title: Perioperative outcomes of esophageal cancer surgery in a mid-volume institution in the era of centralization.
abstract: BACKGROUND
  Centralization of esophageal cancer surgery to high-volume institutions has been shown to improve perioperative outcomes in several studies. However, there is an ongoing debate, whether defined minimal annual hospital volumes for esophagectomies are required for quality assurance. The aim of the study was to assess perioperative outcomes of esophagectomies in a single institution in Switzerland.
  
  
  METHODS
  Data from a database of esophagectomies performed between 2004 and 2013 was analyzed. Perioperative morbidity of esophagectomies due to cancer was assessed according to the Clavien-Dindo classification. Postoperative mortality was defined as death from any cause within the same hospital stay.
  
  
  RESULTS
  A total of 143 operations (125 transthoracic esophagectomies, 18 extended transhiatal gastrectomies) were performed in the surveyed 10-year period. Two surgeons performed 91 % of all procedures. Postoperative morbidity was 43.4 %. Complications with a Clavien-Dindo score of III/IV (requiring surgical, endoscopic, or radiological intervention) occurred in 19 cases (13.4 %). The overall anastomotic leak rate was 3.5 %. Pulmonary complications were the most frequent postoperative problems involving 21 % of patients. In-hospital mortality was 0.7 %. Mean length of hospital stay was 17 days in patients with no complications and 22 days if there were any complications (p < 0.001).
  
  
  CONCLUSIONS
  Esophageal cancer surgery is complex and has a significant risk of morbidity. The most common postoperative problems are pulmonary complications, usually responding well to non-invasive treatment. Appropriate patient selection and preparation, high surgeon volume, and a comprehensive multidisciplinary care pathway can provide a low perioperative mortality rate in a mid-volume institution.
authors.affiliation: Department of Surgery, St. Claraspital, Kleinriehenstrasse 30, 4058, Basel, Switzerland. silvio.daester@usb.ch.
authors.forename: Silvio
authors.initials: S
authors.lastname: Däster
authors.affiliation: Department of Surgery, St. Claraspital, Kleinriehenstrasse 30, 4058, Basel, Switzerland.
authors.forename: Savas D
authors.initials: SD
authors.lastname: Soysal
authors.affiliation: Department of Surgery, St. Claraspital, Kleinriehenstrasse 30, 4058, Basel, Switzerland.
authors.forename: Luca
authors.initials: L
authors.lastname: Koechlin
authors.affiliation: Department of Surgery, St. Claraspital, Kleinriehenstrasse 30, 4058, Basel, Switzerland.
authors.forename: Lea
authors.initials: L
authors.lastname: Stoll
authors.affiliation: Department of Surgery, St. Claraspital, Kleinriehenstrasse 30, 4058, Basel, Switzerland.
authors.forename: Ralph
authors.initials: R
authors.lastname: Peterli
authors.affiliation: Department of Surgery, St. Claraspital, Kleinriehenstrasse 30, 4058, Basel, Switzerland.
authors.forename: Markus
authors.initials: M
authors.lastname: von Flüe
authors.affiliation: Department of Surgery, St. Claraspital, Kleinriehenstrasse 30, 4058, Basel, Switzerland.
authors.forename: Christoph
authors.initials: C
authors.lastname: Ackermann
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000601:surgery*; D002497:Centralized Hospital Services; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy; D005260:Female; D005743:Gastrectomy; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013557:Switzerland; D016896:Treatment Outcome
keywords: Esophageal cancer; Esophagectomy; Hospital volume; Perioperative outcomes