National Trends in Esophageal Surgery—Are Outcomes as Good as We Believe?

  • Geoffrey Paul Kohn
  • Joseph Anton Galanko
  • Michael Owen Meyers
  • Richard Harry Feins
  • Timothy Michael Farrell
2009 SSAT Plenary Presentation



Positive volume–outcome relationships in esophagectomy have prompted support for regionalization of care; however, outcomes have not recently been analyzed. This study examines national trends in provision of esophagectomy and reassesses the volume–outcome relationship in light of changing practice patterns and training paradigms.


The Nationwide Inpatient Sample was queried from 1998 to 2006. Quantification of patients’ comorbidities was made using the Charlson Index. Using logistic regression modeling, institutions’ annual case volumes were correlated with risk-adjusted outcomes over time, as well as presence or absence of fellowship and residency training programs.


A nationwide total of 57,676 esophagectomies were recorded. In-hospital unadjusted mortality fell from 12% to 7%. Adjusting for comorbidities, greater esophagectomy volume was associated with improvements in the incidence of most measured complications, though mortality increased once greater than 100 cases were performed. Hospitals supporting fellowship training or a surgical residency program did not have higher rates of mortality or total complications.


The current national mortality rate of 7% following esophagectomy is higher than is reported in most contemporary case series. A greater annual esophagectomy volume improves outcomes, but only up to a point. Current training paradigms are safe.


Esophagectomy Training programs Residency and internship Factual databases Trends 


