Relationship between Hospital Volume and Short-Term Postoperative Outcomes in Thoracoscopic Esophageal Cancer Surgery: A Study of Mortality and Postoperative Complications Using a Nationwide Database in Japan.

Abstract

Esophagectomy is a high-complexity procedure, and the relationship between hospital volume, measured by the annual number of esophageal surgeries per hospital, and treatment outcomes remains a subject of debate. This study used a nationwide administrative database to identify patients diagnosed with stage 2 and stage 3 esophageal cancer between April 1, 2016, and March 31, 2022. We focused on patients who underwent preoperative chemotherapy and thoracoscopic esophageal cancer surgery and examined the relationship between hospital volume, in-hospital mortality, and postoperative complications. The hospitals were categorized into two groups: the low-volume group (n = 2,629) with less than 12 thoracoscopic esophagectomies performed annually and the high-volume group (n = 5,325) with 12 or more. We conducted propensity score matching analysis to match pairs of patients between the low-volume and high-volume groups (n = 1,984, each). In the analysis after matching, the in-hospital mortality rates were higher in the low-volume group compared to the high-volume group (1.4% vs. 0.5%, p = 0.0022). Furthermore, the incidence of postoperative complications was significantly higher in the low-volume group compared to the high-volume group: wound infections (1.7% vs. 0.7%, p = 0.0337), anastomotic leakage (6.5% vs. 2.8%, < 0.0001), and recurrent laryngeal nerve paralysis (8.3% vs. 6.5%, p = 0.0291). However, the incidence of postoperative pneumonia was higher in the high-volume group (1.7% vs. 3.5%, p = 0.0003). The length of postoperative hospital stay was also significantly longer in the low-volume group compared to the high-volume group (24 days, IQR: 18-35 vs. 20 days, IQR: 16-28, p < 0.0001). Further analysis considering the patient's quality of life, access to hospitals, and careful discussion is necessary to determine the appropriateness of esophagectomy centralization.