1. Esophagectomy for cancer:
Surgeon case volume may be more important than hospital volume for good quality of outcome
INTRODUCTION
Georges Decker, Hélène Groot Koerkamp
Centre de Chirurgie Tumorale, ZithaKlinik Luxembourg
36, rue Sainte Zithe L-2763 Luxembourg
Introduction: Esophagectomy for cancer is considered to be one of the operations with the strongest volume-outcome relationships. Numerous studies have shown that so-called "high-volume" hospitals achieve lower mortality&morbidity rates but also better oncological outcome than "low-volume" hospitals. However, the definitions and ideal volume cut-offs remain controversial and the real determinants of good quality of care in esophageal cancer surgery remain to be defined. These determinants are important to be found since worldwide in many areas, "centralisation" may not be a realistic option.
Methods: We retrospectively analysed the outcome of 63 primary esophagectomies for esophageal cancer performed by a single surgeon between 2002 and 2011 in 2 subsequent "low-volume” hospitals in Luxembourg (34 resections over 7 years at Centre Hospitalier Luxembourg followed by 29 resections over 5 years at Zithaklinik, figure 1). This analysis excludes 8 esophagectomies performed during the same time period for other indications: benign diseases (6), salvage esophagectomies after definitive chemo-radiation (2). Both hospitals in Luxembourg were "low-volume" hospitals (less than 10 resections per year) as no other surgeon had performed any esophagectomy in these hospitals during the same time period. However, the surgeon was a "high-volume" surgeon as during the same time period, he had also performed more than 190 cancer esophagectomies in a University hospital in Belgium (UZ-Leuven).
Results: Sixty-three patients underwent subtotal esophagectomy with partial gastrectomy and radical lymph node dissection (LND): 2 field LND in 56 patients, 3-field LND in 7 patients (11%). Median age was 65 years (36-83). Induction chemo- or chemo-radiotherapy was administered in 14% of patients. Tumor histology was squamous cell cancer in 27% and adenocarcinoma in 71%. All patients, except for one transhiatal resection, underwent trans-thoracic resections. The majority of procedures were performed by a left thoraco-abdominal approach with cervical anastomosis. Overall, 58 patients (92%) had their anastomosis in the neck.
Median operative time was 400 minutes ( ). Median blood loss was 380 ml ( ) and peri-operative transfusion rate was 27%. Fifty-three patients (84%) were extubated in the OR at the end of the operation.
Overall 30-day mortality was 1.6% due to respiratory failure in one patient (day 22). 90-day mortality rate was 3.2% as one patient died from fulgurant metastatic tumor progression after 66 days. Prospective complication assessment found deviations from the ideal protocol in 67% of patients and reoperations in 11% of patients. Overall post-operative hospital stay was 19 days (9-121), being 20 days in the first hospital versus 16 days in the second hospital (p=0.77).
Complete resection (R0) was obtained in 92% of patients. A median of 37 lymph nodes (8-69) were examined per patient. Forty-three patients (68%) were pN+ as they had at least one lymph node involved by tumor (median 2 positive nodes, range 1-29).
After a median follow-up of 23 months ( ), respectively 33 months (7-121) for the survivors, overall median survival was 38 months (mean survival of 65 months).
Five and 10-year survival probabilities were 47% respectively 43%, despite the fact that 65% of all patients were in pTNM stages 3 or 4. 5-year survival for stage p3A patients (TNM 7th edition) was 53%. Mean survival for N0 patients was 83 months, compared to 49 months for N+ patients. Estimated 5-year survival for N+ patients was 41% versus 63% for N0 patients (log Rank test p=0.038).
Conclusion: For cancer esophagectomy, the individual surgeon's training and experience may be a much more important determinant of outcome than "hospital volumes”. “Low-volume" hospitals with adequate organization and equipment can achieve surgical and oncological outcome at least similar to large tertiary referral centers.
Figure 1: Annual case load of esophageal cancer resections
Figure 2: Overall Kaplan-Meier survival curve
Figure 3: Survival curve comparison N0 versus N+ patients, log rank test p=0.038
Figure 4: pTNM stages (7th edition 2009)