Should esophagectomy be performed in a low-volume center?

A significant difference has been reported between rates of morbidity and mortality for elective esophagectomy performed at low-volume centers versus high-volume centers. Some authors have suggested that complex surgical procedures such as esophagectomy should be performed only in regional centers by surgeons with an extensive procedure-specific experience. This study was performed to review recent (5 years) experience with esophagectomy in two university-affiliated hospitals where a limited number of esophageal resections are performed annually. Esophageal resections performed between February 1995 and February 2000 at two university-affiliated tertiary-care hospitals were analyzed for operative morbidity and mortality. Variables reviewed included demographics, surgeon experience, mortality, and complications. Forty-three patients underwent elective esophagectomy during the 5-year study period. In-hospital mortality was 7.0 per cent and 30-day mortality was 4.7 per cent. The anastomotic leak rate was 11.6 per cent. No patients developed myocardial infarction or renal failure. Morbidity and mortality rates from our low-volume centers compared favorably with high-volume centers. We conclude that elective esophagectomy can be safely performed at low-volume centers with favorable morbidity and mortality rates. Recommendations urging regionalization of high-risk procedures should be guided by local outcomes and not by the total number of procedures performed at a specific center.