Skip to main content

Advertisement

SpringerLink
Log in

The role of caseload in determining outcome following laparoscopic colorectal cancer resection: an observational study

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

This study aimed to evaluate using national data the role of surgeon laparoscopic caseload in determining outcome following elective laparoscopic colorectal cancer resection.

Methods

All patients who underwent an elective laparoscopic primary colorectal cancer resection between 2002 and 2008 were included from the Hospital Episode Statistics database. Surgeon teams were divided into tertiles according to the mean laparoscopic caseload per year. High volume corresponded to more than 12 laparoscopic procedures per year and low volume corresponded to seven or fewer procedures per year. Outcome measures were 30-day in-hospital mortality, return to theatre (RTT), 30-day medical morbidity, 365-day medical morbidity, length of stay (LOS), and unplanned 28-day readmission.

Results

There was a significant increase in the number of surgeons selecting patients for the laparoscopic approach between 2002–2003 and 2007–2008. In 2002–2003, a total of 41 surgeon teams performed laparoscopic resections whereas in 2007–2008 there were 398 surgeon teams. The patients of high-volume surgeon teams had a shorter LOS [OR 0.88 (0.85–0.91), p < 0.0001]. Patients of medium-volume surgeon teams had the highest medical morbidity rates [30-day medical morbidity: OR 1.24 (1.04–1.48), p = 0.015; 365-day medical morbidity: OR 1.22 (1.04–1.45), p = 0.018]. There were no differences between the high- and low-volume groups in terms of mortality, morbidity, RTT, or readmission.

Conclusion

Although there has been a significant increase in the number of surgeon teams offering the minimal access approach, this study has not found a consistent relationship between surgeon laparoscopic cancer surgery caseload and outcome.

What’s new in this manuscript

This is the first national study to explore the role of surgical volume in determining outcome following laparoscopic surgery. This study questions the impact of surgeon caseload on laparoscopic surgical outcome.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Abraham NS, Young JM, Solomon MJ (2004) Meta-analysis of short-term outcomes after laparoscopic resection for colorectal cancer. Br J Surg 91(9):1111–1124

    Article  CAS  PubMed  Google Scholar 

  2. Schwenk W, Haase O, Neudecker J, Muller JM (2005) Short term benefits for laparoscopic colorectal resection. Cochrane Database Syst Rev 3:CD003145

    PubMed  Google Scholar 

  3. Faiz O, Warusavitarne J, Bottle A, Tekkis PP, Darzi AW, Kennedy RH (2009) Laparoscopically assisted vs. open elective colonic and rectal resection: a comparison of outcomes in English National Health Service Trusts between 1996 and 2006. Dis Colon Rectum 52(10):1695–1704

    Article  CAS  PubMed  Google Scholar 

  4. Jayne DG, Thorpe HC, Copeland J, Quirke P, Brown JM, Guillou PJ (2010) Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br J Surg 97(11):1638–1645

    Article  CAS  PubMed  Google Scholar 

  5. Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Smith AM et al (2007) Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol 25(21):3061–3068

    Article  PubMed  Google Scholar 

  6. Bonjer HJ, Hop WC, Nelson H, Sargent DJ, Lacy AM, Castells A et al (2007) Laparoscopically assisted vs open colectomy for colon cancer: a meta-analysis. Arch Surg 142(3):298–303

    Article  PubMed  Google Scholar 

  7. Borowski DW, Bradburn DM, Mills SJ, Bharathan B, Wilson RG, Ratcliffe AA et al (2010) Volume-outcome analysis of colorectal cancer-related outcomes. Br J Surg 97(9):1416–1430

    Article  CAS  PubMed  Google Scholar 

  8. Chowdhury MM, Dagash H, Pierro A (2007) A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg 94(2):145–161

    Article  CAS  PubMed  Google Scholar 

  9. Faiz O, Brown T, Bottle A, Burns EM, Darzi AW, Aylin P (2010) Impact of hospital institutional volume on postoperative mortality after major emergency colorectal surgery in English National Health Service Trusts, 2001 to 2005. Dis Colon Rectum 53(4):393–401

    Article  PubMed  Google Scholar 

  10. Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I et al (2002) Hospital volume and surgical mortality in the United States. N Engl J Med 346(15):1128–1137

    Article  PubMed  Google Scholar 

  11. Archampong D, Borowski DW, Dickinson HO (2010) Impact of surgeon volume on outcomes of rectal cancer surgery: a systematic review and meta-analysis. Surgeon 8(6):341–352

    Article  CAS  PubMed  Google Scholar 

  12. Stocchi L, Nelson H, Sargent DJ, O’Connell MJ, Tepper JE, Krook JE et al (2001) Impact of surgical and pathologic variables in rectal cancer: a United States community and cooperative group report. J Clin Oncol 19(18):3895–3902

    CAS  PubMed  Google Scholar 

  13. Martling A, Holm T, Rutqvist LE, Johansson H, Moran BJ, Heald RJ et al (2005) Impact of a surgical training programme on rectal cancer outcomes in Stockholm. Br J Surg 92(2):225–229

