LAUSR

P atients with colorectal cancer whose operations were performed by more technically skilled surgeons were 70% more likely to survive long term, according to a study by Northwestern University researchers published in JAMA Surgery.1 The research, also presented virtually at the American College of Surgeons (ACOS) Commission on Cancer Annual Meeting in October 2020, suggests that the level of technical skill among surgeons widely varies. Findings also indicate that technical skill accounts for more than 25% of the variation in patient outcomes and complication rates. “It makes sense, but to our knowledge, it’s never been demonstrated before,” says lead author and surgical oncologist Karl Y. Bilimoria, MD, the John Benjamin Murphy Professor of Surgery at Northwestern University Feinberg School of Medicine in Chicago. Dr. Bilimoria also serves as director of Northwestern’s Surgical Outcomes and Quality Improvement Center, which incorporates a statewide, 56-center collaborative aimed at conducting research on improving surgical outcomes for patients. A major rationale behind the study was not only to determine whether better technical skills correlated with better patient outcomes but also to seek ways of improving surgical quality. Although the ACOS certifies surgeons after their training and recertifies them every 10 years through a written examination of knowledge and decision-making, currently, there is not a re-certification process based on surgical skills, according to Dr. Bilimoria. “When surgeons finish training, we get almost no feedback on our surgical skills or our technical performance,” he says. “Nobody watches us other than our residents and partners. We’re craving feedback, and we want to see that our skills are up to par. Surgeons also love watching surgical videos. These sessions are always among the most well-attended at any meeting.” Drawing on those concepts for their research, Dr. Bilimoria and his colleagues from across Illinois recruited 17 practicing surgeons to record and submit videos of performing a laparoscopic right hemicolectomy on patients who had stages I to III epithelial-origin colon cancer. The videos were rated by at least 10 blinded peer surgeons and 2 expert raters. Using data from the ACOS National Surgical Quality Improvement Program, researchers then examined the association between surgeons’ technical skill scores and risk-adjusted outcomes. The study was conducted from September 2016 to February 2018, and data analysis was performed from November 2018 to January 2019. The primary outcome was overall survival after surgery, and the secondary outcome was the number of lymph nodes harvested. Other outcomes included any complication, mortality, unplanned hospital reoperation related to the principal procedure, surgical site infection, and serious morbidity. Study findings showed that overall, 5-year survival differed among skill terciles: 79% for high skill, 55% for medium skill, and 60% for low skill. Surgeons’ technical skills were assessed in the study in 2 main ways: by the Objective Structured Assessment of Technical Skills for laparoscopic procedures and by their ability to perform a high ligation, which entails resection in a higher part of the colon to capture all potentially cancerous lymph nodes. This procedure is technically complicated to perform, Dr. Bilimoria says.