Complex gastric surgery in Germany—is centralization beneficial? Observational study using national hospital discharge data



This observational study explored the association between hospital volume and short-term outcome following gastric resections for non-bariatric indication, aiming to contribute to the discussion on centralization of complex visceral surgery in Germany.


Based on complete national hospital discharge data from 2010 to 2015, the association between hospital volume and in-hospital mortality was evaluated according to volume quintiles and volume deciles. Case-mix differences regarding surgical indication, age, sex, and comorbidities were considered for risk adjustment. In addition, rates of major complications and failure to rescue were analyzed across hospital volume categories.


Inpatient episodes (72,528) with gastric resection were analyzed. Risk-adjusted mortality in patients treated in very low volume hospitals (median volume of 5 surgeries per year) was higher (12.0% [95% CI 11.4 to 12.5]) compared to those treated in very high volume hospitals (50 surgeries per year; 10.6% [10.0 to 11.1]). Failure to rescue patients with complications was 28.1% [27.0 to 29.3] in very low volume hospitals and 22.7% [21.6 to 23.8] in very high volume hospitals. Differences were similar within the subgroup of patients operated for gastric cancer.


Treatment in very high volume hospitals is associated with a lower in-hospital mortality compared to treatment in very low volume hospitals. This effect seems to be determined by the ability to rescue patients who experience complications. As the observed benefit is only related to very high volumes, the results do not clearly indicate that centralization may improve short-term results substantially, unless a very high degree of centralization would be achieved. Possibly, further research focusing on other outcome measures, such as clinical processes or long-term results, might lead to divergent conclusions.

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Author information




UN, TH, and DL designed the study. UN performed the data analysis. All authors interpreted the data. UN and TH performed literature search and drafted the manuscript. DL, IG, and TM edited the manuscript and provided intellectual input. TH and UN contributed equally to this article.

Corresponding author

Correspondence to Ulrike Nimptsch.

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Conflicts of interest

All authors have completed the ICMJE uniform disclosure form and declare: The Department for Structural Advancement and Quality Management in Health Care at Technische Universität Berlin, for which UN and TM worked from 2010 to 2018, received ongoing funding from Helios Kliniken GmbH. TH, IG, and DL have nothing to disclose.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors. In accordance with the German guideline for conducting administrative data analyses “Good Practice in Secondary Data Analysis (GPS),” no ethical approval was required for this study.

Swart E, Gothe H, Geyer S, Jaunzeme J, Maier B, Grobe TG, Ihle P; German Society for Social Medicine and Prevention; German Society for Epidemiology. [Good Practice of Secondary Data Analysis (GPS): guidelines and recommendations]. Gesundheitswesen 2015;77(2):120–6.

Informed consent

This study used administrative data provided by the Research Data Centre of the German Federal Statistical Office. In accordance with the terms of use regarding microdata provided by the Research Data Centres of the Federal Statistical Office and the Statistical Offices of the Federal States, no informed consent was required for this study.

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Nimptsch, U., Haist, T., Gockel, I. et al. Complex gastric surgery in Germany—is centralization beneficial? Observational study using national hospital discharge data. Langenbecks Arch Surg 404, 93–101 (2019).

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  • Gastric surgery
  • Centralization
  • Failure to rescue
  • Hospital discharge data
  • Volume outcome relation