Centralization of Esophagectomy in the United States: Might It Benefit Underserved Populations?

Excerpt

For four decades, there has been nearly irrefutable evidence that higher programmatic surgical volume leads to reduced patient mortality for the most complex operations.1 At the turn of this century, Birkmeyer et al. clearly identified a volume–outcomes relationship for hospitals performing the procedure esophagectomy.2 Esophagectomy, as is pancreatectomy and pneumonectomy, is a “varsity level” surgical procedure, where one would assume that “practice” or doing a lot of said procedures “makes perfect.” A literature search in PubMed querying the terms esophagectomy and volume, between the years 2002 (the publication date of Birkmeyer et al. initial paper on the subject) to 2018, yields more than 500 references. Most of those studies support the volume–outcomes relationship for esophagectomy. Although there is no U.S. government mandate for regionalization or centralization of esophagectomy at high-volume centers, there is evidence that the American healthcare system may be voluntarily self-centralizing complex operations to high-volume centers.3 This could be via pressure from consumer advocacy organizations, such as the LeapFrog Group, which has established a minimum annual esophagectomy case number of 13 to define hospital quality, or even peer-pressure, as evidenced by the “volume pledge” taken by three major academic hospitals regarding annual minimums for esophagectomy.4,5 …