Professor and Chair, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Connecticut Health Center, Farmington

Dr. Brewer reports no financial relationships relevant to this field of study.

SYNOPSIS: Generally, gynecologic surgical complications are higher with lower-volume surgeons.

SOURCE: Ruiz MP, et al. Outcomes of hysterectomy performed by very low-volume surgeons. Obstet Gynecol 2018;131:981-990.

Ruiz et al used the New York Statewide Planning and Research Cooperative System to investigate the surgical outcomes for very low-volume surgeons. They defined low-volume surgeons as having an annualized volume of only one hysterectomy and higher-volume surgeons as having an annualized volume of more than one hysterectomy. They measured rates of intraoperative complications, surgical site complications, and medical complications, as well as a composite of all complications. There were 4,600 higher-volume surgeons and 3,197 low-volume surgeons between 2000 and 2014 in New York. Low-volume surgeons were more likely to perform abdominal hysterectomy (79% vs. 59%), the surgery was more likely to be emergent (31% vs. 8%), and it was more likely to be performed in a low-volume hospital. The patient was more likely to be older (> 70 years of age; 17% vs. 8%); be black (20% vs. 16%); have Medicare or Medicaid insurance (23% vs. 20%); have two or more morbidities (43% vs. 36%); and have omentectomy, small or large bowel resection, or bladder resection, and have ovarian, fallopian tube, or peritoneal cancer (7.9% vs. 4.1%). The overall complication rate was 32% for very low-volume surgeons and 9.9% for higher-volume surgeons. Complications were broken down into intraoperative (11.3% vs. 3.1%), surgical site (15.1% vs. 4.1%), medical (19.5% vs. 4.8%), and rate of transfusion (38.5% vs. 11.8%). Patients for whom very low-volume surgeons performed the operations were more likely to have a prolonged length of stay (62% vs. 22%) and excessive hospital charges (59.8% vs. 24.6%).

The authors of other studies have drawn similar conclusions. In a 2016 meta-analysis, Mowat et al evaluated the effect of operative volume on surgical outcomes in all gynecologic surgeries.¹ They reviewed 14 studies and defined low volume as performing the procedure once a month or less. The odds ratio (OR) for complications in low-volume surgeons was 1.3, which was divided into intraoperative (OR, 1.6) and postoperative (OR, 1.4) complications. Disturbingly, among low-volume gynecologic oncologists, the OR for mortality was nearly double for high-volume surgeons (OR, 1.9). In many of the studies evaluated, higher-volume surgeons cared for the patients with the most comorbidities who were more likely to have operative complications, so these differences in outcome between low- and high-volume surgeons are understated. Among all surgeons, there was a 10% complication rate with hysterectomy, which is consistent with the literature. However, low-volume surgeons had consistently higher complication rates. Low-volume surgeons had a 30% increase in risk of all complications, a 60% increase in intraoperative complications, and a 40% increase in perioperative complications.

Wright et al evaluated women with endometrial cancer between 2000 and 2014.² They found that surgical and hospital volume affected surgical outcome less because of the growing trend of endometrial cancer patients being cared for by gynecologic oncologists, a significant paradigm shift. They divided surgical volume rates into low volume (one to seven cases/year), medium-low volume (seven to 23 cases/year), medium-high volume (24 to 42 cases/year), and high volume (42 to 64 cases/year). They found that the morbidity rate was 14.6% among the lowest-volume surgeons, 20.8% for medium-low, 15.7% for medium-high, and 14.1% for high-volume surgeons (P < 0.001). They also found that the number of surgeons treating women with endometrial cancer decreased dramatically between 2000 and 2014, from 845 to 317, while the number of patients increased. Primarily, this decrease occurred because of a major shift in the number of women treated by gynecologic oncologists rather than gynecologists. The number of hospitals treating women with endometrial cancer decreased from 182 to 98. In the multivariate analysis, surgeon volume and hospital volume did not affect complication rate, because the majority of surgeons caring for patients with endometrial cancer are gynecologic oncologists who have more extensive surgical training, are less likely to have adverse outcomes, and are more likely to be high-volume surgeons compared to gynecologists. Studies in other surgical disciplines have suggested that surgeon volume affects patient outcomes similar to the Ruiz paper. In simple emergency general surgery cases, there was no difference in outcome between low- and high-volume surgeons. However, in complex cases, there was an increase in mortality (OR, 1.64) with low-volume surgeons.³ In a study on aortic aneurysm repair, Dubois et al found that high annual surgeon volume was associated with less postoperative complications and re-operations.⁴

COMMENTARY

Given these data, how should we address surgical volume among gynecologists? Since surgical volume in the field of gynecology continues to decrease, this is an issue for both established and new surgeons in our field. Residents have less surgical volume in residency than in past years. When these new surgeons go into practice, unless they join a busy surgical group, their practices likely are dominated by obstetrics and, thus, they join the ranks of low-volume surgeons. Almost half of the gynecologic surgeons in New York perform only one case per year.

In an editorial, Walter addressed the fact that every woman deserves a high-volume gynecologic surgeon.⁵ Low-volume surgeons are less likely to use a minimally invasive approach, which is associated with an increase in morbidity, higher complication rates, and a higher cost (longer operative times, increased hospital length of stay.)

Walter stated there are too many low-volume gynecologic surgeons because of many factors. Increasingly, there is limited resident experience with minimal required hysterectomies. There are more options for the approach to hysterectomy, each of which requires different surgical skills that most residents do not have because of reduced surgical volume. There are too many trainees because of the heavy obstetric load in most residencies and insufficient post-residency surgical volume. He suggested that residency programs should train fewer residents in surgical techniques by encouraging alternative practice opportunities that are nonsurgical. Training fewer gynecologic surgeons would result in more hysterectomies being done minimally invasively, particularly focusing on laparoscopic rather that robotic technique. An increase in minimally invasive hysterectomy would result in lower morbidity and faster return to work for patients and would be in line with the upcoming focus on value-based payment models. We owe it to our patients to be sure that any woman undergoing a hysterectomy, or for that matter any gynecologic surgery, has the most competent and careful surgeon available. Turning out more residents with minimal surgical expertise is not the answer to better care for women. Not all residents need to be surgeons. Our training programs need to address this gap in care and identify how to steer some residents toward nonsurgical practices.

REFERENCES

1. Mowat A, Surgical outcomes for low-volume vs high-volume surgeons in gynecology surgery: A systematic review and meta-analysis. Am J Obstet Gynecol 2016;215:21-33.
2. Wright JD, et al. Changes in surgical volume and outcomes over time for women undergoing hysterectomy for endometrial cancer. Obstet Gynecol 2018;132:59-69.
3. Mehta A, et al. Effect of surgeon and hospital volume on emergency general surgery outcomes. J Am Coll Surg 2017;225:666-675.e2.
4. Dubois L, et al. Higher surgeon annual volume, but not years of experience, is associated with reduced rates of postoperative complications and reoperations after open abdominal aortic aneurysm repair. J Vasc Surg 2018;67:1717-1726.e5.
5. Walter A. Every woman deserves a high-volume gynecologic surgeon. Am J Obstet Gynecol 2017;216:139.e1-139.e3.