Associations of Annual Hospital and Surgeon Volume with Patient Outcomes After Gastrectomy: A Systematic Review and Meta-analysis.

Abstract

Procedural volume is an important determinant of outcomes in cancer surgery. There is a lack of a comprehensive and updated assessment of hospital and surgeon volumes in relation to short- and long-term outcomes after gastrectomy for cancer. The PubMed and Embase databases were searched on January 2021. We conducted meta-analyses and meta-regressions assuming a random effects model to assess the associations of procedural volumes with outcomes after gastrectomy. Effect sizes included hazard ratios (HRs), odds ratios (ORs), and standardized mean differences (SMDs). Heterogeneity was evaluated with the I2 statistic and explored by subgroup analyses. The risk of publication bias, risk of bias, and certainty of evidence were also assessed. We identified 53 primary publications on the effect of hospital (n=48) or surgeon (n=11) volume on 11 gastrectomy outcomes. Patients operated on in high-volume centers had better overall survival (HR 0.82, 95% confidence interval [CI] 0.75-0.90), lower short-term mortality (OR 0.66, 95% CI 0.58-0.75), more adequate lymphadenectomy (OR 2.14, 95% CI 1.76-2.59), and shorter length of stay (SMD -0.08, 95% CI -0.12 to -0.04). The meta-analysis showed no significant associations of hospital volume with surgical complications, R0 or negative margin resection, or disease-free survival (all p>0.05). A higher surgeon volume was associated with lower 30-day mortality (OR 0.94, 95% CI 0.90-0.97). The current study suggested with high confidence that gastric cancer patients operated on in high-volume centers had better overall survival. Centralization of gastrectomy in high-volume centers might lead to an overall improvement in other outcomes, but more studies, especially on surgeon volume, are needed.