Impact of surgeon volume on outcomes of rectal cancer surgery: A systematic review and meta-analysis
Introduction
Colorectal cancer is the most common gastrointestinal cancer in the Western world, and the second most common cause of cancer related mortality.1 Approximately one third of these cancers are located within the rectum.2 In recent years, much interest has been given to the relationship between surgeon caseload and patient outcomes after surgery for cancer,3, 4, 5 including colorectal cancer.6, 7, 8, 9, 10, 11 Some evidence suggests that the surgeon is an important prognostic factor in colorectal cancer surgery: in particular, a higher surgeon caseload7, 8, 10, 11 and specialisation12, 13 have been associated with better outcomes. For rectal cancer surgery, there have been conflicting reports on this volume-outcome relationship.14, 15, 16, 17 The management of rectal cancer differs substantially from that of colon cancer, particularly in the use of more accurate staging investigations, administration of neo-adjuvant chemo-radiotherapy and surgical procedures that often involve specialized skills not required for colon cancer surgery. Furthermore, rectal cancer surgery has seen considerable changes in recent years, including the general acceptance of total mesorectal excision (TME) as a technique to reduce local recurrence and a drive towards more sphincter-preserving procedures with no oncological compromise.18 With such emphasis on surgical skill and techniques, it is important to identify potential risk factors for adverse outcomes, including the level of surgical specialisation and caseload. Surgeon caseload is an objective, quantitative measurement and likely to reflect the qualitative descriptor of “specialisation”, although these may not be completely interchangeable.
Although the volume-outcome relationship in rectal cancer has been previously assessed using meta-analysis,15, 16, 17 these reviews included studies on patients treated from the mid-1980’s when the management of rectal cancer patients was substantially different from current treatment. The aim of this review is to evaluate the effect of surgeon volume on the outcome from modern rectal cancer surgery, selecting only studies which reported on rectal cancer patients treated after 1990, and to give a quantitative estimate of such volume effect using meta-analysis.
Section snippets
Inclusion criteria
We considered all studies reporting surgeon caseload and outcomes for colorectal and rectal cancer surgery in patients undergoing treatment after 1990, including rectosigmoid tumours. We included studies that reported at least one of the following outcome measures: 30-day or postoperative mortality, overall survival, anastomotic leak rate, local recurrence rates, permanent stoma and abdominoperineal excision of the rectum (APER) rates. We excluded studies on colorectal cancer for which it was
Description of included studies
The search strategy identified a total of 1000 potentially relevant studies of which 980 were excluded on the basis of title or abstract as they did not fulfil the inclusion criteria for this review. We obtained full papers for 20 studies, of which a further eleven studies were excluded as they did not meet the inclusion criteria. We found two studies6, 25 not identified by the initial search strategy in the references of the included literature, totalling 11 studies for the review. However, we
30-day or postoperative mortality
Unadjusted meta-analysis of three studies,8, 26, 29 including a total of 4809 patients, showed that patients treated by HV surgeons had a significantly lower risk of postoperative death than those treated by LV surgeons (OR = 0.57, 95% CI: 0.43–0.77, Fig. 4a).
Two studies adjusted for casemix,8, 11 one of which11 was not included in the unadjusted analysis. In a total of 9685 patients, the risk of postoperative death was lower for patients treated by HV surgeons than for those treated by LV
Discussion
This review was performed out of a perceived need to clarify the controversial issue regarding the role of surgeon caseload in the treatment of rectal cancer.32
Conflict of interest statement
We declare no personal, financial or political interest which could influence the findings in the submitted material.
References (44)
- et al.
The effect of hospital and surgeon volume on outcomes for rectal cancer surgery
Clin Gastroenterol Hepatol
(2008) - et al.
Meta-analysis in clinical trials
Controlled Clin Trial
(1986) - et al.
Curative rectal cancer surgery in a low-volume hospital: a quality assessment
Eur J Surg Oncol
(2008) - et al.
Volume-outcome analysis in rectal cancer: a plea for enquiry, evidence and evolution
Eur J Surg Oncol
(2009) - et al.
GLOBOCAN 2002. Cancer incidence, mortality and prevalence worldwide IARC CancerBase No. 5, version 2.0
(2004) - et al.
Cancer statistics, 2009
CA Cancer J Clin
(2009) - et al.
Is volume related to outcome in healthcare? A systematic review and methodologic critique of the literature
Ann Intern Med
(2002) - et al.
Should Operations be regionalized?
N Engl J Med
(1979) - et al.
Impact of hospital volume on operative mortality for major cancer surgery
JAMA
(1998) Consultant surgeons and pathologists of the lothian and borders health boards. Lothian and borders large bowel cancer project: immediate outcome after surgery
Br J Surg
(1995)
Hospital volume can serve as a surrogate for surgeon volume for achieving excellent outcomes in colorectal resection
Ann Surg
Impact of surgeon volume and specialization on short-term outcomes in colorectal cancer surgery
Br J Surg
Surgeon and hospital volume and the management of colorectal cancer patients in Australia
ANZ J Surg
Influence of volume of work on the outcome of treatment for patients with colorectal cancer
Br J Surg
Relation of surgeon and hospital volume to processes and outcomes of colorectal cancer surgery
Ann Surg
Reduction of postoperative morbidity and mortality in patients with rectal cancer following the introduction of a colorectal unit
Br J Surg
Evidence of the effect of ‘specialization’ on the management, surgical outcome and survival from colorectal cancer in Wessex
Br J Surg
Influence of caseload and surgical speciality on outcome following surgery for colorectal cancer: a review of evidence. Part 1: short-term outcome
Colorectal Dis
Influence of caseload and surgical speciality on outcome following surgery for colorectal cancer: a review of evidence. Part 2: long-term outcome
Colorectal Dis
The effect of provider case volume on cancer mortality: systematic review and meta-analysis
CA Cancer J Clin
A national perspective on the decline of abdominoperineal resection for rectal cancer
Ann Surg
Effect of surgeon and hospital factors on the outcome from the surgical management of colorectal cancer, in School of Medical Sciences
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