Association of Surgical Skill Assessment With Clinical Outcomes in Cancer Surgery

Abstract

IMPORTANCE Complex surgical interventions are inherently prone to variation yet they are not objectively measured. The reasons for outcome differences following cancer surgery are unclear.OBJECTIVE To quantify surgical skill within advanced laparoscopic procedures and its association with histopathological and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTSThis analysis of data and video from the Australasian Laparoscopic Cancer of Rectum (ALaCaRT) and 2-dimensional/3-dimensional (2D3D) multicenter randomized laparoscopic total mesorectal excision trials, which were conducted at 28 centers in Australia, the United Kingdom, and New Zealand, was performed from 2018 to 2019 and included 176 patients with clinical T1 to T3 rectal adenocarcinoma 15 cm or less from the anal verge. Case videos underwent blinded objective analysis using a bespoke performance assessment tool developed with a 62-international expert Delphi exercise and workshop, interview, and pilot phases.INTERVENTIONS Laparoscopic total mesorectal excision undertaken with curative intent by 34 credentialed surgeons.MAIN OUTCOMES AND MEASURES Histopathological (plane of mesorectal dissection, ALaCaRT composite end point success [mesorectal fascial plane, circumferential margin, Ն1 mm; distal margin, Ն1 mm]) and 30-day morbidity. End points were analyzed using surgeon quartiles defined by tool scores. RESULTSThe laparoscopic total mesorectal excision performance tool was produced and shown to be reliable and valid for the specialist level (intraclass correlation coefficient, 0.889; 95% CI, 0.832-0.926; P< .001). A substantial variation in tool scores was recorded (range, 25-48). Scores were associated with the number of intraoperative errors, plane of mesorectal dissection, and short-term patient morbidity, including the number and severity of complications. Upper quartile-scoring surgeons obtained excellent results compared with the lower quartile (mesorectal fascial plane: 93% vs 59%; number needed to treat [NNT], 2.9, P = .002; ALaCaRT end point success, 83% vs 58%; NNT, 4; P = .03; 30-day morbidity, 23% vs 50%; NNT, 3.7; P = .03). CONCLUSIONS AND RELEVANCEIntraoperative surgical skill can be objectively and reliably measured in complex cancer interventions. Substantial variation in technical performance among credentialed surgeons is seen and significantly associated with clinical and pathological outcomes.

Do surgical skills affect outcomes?

“…The composite histopathological success was significantly reduced in surgeons scoring in the lower quartile compared to the higher quartile (58% vs 83%), and they had higher 30‐day morbidity (50% vs 23%). We agree with the authors [15–18] that larger, well‐conducted trials are required to validate these results.…”

“…The principle of PBP training is to deconstruct a surgical procedure to operational defined performance metrics [19]. Unlike the performance assessment tool used by Curtis et al [18], the metrics used in PBP training are designed not only for the assessment but have detailed step-by-step guidance for the procedure. PBP training is different from most surgical curricula, such as the Intercollegiate Surgical Curriculum Programme [20], which is designed only for surgical trainees.…”

“…Several research groups have also observed this skill–outcome effect in hepatobiliary, urology and gastric procedures [15–17]. In the colorectal field, Curtis and colleagues [18] utilized patients’ videos (operative interventions) from two randomized studies. They assessed surgeons’ skills in performing laparoscopic total mesorectal excision correlated to histopathological outcomes and 30‐day morbidity.…”

Performance Improvement With Implementation of a Surgical Skills Curriculum

“… 4 Technical skill is highly variable among surgeons; better skills are associated with better patient outcomes. 5 , 6 , 7 Therefore, skill acquisition and optimization is a vital aspect of surgical training.…”

Novel Assessments of Technical and Nontechnical Cardiac Surgery Quality: Protocol for a Mixed Methods Study

“…Assessments, linked to data from the last 2 years of each surgeon’s experience, were significantly inversely associated with the surgeon’s adverse events and mortality outcomes. In another study, surgical skills were associated with outcomes from cancer surgery [ 10 ].…”