What provider volumes and characteristics are appropriate for gastric cancer resection? Results of an international RAND/UCLA expert panel.
BACKGROUND
A relationship between higher volume providers and improved outcomes has been suggested by some studies and has been used to construct guidelines for many diseases. For gastric cancer (GC), however, optimal volume cutoffs are not clear.


METHODS
A multidisciplinary expert panel of 16 physicians from 6 countries scored 120 scenarios regarding provider characteristics for gastric resections for GC. Appropriateness of scenarios was scored from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores from 1 to 3 were considered inappropriate, 4 to 6 uncertain, and 7 to 9 appropriate. Agreement was reached when 12 of 16 panelists scored the statement similarly. Appropriate scenarios agreed on were scored subsequently for necessity.


RESULTS
Surgeon and hospital practice volume scenarios were evaluated. The panel felt it was inappropriate for surgeons doing ≤2 GC cases per year to perform a multivisceral resection (MVR), D2 lymphadenectomy (D2-LND), or laparoscopic total gastrectomy, and ≤6 GC cases per year for an MVR involving a pancreatoduodenectomy (MVR-PD), or endoscopic mucosal resections (EMR). It was considered appropriate for surgeons doing ≥11 GC cases per year to perform open gastrectomy or D2-LND, and ≥20 GC cases per year for any MVR, laparoscopic gastrectomy, or EMR. For hospitals, it was considered inappropriate for hospitals managing ≤4 GC cases per year to perform D2-LND or laparoscopic total gastrectomy, and ≤10 GC cases per year, for MVR-PD or EMR. Hospital volumes ≥21 cases per year was considered appropriate for any GC procedure. It was inappropriate for an MVR to be performed in a hospital without interventional radiology services and for a MVR-PD in a hospital with no level I intensive care unit.


CONCLUSIONS
Appropriate and inappropriate provider volumes for a variety of gastric procedures have been defined by an international expert panel.
Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Surgery, Maimonides Medical Center, Brooklyn, NY.
Matthew
M
Dixon
Alyson
A
Mahar
Lawrence
L
Paszat
Robin
R
McLeod
Calvin
C
Law
Carol
C
Swallow
Lucy
L
Helyer
Rajini
R
Seeveratnam
Roberta
R
Cardoso
Tanios
T
Bekaii-Saab
Ian
I
Chau
Neal
N
Church
Daniel
D
Coit
Christopher H
CH
Crane
Craig
C
Earle
Paul
P
Mansfield
Norman
N
Marcon
Thomas
T
Miner
Sung Hoon
SH
Noh
Geoff
G
Porter
Mitchell C
MC
Posner
Vivek
V
Prachand
Takeshi
T
Sano
Cornelis J H
CJ
Van de Velde
Sandra
S
Wong
Natalie
N
Coburn
D000230:Adenocarcinoma / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000592:standards*; D061846:Hospitals, Low-Volume / Q000592:standards*; D006801:Humans; D038622:Internationality; D013043:Specialties, Surgical / Q000592:standards*; D013274:Stomach Neoplasms / Q000601:surgery*