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surgeon increased the chance of achieving optimal debulking OR = 1.8, 95% CI = 1.2 -2.8, p < 0.05;
adjustment for age, stage and specialization of the gynecologist). Patients operated by both a general
surgeon and a gynecologist underwent a bowel resection in 38% of the cases, compared to 5% of the
patients treated by a gynecologist alone p < 0.0001 .

It should be noted that these results concerning the impact of physician specialty on surgical
outcome must take into account that a potential interobserver bias in assessing the diameter of
residual disease may influence the results.

Impact of physician specialty on the likelihood of repeat surgery: Elit et al.217 assessed whether the LoE 2-
specialty of the surgeon determined the likelihood of unnecessary repeated surgery. After adjustment
for age, residence location, tumour grade, and stage, multivariate analysis showed that surgical
discipline was found to be significantly associated with risk of repeat surgery. Patients who initially
saw a general surgeon were 17 times more likely to undergo repeat surgery thant those who saw
gynecologic oncologists RR = 16.97, 95% CI = 6.35 -45.32, p < 0.05. Those whose surgeries were
performed by obstetricians were 6 times more likely than those who saw gynecologic oncologists to
undergo repeat surgery RR = 6.54, 95% CI = 2.53 -16.93, p < 0.05. The authors mentioned that
surgeon and hospital specialization were strongly correlated data not shown. After adjustment for
hospital effects, patients operated by a general surgeon have an estimated likelihood of repeated
surgery that was 6 times greater than that of patients who saw gynecologic oncologists RR = 5.7,
95% CI = 1.17-28.46, p < 0.05. The interpretation of these results must take into account that the
decision to repeat a surgery is partially subjective, and the answer may lie in clinical decision-
making. Factors that contribute to the decision to perform repeat surgery include the patient’s age,
other comorbidities, opportunity to avoid adjuvant therapy because of the information from a
subsequent staging surgery, the strength of the conviction that optimal debulking improves survival,
physician bias based on who performed the initial surgery and patient preference. Caution is still
warranted because not all clinically relevant prognostic factors could be assessed through patient
records by the authors.

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