title: Is Centralization Needed for Esophageal and Gastric Cancer Patients With Low Operative Risk?: A Nationwide Study.
abstract: OBJECTIVE
  To investigate the impact of center volume on postoperative mortality (POM) according to patient condition.
  
  
  BACKGROUND
  Centralization has been shown to improve POM in esophageal and, to a lesser extent, gastric cancer surgery; however, the benefit of centralization for patients with low operative risk is questionable.
  
  
  METHODS
  All consecutive patients who underwent esophageal or gastric cancer surgery between 2010 and 2012 in France were included (N = 11,196). The 30-day POM was compared in terms of the center volume (low: <20 cases per year, intermediate: 20-39, high: 40-59, and very high: ≥60) and stratified according to the Charlson score (0, 1-2, ≥3). The consistency across the esophageal (n = 3286) and gastric (n = 7910) subgroups, and variations between 30-day and 90-day POM were analyzed.
  
  
  RESULTS
  Low-volume centers treated 64.2% of patients. A linear decrease in 30-day and 90-day POM was observed with increasing center volume, with rates of 5.7% and 10.2%, 4.3% and 7.9%, 3.3% and 6.7%, and 1.7% and 3.6% in low, intermediate, high, and very high-volume centers, respectively (P < 0.001). Comparing low and very high-volume centers, 30-day POM was 4.0% versus 1.1% for Charlson 0 (P = 0.001), 7.5% versus 3.4% for Charlson 1 to 2 (P < 0.001), and 14.7% versus 3.7% for Charlson ≥3 (P = 0.003) patients. A similar linear decrease was observed in the esophageal and gastric cancer subgroups. Between the low and very high-volume centers, an almost 70% reduction in the relative risk of POM was systematically observed, independent of Charlson score or tumor location.
  
  
  CONCLUSIONS
  To improve POM, esophageal and gastric cancer surgery should be centralized, irrespective of the patient's comorbidity or tumor location.
authors.affiliation: *Univ.Lille, Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France†Univ.Lille, UMR-S 1172 - JPARC - Centre de Recherche Jean-Pierre AUBERT Neurosciences et Cancer, Lille, France‡Inserm, UMR-S 1172, F-59000 Lille, France§Department of Digestive and Oncological Surgery, E. Herriot University Hospital, Lyon, France¶Claude Bernard Lyon 1 University, Lyon, France||SIRIC OncoLille, France**Hox-Com Analytiques, Paris, France††UniversityLille, Department of Pathology, Centre de Biologie et de Pathologie, University Hospital, Lille, France.
authors.forename: Arnaud
authors.initials: A
authors.lastname: Pasquer
authors.forename: Florence
authors.initials: F
authors.lastname: Renaud
authors.forename: Flora
authors.initials: F
authors.lastname: Hec
authors.forename: Anne
authors.initials: A
authors.lastname: Gandon
authors.forename: Marguerite
authors.initials: M
authors.lastname: Vanderbeken
authors.forename: Vincent
authors.initials: V
authors.lastname: Drubay
authors.forename: Gilbert
authors.initials: G
authors.lastname: Caranhac
authors.forename: Guillaume
authors.initials: G
authors.lastname: Piessen
authors.forename: Christophe
authors.initials: C
authors.lastname: Mariette
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002497:Centralized Hospital Services; D004938:Esophageal Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D005260:Female; D005602:France / Q000453:epidemiology; D017052:Hospital Mortality; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data*; D061846:Hospitals, Low-Volume / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013274:Stomach Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D015996:Survival Rate; D055815:Young Adult