The influence of surgeon volume on outcomes after pelvic exenteration for a gynecologic cancer

Abstract

ObjectiveTo determine the effect of surgeon experience on intraoperative, postoperative and long-term outcomes among patients undergoing pelvic exenteration for gynecologic cancer.MethodsThis was a retrospective analysis of all women who underwent exenteration for a gynecologic malignancy at MD Anderson Cancer Center, between January 1993 and June 2013. A logistic regression was used to model the relationship between surgeon experience (measured as the number of exenteration cases performed by the surgeon prior to a given exenteration) and operative outcomes and postoperative complications. Cox proportional hazards regression was used to model survival outcomes.ResultsA total of 167 exenterations were performed by 19 surgeons for cervix (78, 46.7%), vaginal (43, 25.8%), uterine (24, 14.4%), vulvar (14, 8.4%) and other cancer (8, 4.7%). The most common procedure was total pelvic exenteration (69.4%), incontinent urinary diversion (63.5%) and vertical rectus abdominis musculocutaneous reconstruction (42.5%). Surgical experience was associated with decreased estimated blood loss (p<0.001), intraoperative transfusion (p=0.009) and a shorter length of stay (p=0.03). No difference was noted in the postoperative complication rate (p=0.12–0.95). More surgeon experience was not associated with overall or disease specific survival: OS (hazard ratio [HR]=1.02; 95% confidence interval [CI]=0.97–1.06; p=0.46) and DSS (HR=1.01; 95% CI=0.97–1.04; p=0.66), respectively.ConclusionPatients undergoing exenteration by more experienced surgeons had improvement in intraoperative factors such as estimated blood loss, transfusion rates and length of stay. No difference was seen in postoperative complication rates, overall or disease specific survival.

Analysis of long-term outcomes in 44 patients following pelvic exenteration due to cervical cancer

“…Other complications included sepsis, thromboembolism, cardiac failure, shock, fistula, and abscess [13]. In a study by Jalloul et al, the types of complications most frequently seen were wound dehiscence (about 55% of cases), urostomy complication, and abscess [11]. In our study, we observed a similar profile of postoperative complications; the most frequently seen were wound complications, and as many as 19% treated due to cancer recurrence required surgical reintervention.…”

“…To increase the overall number of patients, many previous studies have included cases of PE for other types of pelvic malignancies (for example, rectal and ovarian cancers). This practice may be acceptable for reporting early surgical outcomes, but not for analyzing long-term prognostic factors [3,11]. In our study, we found a correlation between tumor histopathological type and the presence of vaginal fistula with long-term outcomes in cervical cancer patients following PE for cancer recurrence.…”

“…It has long been recognized that experienced surgeons working in high-volume hospitals offer a superior level of surgical technique associated with a lower rate of surgical complications, decreased operative mortality, and better long-term outcomes. However, using a logistic regression model to examine the potential relationship between surgical experience (assessed by the number of exenteration procedures the surgeon has performed) and long-term outcomes, Jalloul et al analyzed 167 pelvic exenteration procedures performed by 19 surgeons and were able to demonstrate that the surgeon's experience did not impact the postoperative complication rate [11]. Although surgical experience was associated with fewer intraoperative transfusions and shorter hospital stays, it was not found to impact patient OS or the rate of postoperative complications [11].…”

“…However, using a logistic regression model to examine the potential relationship between surgical experience (assessed by the number of exenteration procedures the surgeon has performed) and long-term outcomes, Jalloul et al analyzed 167 pelvic exenteration procedures performed by 19 surgeons and were able to demonstrate that the surgeon's experience did not impact the postoperative complication rate [11]. Although surgical experience was associated with fewer intraoperative transfusions and shorter hospital stays, it was not found to impact patient OS or the rate of postoperative complications [11]. Nevertheless, surgical experience is essential if the tumor nest is to be properly distinguished from radiation-induced fibrosis during the procedure.…”

Short‐ and long‐term outcomes of selective pelvic exenteration surgery in a low‐volume specialized tertiary setting

“…The impact of volume on PES outcomes has been previously reported. In an analysis of 167 exenterations performed by 19 surgeons for gynaecological malignancies at a single institution, higher individual surgeon volume was associated with an improvement in perioperative outcomes such as estimated blood loss, transfusion rates, and length of stay . However, this was assessed as a continuous variable and cutoffs for high versus low‐volume were not defined.…”