Institutional members access full text with Ovid®

Share this article on:

Surgeon Volume Does Not Predict Outcomes in the Setting of Technical Credentialing: Results From a Randomized Trial in Colon Cancer

Larson, David W. MD*; Marcello, Peter W. MD; Larach, Sergio W. MD; Wexner, Steven D. MD§; Park, Adrian MD; Marks, John MD; Senagore, Anthony J. MD**; Thorson, Alan G. MD††; Young-Fadok, Tonia M. MD, MS‡‡; Green, Erin MD§§; Sargent, Daniel J. PhD§§; Nelson, Heidi MD*

doi: 10.1097/SLA.0b013e31818a157d
Randomized Controlled Trials

Objective: To test the hypothesis that surgeon volume would not predict short- and long-term outcomes when evaluated in the setting of technical credentialing.

Summary Background Data: Surgical volume is a known predictor of outcomes; the importance of technical credentialing has not been evaluated.

Methods: Fifty-three credentialed surgeons operated on 871 patients in the Clinical Outcomes of Surgical Therapy Study (NCT00002575), investigating laparoscopic versus open surgery for colon cancer. Credentialing required that each surgeon document performance of at least 20 laparoscopic colon cases and demonstrate oncologic techniques on a video-recorded case. Surgeons were separated based on volume entered into the trial (low, ≤5 cases (n = 39); medium, 6–10 cases (n = 9); or high, >10 cases (n = 5)) and compared by outcomes.

Results: Patients treated by high volume compared with medium or low volume surgeons were older (70, 66, and 68 years; P < 0.001), more often had right-sided tumors (63%, 46%, and 53%; P < 0.001) and had more previous operations (48%, 38% and 45%; P < 0.004), respectively. Mean operative times were shorter (123, 147 and 145 minutes; P < 0.001), distal margins longer (13.4, 12.4 and 11.6 cm; P = 0.005), and lymph node harvest greater (14.8, 12.8, 12.6; P = 0.05) for high versus medium versus low volume surgeons. However, rates of conversion, complications, 5-year survival, and disease-free survival showed no significant differences.

Conclusion: When tested in a randomized controlled trial with case-specific surgical technical credentialing and auditing, surgeon volume did not predict differences in rates of conversion, complications, or long-term cancer outcomes. Case-specific technical credentialing should be further studied specific to the role it could play in creating consistent, high quality outcomes.

We hypothesized that surgeon volume would not predict outcomes in a randomized trial with credentialing. From the Clinical Outcomes of Surgical Therapy study, 871 patients were separated into groups based on surgeon volume. This did not predict differences in conversion, complications, or cancer outcomes. The relationship between credentialing and quality outcomes should be further considered.

From the *Division of Colon and Rectal Surgery, Mayo Clinic College of Medicine, Mayo Clinic Rochester, Rochester, Minnesota; †Department of Colon & Rectal Surgery, Lahey Clinic, Burlington, Massachusetts; ‡Florida Hospital Orlando, Orlando, Florida; §Department of Colorectal surgery, Cleveland Clinic Florida, Weston, Florida; ¶Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland; ∥Department of Colorectal surgery Main line Health system, Wynnewood, Pennsylvania; **Department of Surgery, Spectrum Health, Michigan State University, Grand Rapids, Michigan; ††Section of colon and rectal surgery, Department of Surgery, Creighton University School of medicine, Omaha, Nebraska; ‡‡Division of Colon and Rectal Surgery, Mayo Clinic Scottsdale, Scottsdale, Arizona; and the §§Division of Biostatistics, Mayo Clinic College of Medicine, Mayo Clinic Rochester, Rochester, Minnesota.

Correspondence: David W. Larson, MD, Assistant Professor of Surgery, Department of Surgery, Division of Colorectal surgery, Mayo Clinic, 200 First Street SW, Rochester MN, 55905. E-mail:

© 2008 Lippincott Williams & Wilkins, Inc.