  1. 1.
    Trivers KF, Sabatino SA, Stewart SL. Trends in esophageal cancer incidence by histology, United States, 1998–2003. Int J Cancer 2008;123(6):1422–1428.CrossRefPubMedGoogle Scholar
  2. 2.
    Horner MJ, Ries LAG, Krapcho M, Neyman N, Aminou R, Howlader N, Altekruse SF, Feuer EJ, Huang L, Mariotto A, Miller BA, Lewis DR, Eisner MP, Stinchcomb DG, Edwards BK (eds). SEER Cancer Statistics Review, 1975–2006. Bethesda: National Cancer Institute., based on November 2008 SEER data submission, posted to the SEER web site, 2009.
  3. 3.
    U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2005 Incidence and Mortality Web-Based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute, 2009. Available at:
  4. 4.
    Luft HS, Bunker JP, Enthoven AC et al. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med 1979;301(25):1364–3649.PubMedGoogle Scholar
  5. 5.
    Miller JD, Jain MK, de Gara CJ et al. Effect of surgical experience on results of esophagectomy for esophageal carcinoma. J Surg Oncol 1997;65(1):20–21.CrossRefPubMedGoogle Scholar
  6. 6.
    Gordon TA, Bowman HM, Tielsch JM et al. Statewide regionalization of pancreaticoduodenectomy and its effect on in-hospital mortality. Ann Surg 1998;228(1):71–78.CrossRefPubMedGoogle Scholar
  7. 7.
    Birkmeyer JD, Finlayson SR, Tosteson AN et al. Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy. Surgery 1999;125(3):250–256.PubMedGoogle Scholar
  8. 8.
    Pal N, Axisa B, Yusof S et al. Volume and outcome for major upper GI surgery in England. J Gastrointest Surg 2008;12(2):353–357.CrossRefPubMedGoogle Scholar
  9. 9.
    Alderson D. Scottish Intercollegiate Guidelines Network (SIGN) 87—the management of oesophageal and gastric cancer. Clin Oncol (R Coll Radiol) 2008;20(7):530–531.Google Scholar
  10. 10.
    National Comprehensive Cancer Network. Clinical practice guidelines in oncology: esophageal cancer. Fort Washington: National Comprehensive Cancer Network, 2009.Google Scholar
  11. 11.
    The Leapfrog Group. Evidence-Based Hospital Referral (EBHR) and Common Acute Conditions (CACs) Coding Specifications for Volume v5.1.1. Washington, DC: The Leapfrog Group, 2008.Google Scholar
  12. 12.
    The Leapgfrog Group Factsheet: Evidence-Based Hospital Referral Accessed May 3, 2009.
  13. 13.
    Birkmeyer JD, Dimick JB. Potential benefits of the new Leapfrog standards: effect of process and outcomes measures. Surgery 2004;135(6):569–575.CrossRefPubMedGoogle Scholar
  14. 14.
    Allareddy V, Konety BR. Specificity of procedure volume and in-hospital mortality association. Ann Surg 2007;246(1):135–139.CrossRefPubMedGoogle Scholar
  15. 15.
    Christian CK, Gustafson ML, Betensky RA et al. The Leapfrog volume criteria may fall short in identifying high-quality surgical centers. Ann Surg 2003;238(4):447–455. discussion 455–7.PubMedGoogle Scholar
  16. 16.
    van Lanschot JJ, Hulscher JB, Buskens CJ et al. Hospital volume and hospital mortality for esophagectomy. Cancer 2001;91(8):1574–1578.CrossRefPubMedGoogle Scholar
  17. 17.
    Dimick JB, Cowan JA Jr., Ailawadi G et al. National variation in operative mortality rates for esophageal resection and the need for quality improvement. Arch Surg 2003;138(12):1305–1309.CrossRefPubMedGoogle Scholar
  18. 18.
    Birkmeyer JD, Siewers AE, Finlayson EV et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346(15):1128–1137.CrossRefPubMedGoogle Scholar
  19. 19.
    Forshaw MJ, Gossage JA, Stephens J et al. Centralisation of oesophagogastric cancer services: can specialist units deliver? Ann R Coll Surg Engl 2006;88(6):566–570.CrossRefPubMedGoogle Scholar
  20. 20.
    Migliore M, Choong CK, Lim E et al. A surgeon’s case volume of oesophagectomy for cancer strongly influences the operative mortality rate. Eur J Cardiothorac Surg 2007;32(2):375–380.CrossRefPubMedGoogle Scholar
  21. 21.
    Yannopoulos P, Theodoridis P, Manes K. Esophagectomy without thoracotomy: 25 years of experience over 750 patients. Langenbecks Arch Surg 2009;394:611–616.CrossRefPubMedGoogle Scholar
  22. 22.
    Decker G, Coosemans W, De Leyn P et al. Minimally invasive esophagectomy for cancer. Eur J Cardiothorac Surg 2009;35(1):13–20. discussion 20–1.CrossRefPubMedGoogle Scholar
  23. 23.
    Collins G, Johnson E, Kroshus T et al. Experience with minimally invasive esophagectomy. Surg Endosc 2006;20(2):298–301.CrossRefPubMedGoogle Scholar
  24. 24.
    Law S, Wong KH, Kwok KF et al. Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer. Ann Surg 2004;240(5):791–800.CrossRefPubMedGoogle Scholar
  25. 25.
    Metzger R, Bollschweiler E, Vallbohmer D et al. High volume centers for esophagectomy: what is the number needed to achieve low postoperative mortality? Dis Esophagus 2004;17(4):310–314.CrossRefPubMedGoogle Scholar
  26. 26.
    Begg CB, Cramer LD, Hoskins WJ et al. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998;280(20):1747–1751.CrossRefPubMedGoogle Scholar
  27. 27.
