The Impact of Hospital Volume on Postoperative Outcomes for Esophagectomy and Gastrectomy: A Systematic Review and Meta-analysis

BACKGROUND: High-volume hospitals tend to have better outcomes in complex surgeries, but outcome variations and volume thresholds complicate conclusions. This systematic review/meta-analysis assessed the impact of hospital volume on postoperative outcomes after esophagogastric surgery and identified volume thresholds beyond which benefits plateau. METHODS: PubMed/MEDLINE was searched for cohort studies (2013-2023) on volume and outcomes after esophagectomy/gastrectomy for cancer. Primary outcome was 30-day mortality. Secondary outcomes included 90-day mortality, complications, length of stay (LOS), and long-term survival. The meta-analysis compared hospital volumes using odds ratios (ORs) for binary outcomes, hazard ratios (HRs) for survival, and mean differences (MDs) for LOS. A generalized estimating equation model assessed the continuous association between volume and 30-day mortality. Segmented regression identified volume thresholds where outcomes plateaued. RESULTS: Of 2679 articles, 56 studies on hospital volume and outcomes after esophagectomy and gastrectomy for cancer were included. High-volume hospitals (4-239 resections/year) showed lower 30-day mortality (OR 0.51; 95% confidence interval [CI] 0.43-0.59), 90-day mortality (OR 0.65; 95% CI 0.56-0.74), fewer complications (OR 0.83; 95% CI 0.74-0.94), shorter LOS (MD -1.50 days; 95% CI 0.97-2.03), and better survival (HR 0.83; 95% CI 0.78-0.87). Each doubling of volume demonstrated a significant reduction in 30-day mortality for esophagectomy (OR/volume-doubling 0.74; 95% CI 0.68-0.81) and gastrectomy (OR/volume-doubling 0.70; 95% CI 0.61-0.82). Breakpoints were identified at 43 cases for esophagectomy and 15 cases for gastrectomy per year, beyond which the association plateaued. CONCLUSIONS: Higher hospital volume is associated with lower mortality, reduced complications, shorter LOS, and improved survival. Identified thresholds exceed existing policy benchmarks, supporting further centralization of esophagogastric cancer surgery.