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Surgical Experience Improves Survival

Colon cancer patients achieve better five-year survival rates when the surgeons who treat them are rated as highly skilled, according to findings from what authors say is the first study to link a surgeon’s technical skills with improved long-term clinical outcomes. The study is published online in JAMA Oncology and virtually presented as part of the American College of Surgeons (ACS) Commission on Cancer’s Annual Research Paper Competition.

“In the last few years, studies have shown that patients of more highly skilled surgeons have fewer immediate postoperative complications. This study moves to the next level and shows that patients of more highly skilled surgeons not only have fewer complications in the short term, they survive longer,” says Brian C. Brajcich, MD, a clinical scholar with the ACS, research fellow at Northwestern University School of Medicine, and lead study author.

The study was conducted by the Illinois Surgical Quality Improvement Collaborative (ISQIC), a group of 56 hospitals that perform 80% of the complex surgical operations across the state. The ISQIC is a collaborative partner with the ACS National Surgical Quality Improvement Program.

“A previous study done by our group found that lapses in surgical technique can result in a complication within a few days of surgery. This study is striking because no one has looked directly at the relationship between surgical skill and improved survival at the five-year mark, and, yes, surgeons with better skill achieve considerably better survival rates for their patients,” says Karl Y. Bilimoria, MD, MS, FACS, director of the Surgical Outcomes and Quality Improvement Center at Northwestern Medicine in Chicago, and an ACS faculty scholar.

Excluding skin cancers, colorectal cancer is the third most common type of cancer diagnosed in both men and women in the United States. The American Cancer Society estimates nearly 105,000 cases of colon cancer and 45,000 cases of rectal cancer will be newly diagnosed in 2021. Surgery is a mainstay of treatment. The type of surgery depends on the extent and location of the cancer and the goal of treatment. During a laparoscopic colectomy, for example, the surgeon removes the cancerous area of the colon, a small segment of normal colon on either side, and nearby lymph nodes.

Study investigators recruited surgeons from the ISQIC in 2016 to participate in a video-based technical skills assessment program. Each surgeon was videotaped while performing a minimally invasive right hemicolectomy (partial surgical removal of the colon). Videos were reviewed by 12 or more surgeons, including two colorectal surgeons experienced in evaluating surgical video tapes. Each reviewer assigned a skill score to the video they reviewed. Skill scores were derived from the American Society of Colon and Rectal Surgeons Video Assessment Tool, which assesses factors such as gentleness of tissue manipulation, efficient and methodical performance of the procedure, and extent of surgical excision. Skill levels for the surgeons in the study reflected the mean skill score from all reviewers.

The study included 609 patients who underwent laparoscopic colectomy by one of the participating surgeons between 2012 and 2017. Five surgeons who achieved the highest technical skill scores also had the highest volume of procedures in the study, as well as the highest average annual number of surgical cases; their totals were more than two times higher than the number of procedures performed by other surgeons. Overall, five-year survival for these surgeons was 79%. Five-year survival rates were 55% for medium-skilled surgeons and 60% for low-skilled surgeons.

“This study demonstrates that surgical technical skill is an important driver of long-term outcomes in cancer surgery. When talking about ways to improve outcomes for patients, we surgeons should not only think about quality measures but ways to improve surgeons’ skills through some form of surgical coaching,” Brajcich says.

Patients also may take proactive steps. “Patients can ask their surgeon how many of these procedures they regularly perform. Volume of cases is a reflection of expertise. Patients also can ask their surgeon what he or she does to stay up to date and improve skills. These questions can help patients make informed decisions about where to seek care,” Bilimoria says.

The Northwestern Medicine health system is bringing surgeons together in the Technical Excellence Collaborative to review one another’s work, find opportunities for improvement in technique, and follow patients to track their outcomes, Bilimoria says.

“High surgical volumes have been shown to result in lower morbidity and improved outcomes for many types of surgery and this study shows that technical skill also results in improved survival for patients with colon cancer,” says Kelly K. Hunt, MD, FACS, who is not affiliated with the study and is a professor and chair of the department of breast surgical oncology at The University of Texas MD Anderson Cancer Center in Houston.

“The ACS Cancer Research Program has also shown that adherence to the critical elements of an operation [operative standards] also results in improved outcomes and quality of life for cancer patients. Therefore, the Cancer Surgery Standards Program was formed to develop synoptic operative reporting templates, electronic documentation tools, and educational content around these operative standards. Ultimately, the program seeks to facilitate adoption and utilization of synoptic operative reporting tools for improved outcomes in all major cancer operations,” concludes Hunt, who serves as Cancer Surgery Standards Program vice-chair.

— Source: American College of Surgeons