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J Thorac Cardiovasc Surg 2009;137:28-29
© 2009 The American Association for Thoracic Surgery

Invited Commentary

Discussion

Dr A. Pennathur (Pittsburgh, Penn). Dr Meguid, that was an excellent presentation and I congratulate you on your efforts to define a cutoff volume. Dr Meguid and colleagues from the Johns Hopkins Hospital have analyzed the outcomes of more than 3000 patients from more than 1000 hospitals derived from the NIS. They analyzed the variable of esophagectomy volume with the primary outcome being in-hospital mortality. Their main objective was to evaluate how valid hospital volume cutoffs are for defining centers of excellence. The number of esophagectomies performed in these hospitals ranged from a minimum of 1 to a maximum of 29. The median was somewhat lower, just 4 esophagectomies per year. The overall mortality rate was 9.9%. After using esophagectomy volume as a dichotomous variable initially, they went on to perform a goodness-of-fit model, concluding that they were unable to establish a cutoff value. They then concluded that volume cutoffs cannot be used to determine centers of excellence and further work is needed to investigate this.

Several large single-institution series have been published with remarkably low mortality rates, including your institution; ours, where in a series of 222 consecutive esophagectomies had a mortality rate of 1.4%; and excellent results from other larger series, such as those from Drs Orringer, Altorki, and Swanson, to name a few.

However, this relationship between esophagectomy volume and outcome is complex, with several factors playing a role. These factors include the surgeon volume, specialty training of the surgeon, comorbidities in the patient, and provision for critical care services. Adding to these factors is the case mix seen at a particular hospital, which may contribute. For example, the . . . [Full Text of this Article]