The Surgeon Volume-Outcome Relationship and Impact on Esophagectomy Mortality

Albert B. Lowenfels, MD


June 30, 2016

Is there any measure, other than increasing number of cases performed by a surgeon, that correlates with reduced hospital mortality for high-risk surgical procedures?

The authors of a paper recently published in Annals of Surgery used the Nationwide Inpatient Sample (2003-2009) to study mortality following esophageal surgery. In addition to examining number of esophagectomies performed by each surgeon, they looked at mortality for the procedure performed by another group of surgeons who may have had fewer esophagectomies but had broad experiences with "surrogate" types of procedures, such as removal of an esophageal diverticulum, various gastric operations, or repair of a hiatal hernia.

The findings confirmed other reports that patients operated on by surgeons with a high volume of esophagectomies had a lower mortality rate (P = .05), but they also found that patients operated on by those surgeons who had a high volume of "surrogate" gastroesophageal operations had a lower mortality rate than patients operated on by less experienced surgeons (P = .002).


Credentialing surgeons on the basis of their volume of surgical procedures, although controversial, is a measure being applied by hospitals in an attempt to improve mortality statistics.[2] Many reports, including this one, have determined that increasing caseloads correlates with better results, especially for more difficult procedures, such as esophagectomies.[1,2,3]

The study authors suggest that experience with similar types of surgery may be a satisfactory surrogate measure that correlates with patient survival. If so, then hospitals, while reviewing their credentialing procedures, might look at the volume of similar types of procedures.

The results of this study[1] suggest that surrogate experience may be a valid substitute for esophagectomy, but there is no information for other complex operations, such as pancreatectomy. A recent nationwide study shows that for three types of major cancer surgery involving the esophagus, pancreas, or the bladder, there is a clear trend to centralization of procedures in high-volume hospitals.[4]

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