Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Annals of Surgical Oncology
Published in: Annals of Surgical Oncology 13/2014

01-12-2014 | Healthcare Policy and Outcomes

Centralization of Esophagectomy: How Far Should We Go?

Authors: Daniel Henneman, MD, Johan L. Dikken, MD, PhD, Hein Putter, PhD, Valery E. P. P. Lemmens, PhD, Lydia G. M. Van der Geest, MSc, Richard van Hillegersberg, MD, PhD, Marcel Verheij, MD, PhD, Cornelis J. H. van de Velde, MD, PhD, Michel W. J. M. Wouters, MD, PhD

Published in: Annals of Surgical Oncology | Issue 13/2014

Login to get access

Abstract

Background

This study was designed to define a statistically sound and clinically meaningful cutoff point for annual hospital volume for esophagectomy. Higher hospital volumes are associated with improved outcomes after esophagectomy. However, reported optimal volumes in literature vary, and minimal volume standards in different countries show considerable variation. So far, there has been no research on the noncategorical, nonlinear, volume-outcome relationship in esophagectomy.

Methods

Data were derived from the Netherlands Cancer Registry. Restricted cubic splines were used to investigate the nonlinear effects of annual hospital volume on 6 month and 2 year mortality rates. Outcomes were adjusted for year of diagnosis, case-mix, and (neo)adjuvant treatment.

Results

Between 1989 and 2009, 10,025 patients underwent esophagectomy for cancer in the Netherlands. Annual hospital volumes varied between 1 and 83 year, increasing over time. Increasing annual hospital volume showed a continuous, nonlinear decrease in hazard ratio (HR) for mortality along the curve. Increasing hospital volume from 20 year (baseline, HR = 1.00) to 40 and 60 year was associated with decreasing 6 month mortality, with a HR of 0.73 (95 % confidence interval (0.65–0.83) and 0.67 (0.58–0.77) respectively. Beyond 60 year, no further decrease was detected. Higher hospital volume also was associated with decreasing 2 year mortality until 50 esophagectomies year with a HR of 0.86 (0.79–0.93).

