Surgical Treatment of Esophageal Cancer: Effect of Operative Volume on Clinical Outcomes

Esophagectomy, a complex, uncommon surgery that carries a high risk of postoperative morbidity and mortality, is usually performed to treat esophageal cancer. According to some authors, it is an ideal model to study the relationship between the volume of surgeries and postoperative outcomes. 
This report aims to determine whether the literature data is sufficient:

1.    to establish a relationship between the volume of esophagectomies (per hospital centre or per surgeon) or the surgeon’s specialty and the short-term results in terms of postoperative mortality (after 30 days or during the initial hospital stay);

and

2.    to define standard thresholds that would ensure better quality of care.
Following this analysis, based on the recommendations in other jurisdictions and on studies whose methodological weaknesses and heterogeneity call for caution when interpreting their results, AETMIS arrives at the following conclusions:

• Regarding the volume of surgeries, most studies show an inversely proportional relationship between hospital or surgeon volume and postoperative mortality. Studies that adjusted their results based on the patients’ profiles confirmed the relationship.

• Regarding the surgeon’s level of specialization, the association between the surgeon’s specialty and surgical outcomes is not sufficiently explored by the studies.

• Regarding standard thresholds, the literature proposes several categories of hospital or surgeon volume, from high to low, but does not define a threshold beyond which centres of excellence for esophagectomies can be identified. However, organizations that have addressed this matter in Canada, the United States and Europe have set minimum thresholds ranging from 6 to 25 esophagectomies per year.

• Regarding the organization of services, the beneficial effect attributed to a high hospital or surgeon volume might be closely related to the hospital’s organizational characteristics, such as the management of patients by a multidisciplinary team or the employment of expert health professionals (oncologists, anesthesiologists, intraoperative and postoperative care team, intensive care, etc). These organizational aspects could be associated with a high annual volume of esophagectomies.

Esophagectomy is a complex surgical procedure that should be reserved for high-surgical-volume facilities and performed by surgeons with extensive experience of this type of surgery, or even a subspecialty in thoracic surgery. In Québec, the hospital databases should be used to perform a more detailed comparison of the postoperative mortality rates observed in hospitals with different esophagectomy volumes and obtain a picture of their quality of care.

This document is the third in a series of three reports on the treatment of esophageal cancer. The first of the series has already been published and covers neoadjuvant therapy and chemoradiotherapy used alone, while the second one addresses the efficiency of various surgical resection techniques for cancers of the esophagus and the gastro esophageal junction.