Key result
Reduced procedural interval for minimally invasive esophagectomy was associated with a significant reduction in 30-day mortality (5% vs. 12%) during the proficiency gain period.
Why the study?
Complex surgical procedures like minimally invasive esophagectomy are associated with a proficiency gain period, but the effect of procedural interval on cases required and adverse outcomes is unknown.
Does a reduced procedural interval improve clinical outcomes during the proficiency gain period for minimally invasive esophagectomy in adult patients with esophageal cancer?
Cohort (n=1,696)
Yes
Does a reduced procedural interval improve clinical outcomes during the proficiency gain period for minimally invasive esophagectomy in adult patients with esophageal cancer?
Absolute Event Rate: 5% vs 12%
p-value: p=<0.01
Reducing the time interval between minimally invasive esophagectomy procedures during a surgeon's proficiency gain period significantly decreases patient morbidity and mortality.
May support shorter intervals during proficiency gain to lower mortality; leaves open randomized confirmation before practice change.
BACKGROUND: Complex surgical procedures including minimally invasive esophagectomy (MIE) are commonly associated with a period of proficiency gain. We aim to study the effect of reduced procedural interval upon the number of cases required to gain proficiency and adverse patient outcomes during this period from MIE. METHODS: All adult patients undergoing MIE for esophageal cancer in England from 2002 to 2012 were identified from Hospital Episode Statistics database. Outcomes evaluated included conversion rate from MIE to open esophagectomy, 30-day re-intervention, 30-day and 90-day mortality. Regression models investigated relationships between procedural interval and the number of cases and clinical outcomes during proficiency gain period. RESULTS: The MIE dataset comprised of 1696 patents in total, with procedures carried out by 148 surgeons. Thresholds for procedural interval extracted from change-point modeling were found to be 60 days for conversion, 80 days for 30-day re-intervention, 80 days for 30-day mortality and 110 days for 90-day mortality. Procedural interval of MIEs did not influence the number of cases required for proficiency gain. However, reduced MIE procedural interval was associated with significant reductions in conversions (0.16 vs. 0.07; P < 0.001), re-interventions (0.15 vs. 0.09; P < 0.01), 30-day (0.12 vs. 0.05; P < 0.01) and 90-day (0.14 vs. 0.06; P < 0.01) mortality during the period of proficiency gain. CONCLUSIONS: This national study has demonstrated that the introduction of MIE is associated with a period of proficiency gain and adverse patient outcomes. The absolute effect of this period of proficiency gain upon patient morbidity and mortality may be reduced by reduced procedural interval of MIE practice within specialized esophageal cancer centers.
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Markar et al. (2020) conducted a cohort in Esophageal cancer (n=1,696). Reduced procedural interval vs. Increased procedural interval was evaluated on 30-day mortality (p=<0.01). Reduced procedural interval for minimally invasive esophagectomy was associated with a significant reduction in 30-day mortality (5% vs. 12%) during the proficiency gain period.
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