Patients of more technically skilled surgeons, as assessed by review of operative video, have better long-term survival after surgery for the treatment of colon cancer, Northwestern Medicine researchers have found. Patients whose surgery was performed by a highly skilled surgeon had a 70 percent lower risk of dying over five years, compared to patients with a lower skilled surgeon. The study, ‘Association Between Surgical Technical Skill and Long-term Survival for Colon Cancer’, was published in JAMA Oncology and presented virtually at the Commission on Cancer Annual Meeting.
"This is pretty mind blowing, it may seem common sense in some ways, but we didn't realize the magnitude of the effect. The long-term effect is huge,” said lead author, Dr Karl Bilimoria, professor of surgery at Northwestern University Feinberg School of Medicine, a Northwestern Medicine surgical oncologist, director of the Surgical Outcomes and Quality Improvement Center of Northwestern and a member of the Robert H Lurie Comprehensive Cancer Center of Northwestern University. "Lots of experience with the procedure is a good marker of skill. General surgeons, colorectal surgeons and surgical oncologists all do colon cancer surgery, and there can be excellent cancer surgeons in each of those fields."
Although the importance of surgical skill has long been presumed, this is the first study, to the authors' knowledge, to demonstrate a surgeon's skill is important to long-term outcomes among patients undergoing cancer treatment surgery.
In a prior study the team conducted, there were 25% fewer short-term complications - such as a colon leak or bleeding - when a highly skilled surgeon performed the colon cancer operation.
One possible reason for the difference is that a skilled surgeon may be more likely to remove lymph nodes that contain colon cancer, said study first author, Dr Brian Brajcich, a Northwestern surgical resident and research fellow.
"A less skilled surgeon may not remove as many lymph nodes, potentially leaving behind cancer," he said. "Patients who would benefit from chemotherapy after surgery won't receive it if we don't know that the cancer has spread to the lymph node."
In the study, a surgeon's technical skill was scored based on review of video footage of colon surgery by other surgeons, including peers and expert reviewers. The outcomes of patients treated by surgeons with higher and lower skill scores were then compared.
Improving outcomes after surgery, especially cancer surgery, should include efforts targeting surgeons' technical skill. Comprehensive approaches to help surgeons improve their technical skill could include surgical coaching and the ability to review and discuss surgical video footage with peers and experts in the field.
The researcher added that further research is needed to determine whether efforts to improve surgical skill lead to improved technical skills and patient outcomes. Additionally, the actual methods to improve surgical skill need to be advanced and studied to determine whether they are effective at improving patient outcomes.
“This study demonstrates an association between surgical technical skill and long-term survival following cancer surgery. This association persists when excluding early postoperative deaths, suggesting that these findings are not solely attributable to mortality from surgical complications,” the authors concluded. “Study limitations include a small surgeon sample and skill assessment based on a single video. Skill may affect survival through oncologic resection quality (eg, lymph node harvesting) or may reflect surgeon characteristics, such as operative volume or guideline adherence. Additionally, fewer complications might reduce long-term morbidity affecting nutrition and physical function.”
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