Surgeon Volume and Laryngectomy Outcomes.

OBJECTIVE: To examine the relationship between surgeon volume and operative morbidity and mortality for laryngectomy. DATA SOURCES: The Nationwide Inpatient Sample was used to identify 45,156 patients who underwent laryngectomy procedures for laryngeal or hypopharyngeal cancer between 2001 and 2011. Hospital and surgeon laryngectomy volume were modeled as categorical variables. METHODS: Relationships between hospital and surgeon volume and mortality, surgical complications, and acute medical complications were examined using multivariable regression. RESULTS: Higher-volume surgeons were more likely to operate at large, teaching, nonprofit hospitals and were more likely to treat patients who were white, had private insurance, hypopharyngeal cancer, low comorbidity, admitted electively, and to perform partial laryngectomy, concurrent neck dissection, and flap reconstruction. Surgeons treating more than 5 cases per year were associated with lower odds of medical and surgical complications, with a greater reduction in the odds of complications with increasing surgical volume. Surgeons in the top volume quintile (>9 cases/year) were associated with a decreased odds of in-hospital mortality (OR = 0.09 [0.01-0.74]), postoperative surgical complications (OR = 0.58 [0.45-0.74]), and acute medical complications (OR = 0.49 [0.37-0.64]). Surgeon volume accounted for 95% of the effect of hospital volume on mortality and 16%-47% of the effect of hospital volume on postoperative morbidity. CONCLUSION: There is a strong volume-outcome relationship for laryngectomy, with reduced mortality and morbidity associated with higher surgeon and higher hospital volumes. Observed associations between hospital volume and operative morbidity and mortality are mediated by surgeon volume, suggesting that surgeon volume is an important component of the favorable outcomes of high-volume hospital care. Laryngoscope, 133:834-840, 2023.

Adult tonsillectomy: current indications and outcomes.

OBJECTIVE: Limited data exist with respect to the current prevalence of indications for tonsillectomy in adults. We sought to determine the indications for adult tonsillectomy and to identify factors associated with postoperative complications. METHODS: The medical records of 361 adult patients who underwent tonsillectomy from 2001 to 2007 were reviewed. RESULTS: Indications for surgery were chronic infection in 207 (57%) patients, upper airway obstruction secondary to tonsillar hypertrophy in 98 (27%) patients, and suspected neoplasm in 56 (16%) patients. Postoperative complications occurred in 54 (15%) cases with hemorrhage in 19 (5%) patients, followed by dehydration in 16 (4%) patients, and admission for postoperative oxygen desaturations in 9 (3%) patients. Hospitalization beyond 24 hours occurred in 18 (5%) cases, with emergency room visits for pain and dehydration in 16 (4%) patients, and readmission for pain control in 17 (5%) cases. Patients who underwent tonsillectomy for upper airway obstruction had an increased incidence of prolonged hospitalization or readmission (19% vs 6%; P = 0.01), whereas patients who underwent tonsillectomy for infection had an increased incidence of postoperative bleeding (6% vs 4%; P = 0.02). CONCLUSIONS: Chronic infection remains the most common indication for adult tonsillectomy in contrast to the pediatric population. Complication rates vary according to the indication for surgery.

Volume-based trends in laryngeal cancer surgery.

OBJECTIVES: Positive volume-outcome relationships exist for diseases treated with technically complex surgery. Contemporary patterns of laryngeal cancer surgery by hospital and surgeon volume are poorly defined. METHODS: The Maryland Health Service Cost Review Commission database was queried for hospital and surgeon laryngeal cancer surgical case volumes from 1990 to 2009. RESULTS: Overall, 1,981 laryngeal cancer surgeries were performed by 288 surgeons at 41 hospitals. Cases performed by high-volume surgeons increased from 19% in 1990 to 1999 to 35% in 2000 to 2009 (odds ratio [OR] = 3.0, P<.001), whereas cases performed at high-volume hospitals increased from 33% to 39% (OR = 2.0, P<.001). High-volume surgeons were more likely to perform total laryngectomy (OR = 1.7, P = .001) and neck dissection (OR = 1.7, P = .002). High-volume hospitals were significantly associated with total laryngectomy (OR = 2.0, P = .003), neck dissection (OR = 1.8, P = .038), flap reconstruction (OR = 5.1, P = .021), prior radiation (OR = 3.0, P = .031), and increased mortality risk scores (OR = 3.2, P = .006). After controlling for other variables, laryngeal cancer surgery in 2000 to 2009 was associated with increased access to high-volume surgeons (OR = 1.9, P<.001) and high-volume hospitals (OR = 1.3, P = .040), a decrease in partial and total laryngectomy procedures (OR = 0.2, P<.001), an increase in neck dissection (OR = 2.2, P< 0.001), an increase in prior radiation (OR = 3.0, P<.001), increased case complexity scores (OR = 5.7, P<.001), and an increase in wound fistula or dehiscence (OR = 2.0, P = .015) compared with 1990 to 1999. CONCLUSIONS: The proportion of laryngeal cancer surgery patients treated by high-volume surgeons and hospitals increased significantly in 2000 to 2009 compared with 1990 to 1999, with a decrease in laryngectomy procedures and an increase in wound complications. These findings may be due to changing trends in primary management of laryngeal cancer.