Decreased Operative Mortality for Esophageal Cancer Resection at Hospitals with Thoracic Training Programs: Should Esophagectomies Only be Performed by Thoracic Surgeons?
Robert A. Meguid, Eric C. Weiss, Stephen M. Cattaneo, Marc S. Sussman, Malcolm V. Brock, Stephen C. Yang; Division of Thoracic Surgery, Johns Hopkins University, School of Medicine, Baltimore, MD
Comment on this Abstract
Objective: Historically, esophageal cancer surgery has been performed by both general and thoracic surgeons. Lower mortality for esophageal resection has been demonstrated at high-volume centers and for specialty-trained surgeons. It is unclear if this distinction holds true at centers with thoracic residency programs. Therefore, we studied outcomes after esophageal cancer resection stratified by surgical residency type.
Methods: Data on esophageal cancer resections in the Nationwide Inpatient Sample dataset (1998-2005) were enriched with data from the Accreditation Council for Graduate Medical Education to reliably identify presence of thoracic surgery (TS) and general surgery (GS) residency programs. The association of hospital teaching status with postoperative in-hospital mortality was assessed via multivariate logistic regression, adjusting for patient demographics and comorbidities.
Results: Of 4,080 esophagectomies, 48% were performed at GS-hospitals, 32% at TS-hospitals (all hospitals with TS residencies also had GS residencies) and 34% at GS-hospitals without TS residencies. Postoperative mortality was significantly lower at GS vs. non-GS-hospitals (7.4% vs. 11.1%; P<0.001) and at TS vs. non-TS-hospitals (6.2% vs. 10.8%; P<0.001). At GS-hospitals without TS residencies, mortality rate was significantly higher than TS-hospitals (9.8% vs. 6.2%; P=0.01). On multivariate regression, overall risk of postoperative death was independently reduced by 38% at GS vs. non-GS-hospitals [Odds Ratio (OR) 0.62, 95% confidence interval (CI) 0.46-0.83; P=0.001] and by 45% at TS vs. non-TS-hospitals (OR 0.55, 95% CI 0.40-0.75; P<0.001). TS-hospitals did not confer a statistically significant protective effect when compared to GS-hospitals without TS residencies.
Conclusion: In-hospital mortality is reduced for patients undergoing esophagectomy for cancer at teaching hospitals with thoracic and/or general surgery residencies. However, the greatest reduction in risk of death was at hospitals with thoracic surgery residencies, as opposed to those with general surgery residencies only. These data may serve to stimulate further study into the processes of care associated with these settings, as well as shape esophageal cancer patient-preference toward treatment by thoracic surgeons.
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