    Article  CAS  PubMed  Google Scholar 

  14. Schrag D, Panageas KS, Riedel E, Cramer LD, Guillem JG, Bach PB et al (2002) Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection. Ann Surg 236(5):583–592

    Article  PubMed  Google Scholar 

  15. Meyerhardt JA, Catalano PJ, Schrag D, Ayanian JZ, Haller DG, Mayer RJ et al (2003) Association of hospital procedure volume and outcomes in patients with colon cancer at high risk for recurrence. Ann Intern Med 139(8):649–657

    Article  PubMed  Google Scholar 

  16. Panageas KS, Schrag D, Riedel E, Bach PB, Begg CB (2003) The effect of clustering of outcomes on the association of procedure volume and surgical outcomes. Ann Intern Med 139(8):658–665

    Article  PubMed  Google Scholar 

  17. Kuhry E, Bonjer HJ, Haglind E, Hop WC, Veldkamp R, Cuesta MA et al (2005) Impact of hospital case volume on short-term outcome after laparoscopic operation for colonic cancer. Surg Endosc 19(5):687–692

    Article  CAS  PubMed  Google Scholar 

  18. McGrath DR, Leong DC, Gibberd R, Armstrong B, Spigelman AD (2005) Surgeon and hospital volume and the management of colorectal cancer patients in Australia. ANZ J Surg 75(10):901–910

    Article  PubMed  Google Scholar 

  19. Hermanek P, Hohenberger W (1996) The importance of volume in colorectal cancer surgery. Eur J Surg Oncol 22(3):213–215

    Article  CAS  PubMed  Google Scholar 

  20. Parry JM, Collins S, Mathers J, Scott NA, Woodman CB (1999) Influence of volume of work on the outcome of treatment for patients with colorectal cancer. Br J Surg 86(4):475–481

    Article  CAS  PubMed  Google Scholar 

  21. Tekkis PP, Senagore AJ, Delaney CP, Fazio VW (2005) Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg 242(1):83–91

    Article  PubMed  Google Scholar 

  22. Schlachta CM, Mamazza J, Seshadri PA, Cadeddu M, Gregoire R, Poulin EC (2001) Defining a learning curve for laparoscopic colorectal resections. Dis Colon Rectum 44(2):217–222

    Article  CAS  PubMed  Google Scholar 

  23. Finlayson SR, Birkmeyer JD (1997) The learning curve for laparoscopic colorectal surgery. Arch Surg 132(8):931 author reply 2

    CAS  PubMed  Google Scholar 

  24. Yasunaga H, Matsuyama Y, Ohe K (2009) Effects of hospital and surgeon volumes on operating times, postoperative complications, and length of stay following laparoscopic colectomy. Surg Today 39(11):955–961

    Article  PubMed  Google Scholar 

  25. Almoudaris AM, Burns EM, Bottle A, Aylin P, Darzi A, Faiz O (2011) A colorectal perspective on voluntary submission of outcome data to clinical registries. Br J Surg 98(1):132–139

    Article  CAS  PubMed  Google Scholar 

  26. Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K (2009) Impact of hospital case volume on the quality of laparoscopic colectomy in Japan. J Gastrointest Surg 13(9):1619–1626

    Article  PubMed  Google Scholar 

  27. Larson DW, Marcello PW, Larach SW, Wexner SD, Park A, Marks J et al (2008) Surgeon volume does not predict outcomes in the setting of technical credentialing: results from a randomized trial in colon cancer. Ann Surg 248(5):746–750

    Article  PubMed  Google Scholar 

  28. Burns EM, Naseem H, Bottle A, Lazzarino AI, Aylin P, Darzi A et al (2010) Introduction of laparoscopic bariatric surgery in England: observational population cohort study. BMJ 341:c4296

    Article  PubMed  Google Scholar 

  29. Burns EM, Bottle A, Aylin P, Clark SK, Tekkis PP, Darzi A et al (2011) Volume analysis of outcome following restorative proctocolectomy. Br J Surg 98(3):408–417

    Article  CAS  PubMed  Google Scholar 

  30. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383

    Article  CAS  PubMed  Google Scholar 

  31. Carstairs V, Morris R (1989) Deprivation: explaining differences in mortality between Scotland and England and Wales. BMJ 299(6704):886–889

    Article  CAS  PubMed  Google Scholar 

  32. Burns EM, Bottle A, Aylin P, Darzi A, Nicholls RJ, Faiz O (2011) Variation in reoperation after colorectal surgery in England as an indicator of surgical performance: retrospective analysis of Hospital Episode Statistics. BMJ 343:d4836

    Article  PubMed Central  PubMed  Google Scholar 

  33. Mamidanna R, Burns EM, Bottle A, Aylin P, Stonell C, Hanna GB et al (2012) Reduced risk of medical morbidity and mortality in patients selected for laparoscopic colorectal resection in England: a population-based study. Arch Surg 147(3):219–227

