The effect of centralisation on the outcomes of oesophagogastric surgery--a fifteen year audit.
BACKGROUND
Centralisation of oesophagogastric (OG) resectional services has been proposed to improve patient outcomes in terms of perioperative mortality and long-term survival. Centralisation of services occurred in Gloucester 5 years ago. The aim of this paper is to assess if local patient outcomes have benefited from centralisation.


METHODS
All oesophagogastric resections performed in our unit over a 15-year period (10-years pre-centralisation and 5-years post-centralisation) were assessed retrospectively. Patient demographics, pathological details and date of death were identified. Perioperative mortality (30 and 90 day) and estimated Kaplan-Meier survival was compared for cases performed pre- and post-centralisation of services.


RESULTS
456 resections for cancer were performed in the 15-year period; 234 of these were performed pre-centralisation (mean 23.4, range 13-31) and 222 were performed post-centralisation (mean 44.4, range 40-50). Median survival rates for gastric cancer were 1.1 years pre-centralisation and 1.5 years post-centralisation (p = 0.147) and median survival for oesophageal cancer improved from 1.1 years to 2.1 respectively (p = 0.028). Combined OG 30-day mortality rates improved from 10.3% pre-centralisation to 3.6% post-centralisation (p = 0.006, Fisher's exact test).


CONCLUSIONS
Centralisation of OG services in Gloucester has resulted in twice as many resections being performed locally. Median survival for patients with oesophageal cancer has increased by 1 year and the 30-day mortality rate following resection has reduced by almost two thirds. Although other factors (such as improvements in oncological treatments, staging and critical care management over the 15-year time period) have undoubtedly had roles to play in these improvements, the results of this study support the policy of centralisation of upper GI cancer services.
Department of Upper GI Surgery, Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK. alexboddy@doctors.org.uk
Alexander P
AP
Boddy
James M L
JM
Williamson
Mark N
MN
Vipond
D002497:Centralized Hospital Services / Q000458:organization & administration*; D013505:Digestive System Surgical Procedures / Q000379:methods*; D004938:Esophageal Neoplasms / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008485:Medical Audit; D009367:Neoplasm Staging; D012189:Retrospective Studies; D013043:Specialties, Surgical / Q000458:organization & administration*; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D015996:Survival Rate; D016896:Treatment Outcome