Conclusions

Centralization of esophagectomy to a minimum of 20 resections/year has been effectively introduced in the Netherlands. Increasing annual hospital volume was associated with a nonlinear decrease in mortality up to 40–60 esophagectomies/year, after which a plateau was reached. This finding may guide quality improvement efforts worldwide.
Literature
1.
2.
van Hagen P, Hulshof MC, van Lanschot JJ, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med. 2012;366:2074–2084.PubMedCrossRef
3.
Dikken JL, Dassen AE, Lemmens VE, et al. Effect of hospital volume on postoperative mortality and survival after oesophageal and gastric cancer surgery in the Netherlands between 1989 and 2009. Eur J Cancer. 2012;48:1004–1013.PubMedCrossRef
4.
Wouters MW, Gooiker GA, van Sandick JW, Tollenaar RA. The volume-outcome relation in the surgical treatment of esophageal cancer: a systematic review and meta-analysis. Cancer. 2012;118:1754–1763.PubMedCrossRef
5.
Markar SR, Karthikesalingam A, Thrumurthy S, Low DE. Volume-outcome relationship in surgery for esophageal malignancy: systematic review and meta-analysis 2000-2011. J Gastrointest Surg. 2012;16:1055–1063.PubMedCrossRef
6.
Ben-David K, Ang D, Grobmyer SR, Liu H, Kim T, Hochwald SN. Esophagectomy in the state of Florida: is regionalization of care warranted? Am Surg. 2012;78:291–295.PubMed
7.
8.
9.
Al-Sarira AA, David G, Willmott S, Slavin JP, Deakin M, Corless DJ. Oesophagectomy practice and outcomes in England. Br J Surg. 2007;94:585–591.PubMedCrossRef
10.
Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA. 1998;280:1747–1751.PubMedCrossRef
11.
Dimick JB, Pronovost PJ, Cowan JA, Lipsett PA. Surgical volume and quality of care for esophageal resection: do high-volume hospitals have fewer complications? Ann Thorac Surg. 2003;75:337–341.PubMedCrossRef
12.
Finlayson EV, Goodney PP, Birkmeyer JD. Hospital volume and operative mortality in cancer surgery: a national study. Arch Surg. 2003;138:721–725; discussion 726.PubMedCrossRef
13.
Fujita H, Ozawa S, Kuwano H, Ueda Y, Hattori S, Yanagawa T. Esophagectomy for cancer: clinical concerns support centralizing operations within the larger hospitals. Dis Esophagus. 2010;23:145–152.PubMedCrossRef
14.
Funk LM, Gawande AA, Semel ME, et al. Esophagectomy outcomes at low-volume hospitals: the association between systems characteristics and mortality. Ann Surg. 2011;253:912–917.PubMedCrossRef
15.
Gasper WJ, Glidden DV, Jin C, Way LW, Patti MG. Has recognition of the relationship between mortality rates and hospital volume for major cancer surgery in California made a difference? A follow-up analysis of another decade. Ann Surg. 2009;250:472–483.PubMed
16.
Gordon TA, Bowman HM, Bass EB, et al. Complex gastrointestinal surgery: impact of provider experience on clinical and economic outcomes. J Am Coll Surg. 1999;189:46–56.PubMedCrossRef
17.
Kazui T, Osada H, Fujita H. An attempt to analyze the relation between hospital surgical volume and clinical outcome. Gen Thorac Cardiovasc Surg. 2007;55:483–492.PubMedCrossRef
18.
Kuo EY, Chang Y, Wright CD. Impact of hospital volume on clinical and economic outcomes for esophagectomy. Ann Thorac Surg. 2001;72:1118–1124.PubMedCrossRef
19.
Leigh Y, Goldacre M, McCulloch P. Surgical specialty, surgical unit volume and mortality after oesophageal cancer surgery. Eur J Surg Oncol. 2009;35:820–825.PubMedCrossRef
20.
Lin HC, Xirasagar S, Lee HC, Chai CY. Hospital volume and inpatient mortality after cancer-related gastrointestinal resections: the experience of an Asian country. Ann Surg Oncol. 2006;13:1182–1188.PubMedCrossRef
21.
McCulloch P, Ward J, Tekkis PP. Mortality and morbidity in gastro-oesophageal cancer surgery: initial results of ASCOT multicentre prospective cohort study. BMJ. 2003;327:1192–1197.PubMedCentralPubMedCrossRef
22.
Pal N, Axisa B, Yusof S, et al. Volume and outcome for major upper GI surgery in England. J Gastrointest Surg. 2008;12:353–357.PubMedCrossRef
23.
Patti MG, Corvera CU, Glasgow RE, Way LW. A hospital’s annual rate of esophagectomy influences the operative mortality rate. J Gastrointest Surg. 1998;2:186–192.PubMedCrossRef
24.
Ra J, Paulson EC, Kucharczuk J, et al. Postoperative mortality after esophagectomy for cancer: development of a preoperative risk prediction model. Ann Surg Oncol. 2008;15:1577–1584.PubMedCrossRef
25.
Reavis KM, Smith BR, Hinojosa MW, Nguyen NT. Outcomes of esophagectomy at academic centers: an association between volume and outcome. Am Surg. 2008;74:939–943.PubMed
26.
Rodgers M, Jobe BA, O’Rourke RW, Sheppard B, Diggs B, Hunter JG. Case volume as a predictor of inpatient mortality after esophagectomy. Arch Surg. 2007;142:829–839.PubMedCrossRef
27.
Simunovic M, Rempel E, Theriault ME, et al. Influence of hospital characteristics on operative death and survival of patients after major cancer surgery in Ontario. Can J Surg. 2006;49:251–258.PubMedCentralPubMed
28.
Stavrou PE, Smith SG, Baker DF. Surgical outcomes associated with oesophagectomy in New South Wales: an investigation of hospital volume. J Gastrointest Surg. 2010;14:951–957.CrossRef
29.
Suzuki H, Gotoh M, Sugihara K, et al. Nationwide survey and establishment of a clinical database for gastrointestinal surgery in Japan: Targeting integration of a cancer registration system and improving the outcome of cancer treatment. Cancer Sci. 2011;102:226–230.PubMedCrossRef
30.
