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.