Effect of Esophageal Cancer Surgeon Volume on Management and Mortality From Emergency Upper Gastrointestinal Conditions: Population-based Cohort Study

Objective: To study the influence of esophageal cancer surgeon volume upon mortality from upper gastrointestinal emergencies. Background: Volume-outcome relationships led to the centralization of esophageal cancer surgery. Methods: Hospital Episode Statistics data were used to identify patients admitted to hospitals within England (1997–2012). The influence of esophageal high-volume (HV) cancer surgeon status (≥5 resections per year) upon 30-day and 90-day mortality from esophageal perforation (EP), paraesophageal hernia causing obstruction or gangrene (PEH) and perforated peptic ulcer (PPU) was analyzed, independent of HV esophageal cancer center status and patient and disease-specific confounding factors. Results: A total of 3707, 12,411, and 57,164 patients with EP, PEH, and PPU, respectively, were included. The observed 90-day mortality was 36.5%, 11.5%, and 29.0% for EP, PEH, and PPU, respectively. Management by HV cancer surgeon was independently associated with significant reductions in 30-day and 90-day mortality from EP (odds ratio, OR 0.51, 95% confidence interval, CI, 0.40–0.66), PEH (OR=0.70, 95% CI 0.53–0.91), and PPU (OR=0.85, 95% CI 0.7–0.95). Subset analysis of those patients receiving primary surgery as treatment showed no change in mortality when performed by HV cancer surgeons. However HV cancer surgeons performed surgery as primary treatment more commonly for EP (OR=2.38, 95% CI 1.87–3.04) and PEH (OR=2.12, 95% CI 1.79–2.51). Furthermore surgery was independently associated with reduced mortality for all 3 conditions. Conclusion: The complex elective workload of HV esophageal cancer surgeons appears to lower the threshold for surgical intervention in specific upper gastrointestinal emergencies such as EP and PEH, which in turn reduces mortality.

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