Systematic review of the impact of volume of oesophagectomy on patient outcome

Abstract

Purpose: This systematic review aims to assess whether overall survival, mortality, morbidity, length of stay and cost of performing oesophagectomy are related to surgical volume. Methods: A systematic search strategy from 1997 until December 2006 was used to retrieve relevant studies. Inclusion of articles was established through application of a predetermined protocol, independent assessment by two reviewers and a final consensus decision. Results: A total of 55 studies were identified of which 27 studies, representing 68 882 patients, met the inclusion criteria. Twenty-one of these solely examined hospital volume, 5 examined both hospital and surgeon volume, and 1 examined surgeon volume in isolation. All but one of the studies were retrospective in nature, and because of the heterogeneity of the literature, no meta-analysis could be performed. Of the studies exploring the relationship between hospital volume and mortality, 20 reported a statistically significant benefit to large volume centres. Five of six included studies showed significant evidence for a reduced mortality risk with greater surgeon volume. Conclusions: Based on the evidence from these retrospective studies, oesophagectomy performed in high volume centres would appear to be associated with better outcome compared with low volume centres.

Centralization of Highly Complex Low-Volume Procedures in Upper Gastrointestinal Surgery. A Summary of Systematic Reviews and Meta-Analyses

“…One systematic review did not state cutoff points but reported a significant decrease in mortality rates in the HV hospitals and HV surgeons [18]. The second review concluded that esophageal surgery in HV hospitals had better outcomes compared with LV hospitals regarding mortality, without exact data [22].…”

Hospital Volume and Operative Mortality in the Modern Era

“…Over the last ten years, a large body of literature supporting the presence of a hospital volume-outcome relationship, including numerous systematic reviews, [18][19][20][21][22][23][24][25] has been developed. An early definitive systematic review on the subject was performed by Halm and colleagues and reported a significant association across a wide range of procedures and conditions.…”

Assessment of a scoring system for predicting complications after esophagectomy

“…Although there has been some improvement over time in operative mortality rates, nonfatal postoperative morbidity remains high 12,13 . Reasons for this include the inherent high‐risk nature of the operation, performance of the majority of such operations at low‐volume centers or by low‐volume surgeons with attendant poorer outcomes, and the belief on the part of many physicians that esophagectomy is the only reliable curative modality for esophageal cancer, which sometimes leads to recommending a resection even when surgical risks are known to be much higher than usual 13,14 …”

“…12,13 Reasons for this include the inherent high-risk nature of the operation, performance of the majority of such operations at low-volume centers or by low-volume surgeons with attendant poorer outcomes, and the belief on the part of many physicians that esophagectomy is the only reliable curative modality for esophageal cancer, which sometimes leads to recommending a resection even when surgical risks are known to be much higher than usual. 13,14 A number of studies have identified risk factors for morbidity (especially pulmonary morbidity) and mortality after esophagectomy, and there is some consistency among their findings. [1][2][3]8,9,[15][16][17] Knowledge of these risk factors could assist in selection of appropriate preoperative testing for patients who are candidates for esophagectomy and could provide information regarding operative risk, especially if the relative impact of each factor was easily identified.…”