Abstract
Background
Performance of technically complex surgery at high-volume (HV) centers is associated with improved outcomes.
Objective
The aim of this study was to assess whether hospital gastrectomy volume is associated with surgical outcomes, and what threshold of case volume meaningfully impacts surgical outcomes.
Methods
We conducted a retrospective review of adult NCDB patients with gastric adenocarcinoma undergoing gastrectomy between 2004 and 2015. A multivariable Cox proportional hazards model with restricted cubic splines was used to examine the association of annual hospital gastrectomy volume and overall survival. Bootstrap simulation was used to estimate the cut-point corresponding to maximum change in log hazard ratio. Hospitals were divided into HV (≥ 17 cases/year) and low-volume (LV; < 17 cases/year) groups. We examined the relationship between volume groups and adequate nodal examination, R0 resection, unplanned readmission, and 30- and 90-day mortality.
Results
Our cohort consisted of 29,559 patients (7.8% treated at an HV center). Treatment at an HV center was associated with an increased likelihood of adequate nodal examination [odds ratio (OR) 2.12, 95% confidence interval (CI) 1.94–2.32] and R0 resection among patients with cardia tumors (OR 1.42, 95% CI 1.07–1.88). Patients treated at HV centers had decreased 30- and 90-day postoperative mortality, which was more pronounced in those undergoing total gastrectomy.
Conclusions
Treatment at an HV gastrectomy center is associated with improved surgical outcomes. Our study identified 17 cases/year as a clinically meaningful distinction between HV and LV centers. This definition of an HV center should be considered when evaluating regionalization of gastric cancer care to improve patient outcomes.
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References
Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? N Engl J Med. 1979;301(25):1364–9.
Ho V, Heslin MJ. Effect of hospital volume and experience on in-hospital mortality for pancreaticoduodenectomy. Ann Surg. 2003;237(4):509–14.
Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349(22):2117–27.
Sosa JA, Bowman HM, Gordon TA, et al. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg. 1998;228(3):429–38.
Luo G, Zhang Y, Guo P, Wang L, Huang Y, Li K. Global patterns and trends in stomach cancer incidence: age, period and birth cohort analysis. Int J Cancer. 2017;141(7):1333–44.
Hannan EL, Radzyner M, Rubin D, Dougherty J, Brennan MF. The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer. Surgery. 2002;131(1):6–15.
Finlayson EV, Goodney PP, Birkmeyer JD. Hospital volume and operative mortality in cancer surgery: a national study. Arch Surg. 2003;138(7):721–725; discussion 726.
Ikoma N, Kim B, Elting LS, Shih YT, Badgwell BD, Mansfield P. Trends in volume-outcome relationship in gastrectomies in Texas. Ann Surg Oncol. 2019;26(9):2694–702.
Enzinger PC, Benedetti JK, Meyerhardt JA, et al. Impact of hospital volume on recurrence and survival after surgery for gastric cancer. Ann Surg. 2007;245(3):426–34.
Macdonald JS, Smalley SR, Benedetti J, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med. 2001;345(10):725–30.
Karimi P, Islami F, Anandasabapathy S, Freedman ND, Kamangar F. Gastric cancer: descriptive epidemiology, risk factors, screening, and prevention. Cancer Epidemiol Biomark Prevent. 2014;23(5):700–13.
Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355(1):11–20.
Shapiro J, van Lanschot JJB, Hulshof M, et al. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS): long-term results of a randomised controlled trial. Lancet Oncol. 2015;16(9):1090–8.
Mokdad AA, Ali A, Yopp AC, et al. Adoption of evidence-based novel therapies in the treatment of gastric cancer: a national observational study. Cancer. 2018;124(6):1122–31.
Ju MR, Wang SC, Zeh HJ, Porembka MR. Minimally invasive gastrectomy for cancer and anastomotic options. J Surg Oncol. 2020;122(1):49–60.
American College of Surgeons. National Cancer Data Base. 1996–2016. https://www.facs.org/Quality-Programs/Cancer/NCDB.
American College of Surgeons. About the National Cancer Database. https://www.facs.org/quality-programs/cancer/ncdb/about.
Desquilbet L, Mariotti F. Dose-response analyses using restricted cubic spline functions in public health research. Stat Med. 2010;29(9):1037–57.
Wainess RM, Dimick JB, Upchurch GR Jr, Cowan JA, Mulholland MW. Epidemiology of surgically treated gastric cancer in the United States, 1988–2000. J Gastrointest Surg. 2003;7(7):879–83.
Datta J, Lewis RS Jr, Mamtani R, et al. Implications of inadequate lymph node staging in resectable gastric cancer: a contemporary analysis using the National Cancer Data Base. Cancer. 2014;120(18):2855–65.
Wu H, Rusiecki JA, Zhu K, Potter J, Devesa SS. Stomach carcinoma incidence patterns in the United States by histologic type and anatomic site. Cancer Epidemiol Biomark Prev. 2009;18(7):1945–52.
Diaz A, Pawlik TM. Optimal location for centralization of hospitals performing pancreas resection in California. JAMA Surg. 2020;155(3):261–3.
Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Med Care. 2011;49(12):1076–81.
Gordon TA, Burleyson GP, Tielsch JM, Cameron JL. The effects of regionalization on cost and outcome for one general high-risk surgical procedure. Ann Surg. 1995;221(1):43–9.
Gordon TA, Bowman HM, Tielsch JM, Bass EB, Burleyson GP, Cameron JL. Statewide regionalization of pancreaticoduodenectomy and its effect on in-hospital mortality. Ann Surg. 1998;228(1):71–8.
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Michelle R. Ju, James-Michael Blackwell, Herbert J. Zeh III, Adam C. Yopp, Sam C. Wang, and Matthew R. Porembka have no conflicts of interest to disclose.
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Ju, M.R., Blackwell, JM., Zeh, H.J. et al. Redefining High-Volume Gastric Cancer Centers: The Impact of Operative Volume on Surgical Outcomes. Ann Surg Oncol 28, 4839–4847 (2021). https://doi.org/10.1245/s10434-021-09655-y
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DOI: https://doi.org/10.1245/s10434-021-09655-y