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More practice - better results: applicable even in visceral surgery

Daniel Scheidegger

DOI: https://doi.org/10.4414/smw.2017.14492
Publication Date: 25.08.2017
Swiss Med Wkly. 2017;147:w14492

The population-based analyses by Guller and coauthors [1], now in Swiss Medical Weekly, provide evidence that patients undergoing oesophageal, gastric, pancreatic and rectal cancer resection in low-volume hospitals in Switzerland have a remarkably higher postoperative mortality rate compared with those in high-volume hospitals. They found for all cancer entities a relative decrease of postoperative mortality of between 29 and 68% in high-volume hospitals. Thus, the well-known association of lower hospital volume and higher mortality holds true even for Switzerland.

Eight years ago, the Swiss Cantons decided to elect a Decision Board and an additional Scientific Board for the concentration of highly specialised medicine in order to improve outcome quality. The initial recommendation by the Scientific Board to concentrate visceral surgery procedures relied entirely on the publications and experience of J.D. Birkmeyer. His New England Journal of Medicine paper on that topic had been published in 2002 [2] and the Scientific Board had had the opportunity to discuss the subject with him during a visit to Switzerland in 2010. We then thought that we had enough evidence to propose a concentration of oesophageal, liver, pancreatic and rectal surgery for cancer. We initially set the limit for a high-volume hospital for oesophageal surgery to 15 patients/year, for liver, pancreas and rectal surgery to 25 patients/year, based on the international literature.

The opposition from our colleagues and from several hospitals was very strong. We were taught that the training and skills of surgeons in the US and Switzerland could not be compared. A well-trained Swiss surgeon could perform these procedures with a high outcome quality in any hospital, even if performing them only once or twice a year. Since there were no outcome data available for our country, and since our second strong argument, that an experienced hospital team was also needed to look after these patients – including specially trained nurses, etc. – did not convince anyone, we were left with only two options: abandon the idea of concentrating a few highly specialised procedures in visceral surgery or start with 10 cases/year for a so-called high-volume hospital. That number of 10 was not supported by any scientific data, but was a compromise to get started.

It is therefore very encouraging to see in the present paper by Guller and co-authors [1] that even a low number of 10 patients/year for oesophageal surgery already results in an improvement of in-hospital mortality.

Will this paper help us to speed up with the planned centralization of those operations in high volume hospitals?

Unfortunately, scientific publications and evidence-based facts have never had any significant impact on such decisions. They are purely based on politics and prestige.

At the moment, a lot of money is spent by hospitals on employing lawyers to detect minor procedural deviations by the Scientific Board or the Decision Board. By bringing these to court, they can easily postpone the final decision by at least another 2 to 3 years. During that time, many patients who are not aware of these huge differences in in-hospital survival will still not be treated at the place where they would receive the best care.

1 Güller U, Warschkow R, Ackermann CJ, Schmied BM, Cerny T, Ess S. Lower hospital volume is associated with higher mortality after oeosophageal, gastric, pancreatic and rectal cancer resection: a Swiss population-based analysis. Swiss Med Wkly. 2017;147:w14473. http://dx.doi.org/10.4414/smw.2017.14473 PubMed

2 Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, et al.Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346(15):1128–37. doi:. http://dx.doi.org/10.1056/NEJMsa012337 PubMed

Scheidegger Daniel

Swiss Academy of Medical Science, Bern, Switzerland

No financial support and no other potential conflict of interest relevant to this article was reported.

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Daniel Scheidegger, MD, Swiss Academy of Medical Science, Laupenstrasse 7, CH - 3001 Bern, d.scheidegger[at]samw.ch