Is There a Rationale for Structural Quality Assurance in Esophageal Surgery?

Abstract

Background: Advances regarding perioperative mortality rates and oncological outcomes after esophagectomy have been reported extensively by specialized high-volume centers in Europe and the USA over the last decade. However, recent database analyses reveal that the perioperative mortality of esophagectomy remains high in these countries, indicating a discrepancy between surgical quality in baseline hospitals and specialized centers.

Methods: This article provides an overview over the existing literature on the correlation between structural quality, procedural volume, and surgical outcome in e- sophageal surgery.

Results: Structural, procedural and outcome measures can be used to assess the quality of surgical treatment and perioperative management. Surgical procedures on the esophagus for both benign and malignant diseases are rare and typically associated with high perioperative morbidity and mortality. Usually, direct outcome measures do not provide enough statistical power to actually identify differences in surgical quality between hospitals, making structural quality measures the only feasible parameter to compare the quality of e- sophageal surgery among different centers. Several analyses from different countries have shown a strong correlation between hospital volume and postoperative mortality. Data from countries in which esophageal surgery has been centralized indicate beneficial effects of a centralized health care system on postoperative mortality after esophagectomy. Additionally, only high-volume centers generally provide optimal preoperative and postoperative management and comprehensive access to modern multimodal treatment. In Germany, esophageal surgery is still decentralized, but hospitals performing complex esophageal procedures have to fulfill minimum caseload requirements of 10 cases per year. In practice, these requirements are not met by the majority of hospitals and a detrimental effect on the achieved surgical outcomes can be noted.

Conclusion: Therefore, we conclude that structural quality assurance is crucial to further reduce postoperative morbidity after esophageal surgery and to improve long-term results.

Keywords: Esophageal cancer; Esophagectomy; Hospital volume; Structural quality.

Fig. 1

Percentage of cases treated in institutions in Germany that did not meet minimum caseload requirements from 2005 to 2011. Esophageal surgery has the highest percentage of patients treated outside of hospitals that fulfill minimum caseload requirements of all applicable procedures. *¹Institutions that only performed post-mortem organ removal have been excluded; *²two-tailed p-value for linear trend (2006–2011), < 0.05. Adapted from [39]. Reprinted with kind permission. © 2017 Deutscher Ärzteverlag GmbH. All rights reserved.