Centralization of

Esophagectomy:
How Far Should We Go?
Daniel Henneman, MD, Johan L. Dikken, MD, PhD, Hein Putter, PhD, Valery E. P. P. Lemmens, PhD,
Lydia G. M. Van der Geest, MSc, Richard van Hillegersberg, MD, PhD, Marcel Verheij, MD, PhD,
Cornelis J. H. van de Velde, MD, PhD, and Michel W. J. M. Wouters, MD, PhD

Annals of Surgical Oncology. (2014). 21: 4068-4074

1
Outline
Introduction
Methods
Results
Discussions
Critiques

2
INTRODUCTION
n Esophagectomy:
High postoperative mortality (8.9%) in the western world.
5 year survival rate after the surgery is around 50%.
n Compelling evidence showed that patients have better short- and
long-term outcomes when operated in high caseload of
esophagectomy hospitals.
n Minimum volume standards

3
 Minimum volume standards
American Leapfrog group
2000svolume outcomes

10 (2017)

Source: http://www.leapfroggroup.org/sites/default/files/Files/Proposed-Changes-2017-
Leapfrog-Hospital-Survey-Final.pdf 4
Minimum volume standards for esophagectomy

(minimum esophagectomies per
hospital annually)
American Leapfrog group 13 (2011)
20 (2017)
Netherlands 10 (2006)
20 (2011)
Great Britain and Ireland 60 (2010)

5
INTRODUCTION
n
volume categories case-mix adjusted outcomes

An American study shows a cutoff point of 15 resections per year showed
the largest difference in postoperative mortality.
1999-2000 UHC clinical database: found the volume threshold of 22
resections showing greatest difference.
A meta-analysis of relevant literatures (1990-2003) showed the differences
were best discriminated using a volume threshold of at least 20 resections.
20

6
INTRODUCTION
n However,

?
nonlinear statistical modelingcutoff
point

Purpose
Define a meaningful cutoff point for annual hospital volume for esophagectomy
by using nonlinear statistical modeling techniques.

7
METHODS

Dataset Patients

Statistical
Analyses

8
METHODS

Dataset
n Netherlands Cancer Registry(NCR)

n ICD-O
classify tumors as adenocarcinoma(8,1408,145, 8,190, 8,2018,211, 8,243, 8,2558,401, 8,4538,520,
8,572, 8,573, 8,576), squamous cell carcinoma (SCC) (8,032, 8,033, 8,0518,074, 8,0768,123), and
other/unknown histology (8,0008,022, 8,0418,046, 8,075, 8,147, 8,153, 8,200, 8,2308,242, 8,244
8,249, 8,430, 8,530, 8,560, 8,570, 8,574, 8,575)
n Staging:
International Union Against Cancer (UICC) Tumor
Node Metastases (TNM) classification

9
METHODS

Patients
January 1989 - December 2009

37,560
esophageal or gastric cardia cancer

(N=26,521)

11,039

situ and M1 disease (N=1,104)

10,025
10
METHODS

Statistical Analyses
Year of diagnosis
adjust

Outcomes (HR)
1.
2.
nCox regression
Patients adjusted for sex, age, socioeconomic status, tumor
stage, morphology, preoperative therapy use,
postoperative therapy use (only for 2 year
mortality)
n Nonlinear statistical modeling
11
METHODS

Statistical Analyses
n Chi square test Baseline difference
n Cox regression
adjusted for sex, age, socioeconomic status, tumor stage, morphology,
preoperative therapy use, postoperative therapy use (only for 2 year mortality)

n Robust standard errors

n Sensitivity analysis

n Softwares: SPSS (version 17.0.2) and R (version 2.12.2)

12
RESULTS
1. Patient characteristics

13
RESULTS
2. Hospital Volumes

n
1989: 352 2009: 723
n range: 1-83 per year
n 20
1989: 7% 2009: 64%
n 20099244

14
RESULTS
3.1 Volume-outcome analyses

15
RESULTS
3.2 Volume-outcome curve

16
DISSCUSSIONS
n 20 per year minimum volume standard

n Further centralization up to 40-60 esophagectomies per year per
hospital improved both short-term mortality and long-term survival.
n Beyond 60 point, no further improvement was detected.
n It is possible to detect a greater effect of volumes >60 resections per
year with more hospitals in this higher end of the spectrum.

17
DISSCUSSIONS
n


n Volume-based referral V.S. Outcome-based referral

18
CRITIQUES
n 2012paper

n 20

n Preoperative therapy
bias?

19
CRITIQUES
n 2012paper

20
CRITIQUES
n 2012paper

n 20

n Preoperative therapy
bias?

(Dikken,2012)
21
CRITIQUES
n 2012paper

n 20

n Preoperative therapy
bias?
n Outcomes6 months mortality 2 year mortality
readmission rateoutcome
n Sensitivity analysis

22
CRITIQUES
n Volume-outcome curvevolume606 months
mortality 2 year mortality
mortality

n44

23
THANK YOU.

24