Volume-Outcome Relationship in Surgery for Esophageal malignancy: Systematic Review and Meta-analysis 2000-2011

The aim of this study is to provide a contemporary quantitative analysis of the existing literature examining the relationship between surgical caseload and outcome following esophageal resection. Medline, Embase, trial registries, conference proceedings and reference lists were searched for trials comparing clinical outcome following esophagectomy from high- and low-volume hospitals since 2000. Primary outcomes were in-hospital and 30-day mortality. Secondary outcomes were length of hospital stay and post-operative complications. Nine appropriate publications comprising 27,843 esophagectomy operations were included, 12,130 and 15,713 operations were performed in low- and high-volume surgical units, respectively. Esophagectomy at low-volume hospitals was associated with a significant increase in incidence of in-hospital (8.48% vs. 2.82%; pooled odds ratio (POR) = 0.29; P < 0.0001) and 30-day mortality (2.09% vs. 0.73%; POR = 0.31; P < 0.0001). There was insufficient data for conclusive statistical analysis of length of hospital stay or post-operative complications. This meta-analysis does suggest a benefit in the centralization of esophageal cancer surgery to high-volume institutions with respect to mortality. The outcomes of this study are of interest to patients, healthcare providers and payers, particularly regarding service reconfiguration and more specifically centralization of services. Future studies that look at long-term survival will help improve understanding of any late consequences such as survival and quality of life following esophageal surgery at low- and high-volume hospitals.