Swisher SG, Deford L, Merriman KW, et al. Effect of operative volume on morbidity, mortality, and hospital use after esophagectomy for cancer. J Thorac Cardiovasc Surg. 2000;119:1126–1132.PubMedCrossRef
31.
van Lanschot JJ, Hulscher JB, Buskens CJ, Tilanus HW, ten Kate FJ, Obertop H. Hospital volume and hospital mortality for esophagectomy. Cancer. 2001;91:1574–1578.PubMedCrossRef
32.
Wenner J, Zilling T, Bladstrom A, Alvegard TA. The influence of surgical volume on hospital mortality and 5 year survival for carcinoma of the oesophagus and gastric cardia. Anticancer Res. 2005;25:419–424.PubMed
33.
Wouters MW, Wijnhoven BP, Karim-Kos HE, et al. High-volume versus low-volume for esophageal resections for cancer: the essential role of case-mix adjustments based on clinical data. Ann Surg Oncol. 2008;15:80–87.PubMedCentralPubMedCrossRef
34.
Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346:1128–1137.PubMedCrossRef
35.
Milstein A, Galvin RS, Delbanco SF, Salber P, Buck CR Jr. Improving the safety of health care: the Leapfrog initiative. Effective Clin Prac. 2000;3:313–316.
36.
Varghese TK Jr, Wood DE, Farjah F, et al. Variation in esophagectomy outcomes in hospitals meeting Leapfrog volume outcome standards. Ann Thorac Surg. 2011;91:1003–1009; discussion 1009-10.PubMedCrossRef
37.
38.
39.
World Health Organisation (WHO). International Classification of Diseases for Oncology (ICD-O-3). 2000.
40.
Therneau TM, Grambsch PM. Modeling survival data: extending the Cox model. Springer, New York; 2000.CrossRef
41.
Molinari N, Daures JP, Durand JF. Regression splines for threshold selection in survival data analysis. Stat Med. 2001;20:237–247.PubMedCrossRef
42.
Heinzl H, Kaider A. Gaining more flexibility in Cox proportional hazards regression models with cubic spline functions. Comp Meth Prog Biomed. 1997;54:201–208.CrossRef
43.
Coupland VH, Lagergren J, Luchtenborg M, et al. Hospital volume, proportion resected and mortality from oesophageal and gastric cancer: a population-based study in England, 2004-2008. Gut. 2013;62(7):961–966.PubMedCrossRef
44.
Meguid RA, Weiss ES, Chang DC, Brock MV, Yang SC. The effect of volume on esophageal cancer resections: what constitutes acceptable resection volumes for centers of excellence? J Thorac Cardiovasc Surg. 2009;137:23–29.PubMedCentralPubMedCrossRef
45.
Christian CK, Gustafson ML, Betensky RA, Daley J, Zinner MJ. The Leapfrog volume criteria may fall short in identifying high-quality surgical centers. Ann Surg. 2003;238:447–455; discussion 55-7.PubMedCentralPubMed
46.
Metzger R, Bollschweiler E, Vallbohmer D, Maish M, DeMeester TR, Holscher AH. High volume centers for esophagectomy: what is the number needed to achieve low postoperative mortality? Dis Esophagus. 2004;17:310–314.PubMedCrossRef
47.
Schouten LJ, Jager JJ, van den Brandt PA. Quality of cancer registry data: a comparison of data provided by clinicians with those of registration personnel. Br J Cancer. 1993;68:974–977.PubMedCentralPubMedCrossRef
48.
Dikken JL, Lemmens VE, Wouters MW, et al. Increased incidence and survival for oesophageal cancer but not for gastric cardia cancer in the Netherlands. Eur J Cancer. 2012;48:1624–1632.PubMedCrossRef
49.
Birkmeyer JD, Sun Y, Goldfaden A, Birkmeyer NJ, Stukel TA. Volume and process of care in high-risk cancer surgery. Cancer. 2006;106:2476–2481.PubMedCrossRef
50.
Wouters MW, Krijnen P, Le Cessie S, et al. Volume- or outcome-based referral to improve quality of care for esophageal cancer surgery in The Netherlands. J Surg Oncol. 2009;99:481–487.PubMedCrossRef
51.
Ingraham AM, Richards KE, Hall BL, Ko CY. Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach. Adv Surg. 2010;44:251–267.PubMedCrossRef
52.
Jensen LS, Nielsen H, Mortensen PB, Pilegaard HK, Johnsen SP. Enforcing centralization for gastric cancer in Denmark. Eur J Surg Oncol. 2010;36 Suppl 1:S50-4.PubMedCrossRef
53.
van Gijn W, van de Velde CJ. 2010 SSO John Wayne clinical research lecture: rectal cancer outcome improvements in Europe: population-based outcome registrations will conquer the world. Ann Surg Oncol. 2011;18:691–696.PubMedCentralPubMedCrossRef
Metadata
Title
Centralization of Esophagectomy: How Far Should We Go?
Authors
Daniel Henneman, MD
Johan L. Dikken, MD, PhD
Hein Putter, PhD
Valery E. P. P. Lemmens, PhD
Lydia G. M. Van der Geest, MSc
Richard van Hillegersberg, MD, PhD
Marcel Verheij, MD, PhD
Cornelis J. H. van de Velde, MD, PhD
Michel W. J. M. Wouters, MD, PhD
Publication date
01-12-2014
Publisher
Springer US
Published in
Annals of Surgical Oncology / Issue 13/2014
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-014-3873-5

Other articles of this Issue 13/2014

Annals of Surgical Oncology 13/2014 Go to the issue

Endocrine Tumors

Failure of Radioactive Iodine in the Treatment of Hyperthyroidism

Pancreatic Tumors

Readmission After Pancreatic Resection: Causes and Causality Pattern

Head and Neck Oncology

The hMLH1 −93G>A Promoter Polymorphism is Associates with Outcomes in Oral Squamous Cell Carcinoma Patients

Bone and Soft Tissue Sarcomas

A Promise to Our Patients with Metastatic Bone Disease

Hepatobiliary Tumors

Favorable Outcome After Repeat Resection for Colorectal Liver Metastases

Gastrointestinal Oncology

The American Society of Peritoneal Surface Malignancies (ASPSM) Multiinstitution Evaluation of the Peritoneal Surface Disease Severity Score (PSDSS) in 1,013 Patients with Colorectal Cancer with Peritoneal Carcinomatosis