Outcome of low-volume surgery for esophageal cancer in a high-volume referral center

Background: There is a known inverse relationship between the number of esophagectomies and in-hospital mortality. Our institute is a tertiary referral center with a high caseload of esophageal cancer patients, but with a low annual volume of esophagectomies. The objective of our study was to evaluate the results of esophageal cancer surgery in our institute and to compare these results with published data from high-surgical-volume institutions. Methods: Between 1995 and 2007, 1,499 patients with esophageal cancer were referred: for a second opinion only (n = 568), following earlier treatment (n = 103), for palliative treatment (n = 665) or for potentially curative treatment (local endoscopic therapy n = 5, definitive chemoradiotherapy n = 71, or surgery n = 87). The surgically treated patients were studied in detail, and compared with patients treated in high-surgical-volume hospitals. Results: Surgery consisted of a transhiatal (n = 71) or transthoracic (n = 12) esophagectomy, or exploration only (n = 4). Fifty-six (64%) patients received neoadjuvant treatment. A microscopic radical resection was achieved in 96%. Pathologic complete response rate was 25%. Forty-four (53%) patients had a complicated postoperative course, and one (1%) patient died. At a median postoperative follow-up of 30 (1-149) months, 1- and 3-year overall survival rates were 89% and 60%, respectively. No major differences were observed between our results and those presented in six large study cohorts with high operative volumes. Conclusions: Outcome of low-volume esophageal surgery can be comparable to published high-surgical-volume results. More relevant factors other than hospital volume alone should be taken into account to improve outcome of esophageal cancer surgery.