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SURGERY: Laurent G. Glance, Andrew W. Dick, Turner M. Osler, and Dana B. Mukamel The Relation Between Surgeon Volume and Outcome Following Off-Pump vs On-Pump Coronary Artery Bypass Graft Surgery Chest 2005; 128: 829-837 [Abstract] [Full text] [PDF]

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The Relation Between Surgeon Volume and Outcome Following Off-Pump vs On-Pump Coronary Artery Bypass

Chee F Chong   (8 November 2005)

The Relation Between Surgeon Volume and Outcome Following Off-Pump vs On-Pump Coronary Artery Bypass 8 November 2005
Chee F Chong, Cardiothoracic Surgeon Gleneagles JPMC Cardiac Centre/RIPAS Hospital Send letter to journal: Re: The Relation Between Surgeon Volume and Outcome Following Off-Pump vs On-Pump Coronary Artery Bypass chong_chee_fui{at}hotmail.com Chee F Chong	Dear Editor, I was reading with great interest the findings of Glance et al regarding the relation of surgical volume to mortality in Off Pump CABG. It has generally been accepted that Off Pump CABG is technically difficult and challenging and one would expect higher surgical volume to influence surgical results. However Glance et al has provided evidence to the contrary. There are several weakness to the study and the final conclusions. First the study was based on data collected from 1998-1999 when Off Pump CABG was at its infancy. Furthermore, most Off Pump cases performed during this period were highly selected with good cormobidities and LVEF as is the case for all new procedures that were being developed. Secondly, only 14.1% of the total patients population underwent Off Pump CABG which in most cases is considered low. Thirdly, the division between low volume and high volume is arbitrary and in case of high volume Off Pump cases of >35, when compared to high volume on-pump cases was still only 11% which is considered by most Off Pump surgeons to be low. Thus this study has only compared the learning curve of individual surgeons, which is like for like. Glance et al in his discussion has reported no difference in a separate analysis comparing surgeons with high case volume > 126 cases over 2 years. A more valid comparison is to compare this group with the low volume group of <37 cases. Finally, the end point of mortality perhaps is not a good measure of the difference and a better comparison would have been morbidity which has been bored out by numerous other studies. With their intention to treat, any differences in mortality would have been covered by conversion to on-pump after a failed Off Pump CABG. Lastly they have concluded that the reason for this difference may be due to selective referral to surgeons with good on-pump experience at a time when Off-Pump CABG was just developing. However we are aware that this is highly unlikely as is bored out by the paper by Khan et al in the NEJM 2004, which showed that a good on-pump CABG surgeon does not necessary equate to a good Off Pump surgeon. Thus I would give credit to Glance et al for conducting such a unique study but would not for arriving at such a poor conclusion. Thank. Your sincerely, Mr Chee Fui Chong, BSc MBBS FRCS FRCSEd(CTh)