Surgeon-Level Variation in Outcome following Esophageal Atresia Repair Is Not Explained by Volume

Abstract

Introduction To assess whether there is a difference in operative outcome for esophageal atresia (EA) depending on a surgeon's seniority as defined by years in consultant practice or number of cases performed. In addition a Clavien–Dindo score was used to sequentially analyze the outcome of each surgeon's EA procedure.

Materials and Methods All repairs performed over 22 years in an English regional center were analyzed. Outcomes were: death, anastomotic leak, need for dilatation, need for more than three dilatations, need for fundoplication, and a Clavien–Dindo adverse outcome of ≥3b. Possible explanatory variables were: number of prior repairs by the surgeon, surgeon's years of consultant experience. We also examined the effect of variables intrinsic to the infant as possible confounding variables and as independent predictors of outcome.

Results A total of 190 repairs were performed or supervised by 12 consultants. There was no significant association between consultant experience and any objective outcome. However, sequential analysis suggests there is variation between surgeons in the incidence of Clavien–Dindo events of ≥3b. Performance showed deterioration in one case. Mortality was explicable by cardiac and renal anomalies.

Conclusion There are surgeon-level variations in outcomes for the procedure of EA repair, but they are not explained by volume. Surgeon performance can deteriorate. Our study would not support the concept that patient outcomes could be improved by concentrating the provision of this surgery to fewer hospitals or surgeons.

Keywords

Clavien–Dindo - volume outcome - esophageal atresia

Publication History

Received: 15 August 2020

Accepted: 23 October 2020

Article published online:
27 December 2020

• References

• 1 Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 2011; 364 (22) 2128-2137
• 2 Langer JC, To T. Does pediatric surgical specialty training affect outcome after Ramstedt pyloromyotomy? A population-based study. Pediatrics 2004; 113 (05) 1342-1347
• 3 Lansdale N, Al-Khafaji N, Green P, Kenny SE. Population-level surgical outcomes for infantile hypertrophic pyloric stenosis. J Pediatr Surg 2017
• 4 Wilkinson DJ, Green PA, Beglinger S. et al. Hypospadias surgery in England: higher volume centres have lower complication rates. J Pediatr Urol 2017; 13 (05) 481.e1-481.e6
• 5 Davenport M, De Ville de Goyet J, Stringer MD. et al. Seamless management of biliary atresia in England and Wales (1999-2002). Lancet 2004; 363 (9418): 1354-1357
• 6 Spiegelhalter DJ. Mortality and volume of cases in paediatric cardiac surgery: retrospective study based on routinely collected data. BMJ 2002; 324 (7332): 261-263
• 7 Sulkowski JP, Cooper JN, Lopez JJ. et al. Morbidity and mortality in patients with esophageal atresia. Surgery 2014; 156 (02) 483-491
• 8 Dingemann C, Dietrich J, Zeidler J. et al. Early complications after esophageal atresia repair: analysis of a German health insurance database covering a population of 8 million. Dis Esophagus 2016; 29 (07) 780-786
• 9 Hartley MJ, Smith NP, Jaffray B. Statistical modelling of survival for babies with oesophageal atresia. J Pediatr Surg 2016; 51 (07) 1110-1114
• 10 Lawrence AE, Minneci PC, Deans KJ, Kelley-Quon LI, Cooper JN. Relationships between hospital and surgeon operative volumes and outcomes of esophageal atresia/tracheoesophageal fistula repair. J Pediatr Surg 2019; 54 (01) 44-49
• 11 Jawaid W, Chan B, Jesudason EC. Subspecialization may improve an esophageal atresia service but has not addressed declining trainee experience. J Pediatr Surg 2012; 47 (07) 1363-1368
• 12 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240 (02) 205-213
• 13 Jaffray B. Am I out of control? The application of statistical process control charts to children's surgery. J Pediatr Surg 2020; 55 (09) 1691-1698
• 14 Rogers CA, Reeves BC, Caputo M, Ganesh JS, Bonser RS, Angelini GD. Control chart methods for monitoring cardiac surgical performance and their interpretation. J Thorac Cardiovasc Surg 2004; 128 (06) 811-819
• 15 Quiroz HJ, Turpin A, Willobee BA. et al. Nationwide analysis of mortality and hospital readmissions in esophageal atresia. J Pediatr Surg 2020; 55 (05) 824-829
• 16 Dylkowski D, Dave S, Andrew McClure J, Welk B, Winick-Ng J, Jones S. Repair of congenital esophageal atresia with tracheoesophageal fistula repair in Ontario over the last 20years: volume and outcomes. J Pediatr Surg 2018; 53 (05) 925-928
• 17 McAteer JP, LaRiviere CA, Drugas GT, Abdullah F, Oldham KT, Goldin AB. Influence of surgeon experience, hospital volume, and specialty designation on outcomes in pediatric surgery: a systematic review. JAMA Pediatr 2013; 167 (05) 468-475
• 18 Sømme S, Shahi N, McLeod L, Torok M, McManus B, Ziegler MM. Neonatal surgery in low- vs. high-volume institutions: a KID inpatient database outcomes and cost study after repair of congenital diaphragmatic hernia, esophageal atresia, and gastroschisis. Pediatr Surg Int 2019; 35 (11) 1293-1300
• 19 Langer JC, Gordon JS, Chen LE. Subspecialization within pediatric surgical groups in North America. J Pediatr Surg 2016; 51 (01) 143-148
• 20 Burge DM, Shah K, Spark P. et al. British Association of Paediatric Surgeons Congenital Anomalies Surveillance System (BAPS-CASS). Contemporary management and outcomes for infants born with oesophageal atresia. Br J Surg 2013; 100 (04) 515-521
• 21 Alshehri A, Lo A, Baird R. An analysis of early nonmortality outcome prediction in esophageal atresia. J Pediatr Surg 2012; 47 (05) 881-884
• 22 Fonkalsrud EW, O'Neill JA, Jabaji Z, Dunn JCY. Changing relationship of pediatric surgical workforce to patient demographics. Am J Surg 2014; 207 (02) 275-280
• 23 Johnson SM, Lee WG, Puapong DP, Woo RK. The pediatric surgical team: a model for increased surgeon index case exposure. J Pediatr Surg 2019; 54 (09) 1878-1883