Skip to main content
SpringerLink
Log in

Surgical team proficiency in minimally invasive esophagectomy is related to case volume and improves patient outcomes

  • Original Article
  • Published:
Esophagus Aims and scope Submit manuscript

Abstract

Background

Minimally invasive esophagectomy (MIE) is being increasingly performed; however, it is still associated with high morbidity and mortality. The correlation between surgical team proficiency and patient load lacks clarity. This study evaluates surgical outcomes during the first 3-year period after establishment of a new surgical team.

Methods

A new surgical team was established in September 2013 by two expert surgeons having experience of performing more than 100 MIEs. We assessed 237 consecutive patients who underwent MIE for esophageal cancer and evaluated the impact of surgical team proficiency on postoperative outcomes, as well as the team learning curve.

Results

In the cumulative sum analysis, a point of downward inflection for operative time and blood loss was observed in case 175. After 175 cases, both operative time and blood loss significantly decreased (P < 0.001 and P < 0.001, respectively), and postoperative incidence of pneumonia significantly decreased from 18.9 to 6.5% (P = 0.024). Median postoperative hospital stay also decreased from 20 to 18 days (P = 0.022). Additionally, serum CRP levels on postoperative day 1 showed a significant, but weak inverse association with the number of cases (P = 0.024).

Conclusions

After 175 cases, both operative time and blood loss significantly decreased. In addition, the incidence of pneumonia decreased significantly. Additionally, surgical team proficiency may decrease serum CRP levels immediately after MIE. Surgical team proficiency based on team experience had beneficial effects on patients undergoing MIE.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med. 2011;364:2128–37.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Jafari MD, Halabi WJ, Smith BR, et al. A decade analysis of trends and outcomes of partial versus total esophagectomy in the United States. Ann Surg. 2013;258:450–8.

    Article  PubMed  Google Scholar 

  3. Takeuchi H, Miyata H, Gotoh M, et al. A risk model for esophagectomy using data of 5354 patients included in a Japanese nationwide web-based database. Ann Surg. 2014;260:259–66.

    Article  PubMed  Google Scholar 

  4. Visser E, van Rossum PSN, Verhoeven RHA, et al. Impact of weekday of esophagectomy on short-term and long-term oncological outcomes: a nationwide population-based cohort study in the Netherlands. Ann Surg. 2017;266:76–81.

    Article  PubMed  Google Scholar 

  5. Cuschieri A, Shimi S, Banting S. Endoscopic oesophagectomy through a right thoracoscopic approach. J R Coll Surg Edinb. 1992;37:7–11.

    CAS  PubMed  Google Scholar 

  6. Biere SS, van Berge Henegouwen MI, Maas KW, et al. Minimally invasive versus open oesophagectomy for patients with esophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet. 2012;379:1887–92.

    Article  PubMed  Google Scholar 

  7. Takeuchi H, Miyata H, Ozawa S, et al. Comparison of short-term outcomes between open and minimally invasive esophagectomy for esophageal cancer using a nationwide database in Japan. Ann Surg Oncol. 2017;24:1821–7.

    Article  PubMed  Google Scholar 

  8. Derogar M, Sadr-Azodi O, Johar A, et al. Hospital and surgeon volume in relation to survival after esophageal cancer surgery in a population-based study. J Clin Oncol. 2013;31:551–7.

    Article  PubMed  Google Scholar 

  9. Henneman D, Dikken JL, Putter H, et al. Centralization of esophagectomy: how far should we go? Ann Surg Oncol. 2014;21:4068–74.

    Article  PubMed  Google Scholar 

  10. Mamidanna R, Ni Z, Anderson O, et al. Surgeon volume and cancer esophagectomy, gastrectomy, and pancreatectomy: a population-based study in England. Ann Surg. 2016;263:727–32.

    Article  PubMed  Google Scholar 

  11. Nishigori T, Miyata H, Okabe H, et al. Impact of hospital volume on risk-adjusted mortality following oesophagectomy in Japan. Br J Surg. 2016;103:1880–6.

    Article  CAS  PubMed  Google Scholar 

  12. Osugi H, Takemura M, Higashino M, et al. Learning curve of video-assisted thoracoscopic esophagectomy and extensive lymphadenectomy for squamous cell cancer of the thoracic esophagus and results. Surg Endosc. 2003;17:515–9.

    Article  CAS  PubMed  Google Scholar 

  13. Ninomiya I, Osugi H, Tomizawa N, et al. Learning of thoracoscopic radical esophagectomy: how can the learning curve be made short and flat? Dis Esophagus. 2010;23:618–26.

