Impact of Surgeon Specialty on Perioperative Outcomes of Surgery for Benign Esophageal Diseases: A NSQIP Analysis

Introduction

Previous studies have tried to address the relationship between specialty training and patient outcomes^1,2 or assess whether the result of an operation is influenced by it being performed by a general or specialty-trained surgeons.^3–7 Esophageal surgery, in fact, encompasses a large group of operations for either benign or malignant diseases and in the United States, these are performed, for the most part, either by general surgeons (GS) or cardiothoracic surgeons (CTS). Multiple studies analyzed the relationship between specialty training and patient outcomes in esophagectomy,^8–11 Most of them have shown that specialty matters and better outcomes are achieved when esophagectomy is performed by specialty-trained surgeons. It is unknown, however, if specialty is always better, or just only for complex procedures. To our knowledge, no previous reports have studied the relationship between surgical training and other common esophageal operations. Gastroesophageal reflux disease (GERD) is the most common gastrointestinal outpatient diagnosis in the U.S. and the prevalence of hiatal hernias in the population range from 10% to 50%. ¹² Achalasia also shows a rising prevalence due to the improvement in diagnostic tools. ¹³ Therefore, the purpose of this study was to compare the perioperative outcomes of esophageal surgery for the most common benign esophageal diseases (paraesophageal hernia (PEH), gastroesophageal reflux disease, and achalasia) between GS and CTS in the United States.

Material and Methods

Results

Discussion

In this study we compared the perioperative outcomes of surgeries for benign esophageal diseases between GS group and CTS group. Most of the esophageal surgeries for benign diseases were performed by GS (97.1% of paraesophageal hernias, 97.6% of gastric fundoplications, and 91.6% of Heller esophagomyotomies). For PEH surgery, GS group showed lower mortality rates, less morbidity in terms of return to the OR and shock, shorter LOS, and higher home discharge. Both groups had similar 30-day mortality, overall morbidity, LOS, and readmission rates for gastric fundoplication and Heller esophagomyotomy. These interesting results suggest that specialization per se might not be a determinant factor to influence outcome of esophageal surgery for benign esophageal diseases.

Previous studies have compared outcomes of esophagectomy between general and thoracic surgeons in the United States. Dimick et al. ⁸ concluded that although thoracic surgeons had better mortality odds, hospital and surgeon's volume had a higher influence on mortality. Gopaldas et al. ⁹ affirmed that surgeon subspecialty was associated with mortality and failure to rescue (defined as death from complication). They reported a reduction in both parameters in higher hospital and surgeon volume and in surgeons with a predominant cardiac and thoracic surgery practice. Ferraris et al. ¹⁵ showed that when patients were matched for comorbidities and serious preoperative risk factors, thoracic surgeons had improved outcomes. Smith et al. ¹⁰ on the other hand, using the University Health system Consortium (UHC) clinical database, concluded that while thoracic surgeons favored Ivor Lewis approach and general surgeons the blunt transhiatal approach, specialty training did not seem to affect outcomes of esophagectomy. Using again NSQIP database and evaluating over 5000 esophagectomies, we also previously showed that some specific morbidities and LOS were higher for surgery performed by GS. ¹¹ All of the aforementioned studies compared the outcomes of a very complex surgery such as esophagectomy, and data support that complicated cases are better treated by specialist surgeons. However, is this also true for less complicated surgeries?

Overall surgery for benign esophageal diseases shows very low morbidity and 30-day mortality in previously reported large series of patients.^16–18 It is possible that for surgeries that are not technically complex, specialization does not offer significant short-term benefits. However, the impact of specialization on long-term outcomes remains unknown.

It is worth to mention, however, that GS favored the minimally invasive approach and operated on healthier and younger patients compared with CTS. Moreover, case complexity as the size of the paraesophageal hernia or a previous failed repair was not accounted for and may have significantly affected the approach choice as well as the outcome. A more complex hernia in fact may have been more frequently referred to a thoracic surgeon and a transthoracic approach preferred either due to the hernia complexity or the surgeon's personal preference. A transthoracic approach, especially an open thoracotomy, is associated with higher odds of morbidity than a laparoscopic approach. Mungo et al., ¹⁹ in fact, showed that a transthoracic approach for repair of paraesophageal hernias had significantly increased odds of overall (OR 2.73 95% CI 1.88–3.96) and serious morbidity (OR 2.49 95% CI 1.54–4.00) compared with the laparoscopic approach. Although a thoracotomy might be necessary in case of multiple previous abdominal PEH repairs or other abdominal surgeries, a paraesophageal hernia, which was never treated before, might still be repaired through a thoracotomy if referred to a thoracic surgeon who is not familiar with laparoscopic techniques.

Our results might also reflect a volume–outcome relationship. The inverse association between hospital/surgeons volume and postoperative mortality has been well established for most complex surgeries. ²⁰ Esophagectomy is not an exception, and there is consensus that surgeons/hospitals with higher volume of patients do have better outcomes.^21,22 Even if this relationship has never been demonstrated for esophageal surgery done for benign disease, it is logical to think that volume has a positive influence on outcomes for this type of surgery–and most cases are done by GS in the United States. Regrettably, we were not able to distinguish the surgeon's or hospital's volume in our series and account for differences across groups.

The results of our study should be interpreted in light of some limitations. First, NSQIP does not provide data on the center or surgeon volume, which might affect the relation between specialty training and surgical outcomes. It also does not provide information about esophageal fellowship training without a corresponding Board (i.e., surgical oncology, gastrointestinal surgery), preventing us to account for specific surgical skills. Second, this administrative database does not provide long-term outcomes, it only measures short-term outcomes with 30 postoperative days follow-up and since these surgeries have a very low risk of perioperative morbidities, long-term outcomes might be a more relevant target to investigate. Finally, details about the complexity of cases (type of PEH, reoperations after failed previous surgery, previous abdominal or thoracic surgery, etc.) are not provided by NSQIP, and possibly more difficult cases might have been referred with higher frequency to a specialized surgeon, therefore introducing confounders in our study. However, to our knowledge, our study is the first study that looked at the effect of specialty training on the outcomes of surgeries for benign esophageal diseases. Beside the limitations of the ACS-NSQIP, it is a nationally validated database specifically designed for surgical outcomes with a large sample of esophageal operations from different hospital categories in the United States, which added unique advantages to our study. For this reason, we believe our study provides additional information to the current literature.

In conclusion, general surgeons treat most of the benign esophageal diseases like GERD, achalasia, and paraesophageal hernias in the United States. Our data show that GS group have lower mortality rates, shorter hospital LOS, and higher home discharge for PEH operations and slightly better specific morbidity for PEH and fundoplications. However, older sicker patients with more severe disease handled by thoracic surgeons more frequently might explain these differences. Most certainly the more frequent use of the laparoscopic approach and the higher volume of cases are positive factors in favor of GS. Case complexity, surgeon's volume, and long-term outcomes are not measurable with NSQIP and other large volume databases should be used to better understand the role of specialization in benign foregut surgery.