title: The influence of surgical volume on hospital mortality and 5-year survival for carcinoma of the oesophagus and gastric cardia.
abstract: OBJECTIVE
  To study the effects of hospital operation volume on hospital mortality and 5-year survival in patients treated with resection for carcinoma of the oesophagus and gastric cardia.
  
  
  BACKGROUND
  Surgery due to tumours of the oesophagus and gastric cardia is probably associated with the highest postoperative morbidity and mortality of all elective surgical procedures. Concentration to high-volume centres has been suggested to improve the outcome.
  
  
  METHODS
  Between 1987 and 1996, all patients with squamous cell carcinoma or adenocarcinoma of the oesophagus or gastric cardia were identified from the Swedish Cancer Registry and the Swedish Hospital Discharge Registry. The study population was assessed according to patients operated at hospitals with a low (L-V), intermediate (I-V) or high operation volume (H-V), defined as <5 resections/year, 5-15 resections/year and >15 resections/year, respectively. We analyzed hospital mortality and 5-year survival.
  
  
  RESULTS
  During the study period, 1429 patients were treated with resection for carcinoma of the oesophagus (n=665) or the gastric cardia (n = 764). A total of 74 hospitals were registered with at least one surgical resection, of which 90% performed <5 resections/year. The distribution of gender and age was comparable in the three groups. Hospital mortality was 10.4, 6.3 and 3.5% in the L-V, I-V and H-V groups, respectively. Overall 5-year survival was 17% (L-V), 19% (I-V) and 22% (H-V). Multivariate analysis showed an improved long-term survival for patients operated at H-V compared to L-V hospitals (p=0.02).
  
  
  CONCLUSIONS
  This study supports an inverse relationship between hospital volume and hospital mortality after surgical tumour resection of the oesophagus or gastric cardia. Overall 5-year survival was significantly higher at high-volume hospitals compared to low-volume centres. We believe that concentrating these patients in high-volume hospitals is necessary to achieve high quality surgical treatment and to facilitate research aiming to improve prognosis.
authors.affiliation: Department of Surgery, Lund University Hospital, Lund, Sweden.
authors.forename: Jörgen
authors.initials: J
authors.lastname: Wenner
authors.forename: Thomas
authors.initials: T
authors.lastname: Zilling
authors.forename: Anna
authors.initials: A
authors.lastname: Bladström
authors.forename: Thor A
authors.initials: TA
authors.lastname: Alvegård
mesh_terms: D000230:Adenocarcinoma / Q000453:epidemiology / Q000401:mortality* / Q000601:surgery; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000453:epidemiology / Q000401:mortality* / Q000601:surgery; D002299:Cardia / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000453:epidemiology / Q000401:mortality* / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012042:Registries; D012306:Risk; D013272:Stomach Diseases / Q000453:epidemiology / Q000401:mortality* / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome