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Surgical Proficiency in the Era of Centralization

Publication: Journal of Clinical Oncology

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To the Editor:

The recent study by Markar et al1 sought to determine at what point surgical proficiency was obtained when performing esophagectomy. This is of importance in all surgical specialties, and there are numerous factors that contribute to proficiency. This study was expansive, including all the surgeons within Sweden over a 23-year period. There are inherent problems with trying to extrapolate meaningful conclusions from such a database.
There is no recognition of the level of training that surgeons had obtained before commencing independent operating. This is of paramount importance because the experience gained in training is likely to heavily influence future practice. However, it is not just about experience gained in the operating theater, but also experience gained in managing the variety of difficult complications that are related to esophagectomy.
Furthermore, there is no correlation with the volume of work at surgical units. Short-term outcomes are heavily reliant on surgical selection and postoperative management as well as the actual surgery performed. It is well known that high-volume units have better outcomes.2,3 This is not only related to having more experienced surgeons, but also a result of a more experienced multidisciplinary team that will influence patient selection and can recognize and manage potentially life-threatening complications. Thus, the impact on short-term mortality of being operated on by a less-experienced surgeon should be mitigated by the experience of a whole unit.
Marker et al1 have alluded to the impact of higher lymph node yield with more experienced surgeons, which may consequently impact long-term outcomes. This is a controversial issue, and we would suggest that it is not only the yield that is important, but also the extent of lymphadenectomy.4 It is likely that this extent will have become ingrained through training and is unlikely to change over the course of a surgeon’s career. Furthermore, lymph node yield within this cohort of patients is extremely low, with the first three quartiles obtaining up to 15 nodes.5 This not only leads to understaging, but also may compromise cure. This low yield must be especially acknowledged in this cohort where the proportion of patients receiving neoadjuvant treatment is small.
It is difficult to discern from the data the number of esophagectomies performed by surgeons annually. The median number of operations is 16, which equates to less than one esophagectomy per year of the study, and even the highest-volume surgeon performs potentially a mean of 11 esophagectomies per year. The time over which each surgeon’s resectional total is achieved is an important consideration because a surgeon who reaches a total of 15 resections over several months is likely to attain and maintain a higher standard of practice than a surgeon who attains 15 resections over several years. Centralization of esophagectomy, which has long been advocated, should ensure that surgeons are performing the procedure regularly in high-volume units, and this should impact profoundly on both short- and long-term outcomes. In the United Kingdom, a minimum of 60 resections per center per year has been advocated.6
It is also not indicated what proportion of surgeons met their critical number of cases for short-term (15 and 22 esophagectomies) or long-term (35 and 53 esophagectomies) improvement of outcomes. Furthermore, what were the outcomes of those surgeons in their initial operations, up to the thresholds suggested, compared with surgeons in the cohort that never exceed the thresholds? Is this finding a function of surgeons operating in high-volume centers versus those operating in low-volume centers?
The authors’ suggestion that a competency-based program in surgical training would minimize potential harm to patients is at odds to the main message of the article—that is, increased experience leads to improved outcomes.1 We would agree with this ethos, and although it may be possible for particularly talented surgeons to achieve competency (which remains ill defined) with fewer cases, it is important that a bank of experience is obtained before independent practice. Mentorship is certainly an important component that should be available to all new surgeons as they adjust from being a trainee to independent practitioner.
There is no doubt that increased experience is likely to lead to increased proficiency. However, it is important to realize that time taken to reach competency is different for each individual and depends not only a surgeon’s aptitude but also the training he or she receives. It is important that surgeons are trained in high-volume centers that can provide them with a breadth of experience and ensure optimum patient outcomes.

Authors' Disclosures of Potential Conflicts of Interest

Surgical Proficiency in the Era of Centralization

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to or

Alexander W. Phillips

No relationship to disclose

Barry Dent

No relationship to disclose

Maziar Navidi

No relationship to disclose

S. Michael Griffin

No relationship to disclose


Markar SR, Mackenzie H, Lagergren P, et al: Surgical proficiency gain and survival after esophagectomy for cancer. J Clin Oncol 34:1528-1536, 2016
Dikken JL, Dassen AE, Lemmens VE, et al: Effect of hospital volume on postoperative mortality and survival after oesophageal and gastric cancer surgery in the Netherlands between 1989 and 2009. Eur J Cancer 48:1004-1013, 2012
Wouters MW, Gooiker GA, van Sandick JW, et al: The volume-outcome relation in the surgical treatment of esophageal cancer: A systematic review and meta-analysis. Cancer 118:1754-1763, 2012
Phillips AW, Lagarde SM, Navidi M, et al: Impact of extent of lymphadenectomy on survival post neoadjuvant chemotherapy and trans-thoracic esophagectomy. Ann Surg [e-pub ahead of print on April 25, 2016] doi:
van der Schaaf M, Johar A, Wijnhoven B, et al: Extent of lymph node removal during esophageal cancer surgery and survival. J Natl Cancer Inst 107:djv043, 2015
Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland: Guidance on minimum surgeon volumes.

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Published In

Journal of Clinical Oncology
Pages: 3939 - 3940
PubMed: 27573655


Published online: August 29, 2016
Published in print: November 10, 2016


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Alexander W. Phillips [email protected]
Alexander W. Phillips, Barry Dent, Maziar Navidi, and S. Michael Griffin, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
Barry Dent
Alexander W. Phillips, Barry Dent, Maziar Navidi, and S. Michael Griffin, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
Maziar Navidi
Alexander W. Phillips, Barry Dent, Maziar Navidi, and S. Michael Griffin, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
S. Michael Griffin
Alexander W. Phillips, Barry Dent, Maziar Navidi, and S. Michael Griffin, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom


Corresponding author: Alexander W. Phillips, MA, Northern Oesophagogastric Unit, Royal Victoria Infirmary, Victoria Rd, Newcastle upon Tyne, NE1 4LP, United Kingdom; e-mail: [email protected].

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Alexander W. Phillips, Barry Dent, Maziar Navidi, S. Michael Griffin
Journal of Clinical Oncology 2016 34:32, 3939-3940

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