    Dimick JB, Cattaneo SM, Lipsett PA et al. Hospital volume is related to clinical and economic outcomes of esophageal resection in Maryland. Ann Thorac Surg 2001;72(2):334–339. discussion 339–41.CrossRefPubMedGoogle Scholar
  28. 28.
    Patti MG, Corvera CU, Glasgow RE et al. A hospital’s annual rate of esophagectomy influences the operative mortality rate. J Gastrointest Surg 1998;2(2):186–192.CrossRefPubMedGoogle Scholar
  29. 29.
    Kuo EY, Chang Y, Wright CD. Impact of hospital volume on clinical and economic outcomes for esophagectomy. Ann Thorac Surg 2001;72(4):1118–11124.CrossRefPubMedGoogle Scholar
  30. 30.
    Dimick JB, Wainess RM, Upchurch GR Jr et al. National trends in outcomes for esophageal resection. Ann Thorac Surg 2005;79(1):212–216. discussion 217–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Rohatgi A, Sutcliffe R, Forshaw MJ et al. Training in oesophageal surgery—the gold standard: a prospective study. Int J Surg 2008;6(3):230–233.CrossRefPubMedGoogle Scholar
  32. 32.
    HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). 1998–2006. Rockville: Agency for Healthcare Research and Quality.
  33. 33.
    The Fellowship Council website. Directory of Fellowships Accessed September 11, 2008.
  34. 34.
    National Resident Matching Program. Website Accessed April 29, 2009.
  35. 35.
    The Society of Surgical Oncology. Website Access April 29, 2009.
  36. 36.
    American Medical Association website. FREIDA Online GME program search results. Accessed November 26, 2008.
  37. 37.
    Accreditation Council for Graduate Medical Education. website Access Novermber 26, 2008.
  38. 38.
    Healthcare Cost and Utilization Project (HCUP). 1998–2006 [database online]. Insert City of Publication Here see notes: Agency for Healthcare Research and Quality, Rockville, MD.Google Scholar
  39. 39.
    Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005;294(15):1909–1917.CrossRefPubMedGoogle Scholar
  40. 40.
    Scottish Intercollegiate Guidelines Network. Scottish Intercollegiate Guidelines Network (SIGN) 87—the management of oesophageal and gastric cancer: A national clinical guideline. Edinburgh: SIGN, 2006.Google Scholar
  41. 41.
    Kohn GP, Galanko JA, Overby DW et al. Volume–outcome relationships and other influences of outcome in bariatric surgery. Surg Endosc 2009;23(S1):149.Google Scholar
  42. 42.
    Urbach DR, Austin PC. Conventional models overestimate the statistical significance of volume–outcome associations, compared with multilevel models. J Clin Epidemiol 2005;58(4):391–400.CrossRefPubMedGoogle Scholar
  43. 43.
    Birkmeyer JD, Finlayson EV, Birkmeyer CM. Volume standards for high-risk surgical procedures: potential benefits of the Leapfrog initiative. Surgery 2001;130(3):415–422.CrossRefPubMedGoogle Scholar
  44. 44.
    Muller JM, Erasmi H, Stelzner M et al. Surgical therapy of oesophageal carcinoma. Br J Surg 1990;77(8):845–857.CrossRefPubMedGoogle Scholar
  45. 45.
    Whooley BP, Law S, Murthy SC et al. Analysis of reduced death and complication rates after esophageal resection. Ann Surg 2001;233(3):338–344.CrossRefPubMedGoogle Scholar
  46. 46.
    Gananadha S, Hazebroek EJ, Leibman S et al. The utility of FDG-PET in the preoperative staging of esophageal cancer. Dis Esophagus 2008;21(5):389–394.CrossRefPubMedGoogle Scholar
  47. 47.
    Tomaszek S, Cassivi SD. Esophagectomy for the treatment of esophageal cancer. Gastroenterol Clin North Am 2009;38(1):169–181. x.CrossRefPubMedGoogle Scholar
  48. 48.
    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(1):80–87.CrossRefPubMedGoogle Scholar
  49. 49.
    Rodgers M, Jobe BA, O’Rourke RW et al. Case volume as a predictor of inpatient mortality after esophagectomy. Arch Surg 2007;142(9):829–839.CrossRefPubMedGoogle Scholar
  50. 50.
    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.PubMedGoogle Scholar
  51. 51.
    Quan H, Li B, Saunders LD et al. Assessing validity of ICD-9-CM and ICD-10 administrative data in recording clinical conditions in a unique dually coded database. Health Serv Res 2008;43(4):1424–1441.CrossRefPubMedGoogle Scholar
  52. 52.
    Lacasse Y, Montori VM, Maltais F. Administrative database: validity of recording vs. validity of diagnosis. J Clin Epidemiol 2006;59(1):104. author reply 104–5.CrossRefPubMedGoogle Scholar
  53. 53.
    Kohn GP, Galanko JA, Overby DW et al. Recent trends in bariatric surgery case volume in the United States. Surgery 2009;146(2):375–380.CrossRefPubMedGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2009

Authors and Affiliations

  • Geoffrey Paul Kohn
    • 1
  • Joseph Anton Galanko
    • 2
  • Michael Owen Meyers
    • 3
  • Richard Harry Feins
    • 3
  • Timothy Michael Farrell
    • 3
  1. 1.Department of SurgeryUniversity of North CarolinaChapel HillUSA
  2. 2.Department of MedicineUniversity of North CarolinaChapel HillUSA
  3. 3.Department of SurgeryUniversity of North CarolinaChapel HillUSA

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