outcomes following resection for rectal carcinoma, show data from a German hospital.
The authors hope their evidence will help clarify the ongoing controversy over the impact of surgeon volume, as opposed to hospital volume.
"There is evidence that higher hospital volume confers significant benefit for rectal cancer surgery," say Werner Hohenberger (Universität Erlangen Nürnberg, Germany) and colleagues. "However, a high hospital volume may also include surgeons with a low surgical volume."
The analysis involved 1028 patients who underwent resection at University Hospital Erlangen between 1995 and 2010. Importantly, the authors only included patients who had undergone total mesorectal resection, a technique which has reduced variation in outcomes.
Overall 77.8% of patients were operated on by five high-volume surgeons (7-23 operations/year), 18.8% by seven medium-volume surgeons (3-6/year), and 3.4% by 12 low-volume surgeons (<3/year).
When the authors looked at short-term outcomes, they found that, while most parameters they observed did not significantly differ between the groups, patients operated on by low-volume surgeons had a 5.9-fold increase in the odds for postoperative mortality compared with those operated on by high-volume surgeons (9.0 vs 1.5%).
Long-term analysis of 476 patients following primary surgery revealed that patients who were operated on by low-volume surgeons had a 1.9-fold increase in the odds for death within 5 years (30 vs 23%).
Medium-volume surgeons were also significantly associated with a decreased odds for survival as well as a 1.5-fold increase in the odds for developing distant metastases compared with high-volume surgeons (26.8 vs 22.5%).
In the 212 patients who were operated on following radiochemotherapy, representing more challenging cases, the volume of the surgeon was significantly associated with decreased survival at 7 years (71.7 vs 60.0%; high- vs low-volume).
"There is no doubt that the surgeon is an essential independent prognostic factor in patients with rectal carcinoma," write Hohenberger and colleagues in the International Journal of Colorectal Disease.
However, they add that their findings do not detract for the importance of other factors in patient outcomes.
"Irrespective to surgeon volume, specialization, experience, hospital organization, and above all, quality of mesorectal excision, individual skill, and regular quality assurance are essential prognostic factors securing good results in rectal carcinoma surgery."
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