    Article  PubMed  Google Scholar 

  34. Bilimoria KY, Bentrem DJ, Merkow RP, Nelson H, Wang E, Ko CY et al (2008) Laparoscopic-assisted vs. open colectomy for cancer: comparison of short-term outcomes from 121 hospitals. J Gastrointest Surg 12(11):2001–2009

    Article  PubMed  Google Scholar 

  35. Hewett PJ, Allardyce RA, Bagshaw PF, Frampton CM, Frizelle FA, Rieger NA et al (2008) Short-term outcomes of the Australasian randomized clinical study comparing laparoscopic and conventional open surgical treatments for colon cancer: the ALCCaS trial. Ann Surg 248(5):728–738

    Article  PubMed  Google Scholar 

  36. Braga M, Vignali A, Gianotti L, Zuliani W, Radaelli G, Gruarin P et al (2002) Laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome. Ann Surg 236(6):759–766 disscussion 767

    Article  PubMed  Google Scholar 

  37. Lacy AM, Garcia-Valdecasas JC, Delgado S, Castells A, Taura P, Pique JM et al (2002) Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 359(9325):2224–2229

    Article  PubMed  Google Scholar 

  38. Clinical Outcomes of Surgical Therapy Study Group (2004) A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350(20):2050–2059

    Article  Google Scholar 

  39. National Institute for Health and Clinical Excellence (2006) Colorectal cancer - laparoscopic surgery (review of TA17) (TA105). Available at http://guidance.nice.org.uk/TA105. Accessed 1 Mar 2013

  40. National Training Programme in Laparoscopic Colorectal Surgery (2013). http://www.lapco.nhs.uk/. Accessed 1 Mar 2013

  41. Campbell SE, Campbell MK, Grimshaw JM, Walker AE (2001) A systematic review of discharge coding accuracy. J Public Health Med 23(3):205–211

    Article  CAS  PubMed  Google Scholar 

  42. Audit Commission (2010) Improving data quality in the NHS. Annual report on the PbR assurance programme. Health 2010. Available at http://www.audit-commission.gov.uk/SiteCollectionDocuments/Downloads/26082010pbrnhsdataqualityreport.pdf. Accessed 1 Mar 2013

Download references

Acknowledgments

We are grateful for the support from the NIHR Biomedical Research Centre funding scheme. The Unit is funded largely by a research grant from Dr. Foster Intelligence (an independent health service research organisation). The Dr. Foster Unit at Imperial College is affiliated with the Centre for Patient Safety and Service Quality at Imperial College Healthcare NHS Trust, which is funded by the National Institute of Health Research. This research was funded in part by a research grant from Ethicon Endo-Surgery (Europe) GmbH. This applies to Paul Aylin and Alex Bottle.

Ethical standards

We had approval for this study under Section 251 (formerly Section 60) which was granted by the National Information Governance Board for Health and Social Care (NIGB, formerly the Patient Information Advisory Group). We also received approval for using the data for research from the South East Research Ethics Committee.

Disclosures

Elaine M. Burns is supported by a CR-UK Clinical Lectureship (C42671/A13720). Omar Faiz’s research centre at St Mark’s Hospital is partly funded through the St Mark’s Hospital Foundation. Ravikrishna Mamidanna, Andy Currie, Alex Bottle, Paul Aylin, and Ara Darzi have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations

  1. Department of Surgery, St Mary’s Hospital, Imperial College, Praed Street, London, W2 1NY, UK

    Elaine M. Burns, Ravikrishna Mamidanna, Andy Currie & Ara Darzi

  2. Dr. Foster Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College, 12 Smithfield Street, London, EC1A 9LA, UK

    Alex Bottle & Paul Aylin

  3. Surgical Outcome Trials and Epidemiology Centre, St. Mark’s Hospital, Northwick Park, Watford Road, Harrow, Middlesex, HA1 3UJ, UK

    Omar D. Faiz

Authors
  1. Elaine M. Burns
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ravikrishna Mamidanna
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Andy Currie
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Alex Bottle
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Paul Aylin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ara Darzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Omar D. Faiz
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Elaine M. Burns.

Appendix

Appendix

OPCS coding used to denote and classify colorectal resection:

  • Right sided resection which included right hemicolectomy (H07) and extended right hemicolectomy and transverse colectomy (H06, H08).

  • Left sided resection that included left hemicolectomy (H09), and sigmoid colectomy (H10).

  • Panproctocolectomy (H04.1, H04.3, H04.8, H04.9) and total colectomy (H05) and colectomy of unspecified site (H11) were considered together.

  • Rectal resection, including anterior resection (H33.2, H33.3, H33.4, H33.6, H33.7, H33.8, H33.9), Hartmann’s procedure (H33.5), and abdominoperineal resection (APE H33.1).

Rights and permissions

Reprints and permissions

About this article

Cite this article

Burns, E.M., Mamidanna, R., Currie, A. et al. The role of caseload in determining outcome following laparoscopic colorectal cancer resection: an observational study. Surg Endosc 28, 134–142 (2014). https://doi.org/10.1007/s00464-013-3139-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-013-3139-5

Keywords

Search

Navigation