American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Studies weigh value of experience versus training

OCTOBER 25, 2017
Clinical Congress Daily Highlights, Wednesday Second Edition

Specialists and high-volume surgical centers are increasingly preferred for many types of surgery. This trend toward care centralization for complex operations has raised concerns of unintended negative consequences, such as increased health disparities. Therefore, it is important to identify procedures that result in similar outcomes at low- and high-volume centers. A number of studies presented at this year’s Clinical Congress examined various surgical procedures to determine whether outcomes may be affected by a center’s volume.

Antoinette Esce of the University of Rochester Medical Center in Rochester, NY, and colleagues found that up to 150 open abdominal aortic aneurysm (AAA) repair patients could have avoided perioperative mortality if all procedures had been performed by high-volume surgeons. The researchers, who said that theirs is the first primary study to identify an ideal minimum threshold for annual surgeon case volume for open abdominal aortic aneurysm repair, concluded that if surgeons are going to perform open AAA repair, they should perform at least six procedures yearly.

In the case of distal pancreatectomy for cancer, researchers led by Alexander Fisher, MD, of the University of Wisconsin, Madison, WI, found that a modest volume of four to 10 cases per year is sufficient. Although patients at hospitals performing fewer than four cases per year had significantly worse survival, no significant differences in 90-day mortality or median overall survival were observed between medium-volume hospitals (four to 10 cases per year) and those with higher volume. The authors conclude that this finding can partially decrease the burden and consequences of centralization for this particular procedure.

Paul J. Chung, MD, of the State University of New York Downstate Medical Center, Brooklyn, NY, and his colleagues found that thyroidectomy cases performed by general surgery (GS) exhibited decreased comorbidity burden compared with cases handled by otolaryngology (ENT) . Using American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) data from 2006 to 2014, adult patients were identified who underwent nonemergent total thyroidectomy with or without cervical approach with a diagnosis of non-malignant/non-toxic goiters. Of 18,890 cases performed, 15,756 were done by GS and 3,134 by ENT. Adjusted multivariable analysis found ENT subspecialty to be independently associated with increased length of stay. The authors concluded that an analysis of modifiable practice patterns reducing length of stay is warranted.

Disease-specific experience is a key factor in minimizing morbidity and mortality for patients undergoing surgery for ulcerative colitis (UC), a team led by Robert N. Goldstone, MD, of Massachusetts General Hospital, Boston, MA, found. The team analyzed all UC patients treated with at least a total abdominal colectomy (TAC) in the New York State SPARCS database between 2000 and 2014. On adjusted analysis, high-volume surgeons were associated with significant reduction in operative mortality, but not in postoperative morbidity. High-volume UC surgeons, however, were associated with significant reductions in both postoperative mortality and morbidity.  The authors concluded that disease-specific experience is necessary to achieve these further reductions in complications.

Additional Information:
The four Scientific Forums presented at the 2017 Clinical Congress of the American College of Surgeons Clinical Congress in San Diego, CA were:  Surgeons Performing 6 or more Open Abdominal Aortic Aneurysm (AAA) Repairs per Year Have Improved Survival; Distal Pancreatectomy for Pancreatic Adenocarcinoma: Is Treatment at High Volume Centers Necessary?; Does Specialty Matter? Analysis of Outcomes in Total Thyroidectomy for Goiters between General Surgery and Otolaryngology using ACS NSQIP; Disease-Specific Operative Experience Significantly Reduces Surgical Morbidity and Mortality for Patients with Ulcerative Colitis. Program, webcast and audio information is available online at FACS.org/clincon2017.

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