    Article  CAS  PubMed  Google Scholar 

  14. Tapias LF, Morse CR. Minimally invasive Ivor Lewis esophagectomy: description of a learning curve. J Am Coll Surg. 2014;218:1130–40.

    Article  PubMed  Google Scholar 

  15. Oshikiri T, Yasuda T, Yamamoto M, et al. Trainee competence in thoracoscopic esophagectomy in the prone position: evaluation using cumulative sum techniques. Langenbecks Arch Surg. 2016;401:797–804.

    Article  PubMed  Google Scholar 

  16. Markar SR, Mackenzie H, Lagergren P, et al. Surgical proficiency gain and survival after esophagectomy for cancer. J Clin Oncol. 2016;34:1528–36.

    Article  PubMed  Google Scholar 

  17. Mackenzie H, Markar SR, Askari A, et al. National proficiency-gain curves for minimally invasive gastrointestinal cancer surgery. Br J Surg. 2016;103:88–96.

    Article  CAS  PubMed  Google Scholar 

  18. van Workum F, Stenstra M, Berkelmans GHK, et al. Learning curve and associated morbidity of minimally invasive esophagectomy: a retrospective multicenter study. Ann Surg. 2017. https://doi.org/10.1097/SLA.0000000000002469.

    PubMed  Google Scholar 

  19. Sobin LH, Gospodarowicz MK, Wittekind C. TNM classification of malignant tumours. 7th ed. New York: Wiley-Blackwell; 2010.

    Google Scholar 

  20. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Toh Y, Sakaguchi Y, Ikeda O, et al. The triangulating stapling technique for cervical esophagogastric anastomosis after esophagectomy. Surg Today. 2009;39:201–6.

    Article  PubMed  Google Scholar 

  22. Yoshida N, Baba Y, Watanabe M, et al. Triangulating stapling technique covered with the pedicled omental flap for esophagogastric anastomosis: a safe anastomosis with fewer complications. J Am Coll Surg. 2015;220:e13–6.

    Article  PubMed  Google Scholar 

  23. Bokhari MB, Patel CB, Ramos-Valadez DI, et al. Learning curve for robotic-assisted laparoscopic colorectal surgery. Surg Endosc. 2011;25:855–60.

    Article  PubMed  Google Scholar 

  24. Okrainec A, Ferri LE, Feldman LS, et al. Defining the learning curve in laparoscopic paraesophageal hernia repair: a CUSUM analysis. Surg Endosc. 2011;25:1083–7.

    Article  PubMed  Google Scholar 

  25. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med. 2002;137:511–20.

    Article  PubMed  Google Scholar 

  26. Law S, Wong KH, Kwok KF, et al. Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer. Ann Surg. 2004;240:791–800.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Yoshida N, Watanabe M, Baba Y, et al. Risk factors for pulmonary complications after esophagectomy for esophageal cancer. Surg Today. 2014;44:526–32.

    Article  PubMed  Google Scholar 

  28. Okamura A, Takeuchi H, Matsuda S, et al. Factors affecting cytokine change after esophagectomy for esophageal cancer. Ann Surg Oncol. 2015;22:3130–5.

    Article  PubMed  Google Scholar 

  29. Gelpke H, Grieder F, Decurtins M, et al. Recurrent laryngeal nerve monitoring during esophagectomy and mediastinal lymph node dissection. World J Surg. 2010;34:2379–82.

    Article  PubMed  Google Scholar 

  30. Moorman DW. Building better teams in surgery. J Gastrointest Surg. 2009;13:12–3.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute, Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan

    Akihiko Okamura, Masayuki Watanabe, Ian Fukudome, Kotaro Yamashita, Masami Yuda, Masaru Hayami, Yu Imamura & Shinji Mine

Authors
  1. Akihiko Okamura
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Masayuki Watanabe
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ian Fukudome
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kotaro Yamashita
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Masami Yuda
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Masaru Hayami
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Yu Imamura
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Shinji Mine
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Masayuki Watanabe.

Ethics declarations

Ethical Statement

All procedures were performed in accordance with the ethical standards of our institutional review board and with the Helsinki Declaration of 1964 and later versions. All authors followed the policy concerning Informed Consent.

Conflict of interest

All authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Okamura, A., Watanabe, M., Fukudome, I. et al. Surgical team proficiency in minimally invasive esophagectomy is related to case volume and improves patient outcomes. Esophagus 15, 115–121 (2018). https://doi.org/10.1007/s10388-018-0607-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10388-018-0607-y

Keywords

Search

Navigation