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Overall volume of upper gastrointestinal surgery positively impacts gastric cancer outcomes at centers with low gastrectomy volume
Kelsey Romatoski*, Susanna W. de geus, Sophie H. Chung, Marianna V. Papageorge, Alison P. Woods, Gordana Rasic, Sing Chau Ng, Jennifer F. Tseng, Teviah E. Sachs
General Surgery, Boston Medical Center, Boston, MA

Objective: The relationship between hospital volume and surgical mortality is well documented. However, complete centralization of surgical care is not always feasible due to a variety of factors including geographic constraints, insurance status and patient preference. The present study investigates how the overall volume of upper gastrointestinal surgery performed at a hospital influences patient outcomes following resection for gastric adenocarcinoma.

Design: Retrospective cohort study

Setting: Commission on Cancer accredited hospitals within the United States with low volumes of gastrectomy procedures

Patients: Patients with pathologic stage 1-3 gastric adenocarcinoma who underwent gastrectomy were identified from the National Cancer Database (NCDB) from 2010-2019. Three study cohorts were created: low-volume hospitals (LVH) for both gastrectomy and overall upper gastrointestinal operations, mixed-volume hospital (MVH) for low-volume gastrectomy but high-volume overall upper gastrointestinal operations, and high-volume gastrectomy hospitals (HVH). Sociodemographic factors and surgical outcomes were compared between the three cohorts using Chi-square tests for categorical variables, Wilcoxon rank-sum tests for continuous variables, and the Kaplan-Meier method for survival analysis.

Main outcome measure: 5-year overall survival

Results: In total, 39,125 patients were identified (LVH: 28,611; MVH: 1,218; HVH: 9,296). . 5-year survival was equivalent between MVH and HVH for all stages of disease (MVH: 50.1%, HVH 51.9%; p=0.3691) and when stratified into early (MVH: 62.2%, HVH: 63.7%; p=0.5593) and late stages (MVH: 26.4, HVH: 29.2%; p=0.3117) while LVH had worse survival at all stages. All measured outcomes were worse for LVH. There was no difference between MVH and HVH in post-operative margin status, 30 day readmission rates, and 30- and 90-day mortality rates. MVH had significantly greater proportion of patients with a shorter length of hospital stay compared to HVH.

Conclusions: We found that, despite a lower volume of gastrectomy for cancer, post-operative gastrectomy outcomes at centers that perform a high number of upper gastrointestinal cancer surgeries were similar to hospitals with high volume gastrectomy volume. These hospitals offer a blueprint for providing equivalent outcomes to enhance the availability of quality care for patients who are unable to receive treatment at high volume centers.

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