Centralisation of Oesophagogastric Cancer Services: Can Specialist Units Deliver?

Abstract

INTRODUCTION Oesophagogastric cancer surgery is increasingly being performed in only centralised units. The aim of the study was to examine surgical outcomes and service delivery within a specialist unit.PATIENTS AND METHODS The case notes of all patients undergoing attempted oesophagogastrectomy between January 2000 and May 2003 were identified from a prospective consultant database. RESULTS A total of 187 patients (median age, 63 years; range, 29-83 years; M:F ratio, 3.9:1) underwent attempted oesophagogastrectomy. Of these, 91% were seen within 2 weeks of referral and treatment was instituted after a mean of 31 days (range, 1-109 days). More patients underwent surgery (63%) than neoadjuvant therapy (56%) within 1 month of referral. The main indication for surgery was invasive malignancy in 166 patients (89%). The 30-day mortality was 0.5% (1 death) and in-hospital mortality was 1.1% (2 deaths). The median length of hospital stay was 14 days (range, 7-69 days). Significant postoperative morbidity included: pulmonary complications (36%), cardiovascular complications (16%), wound infection (13%) and clinically significant anastomotic leaks (7%). Of the study group, 28 patients (15%) were admitted to ICU with a median stay of 10 days (range, 1-44 days); this accounted for 0.9% of ICU bed availability. Twelve patients (6.4%) were returned to theatre, most commonly for bleeding. The 1-year survival rates were 78%. During 2002-2003, national waiting list targets for both hernia repair and cholecystectomy were achieved.CONCLUSIONS Despite recent increases in workload, high volume specialist units can deliver an efficient and timely service with both good treatment outcomes and minimal impact upon elective surgical waiting lists and ICU provision.

Short-term outcomes following total minimally invasive oesophagectomy

“…The in-hospital mortality rate was low (1 per cent), especially given the high incidence of gastric tube complications, and was comparable with lowest rates currently reported for open oesophagectomy by specialist units in the UK 1 .…”

“…Open surgical approaches have changed relatively little since their original descriptions. Improvements in patient selection, radicality of resection, perioperative care and development of specialist units 1 have optimized outcomes after open oesophagectomy.…”

Is it worth reorganising cancer services on the basis of multidisciplinary teams (MDTs)? A systematic review of the objectives and organisation of MDTs and their impact on patient outcomes

“…Optimal decision-making in the diagnosis, treatment and support of cancer patients is increasingly associated multidisciplinary care studies overlap with evidence on the importance of caseload concentration [8][9][10][11], raising questions regarding the best approach to cancer care.…”

Workload and Resource Implications of Upper Gastrointestinal Cancer Surgical Centralisation in South East Wales

“…Not all new cases of oesophagastric cancer from South East Wales were included as patients diagnosed at Merthyr Tydfil and Royal Glamorgan hospitals were not included. It was not within the remit of this study to analyse cost effectiveness; in the study by Forshaw et al 19 in one regional cancer centre, the cost of an oesophageal resection was reported to be £8070, with palliation costs varying from £1390 to £4720 according to modality. Clearly, there are several aspects to costs, not only fiscal considerations but also a possible trade-off in a deterioration of services elsewhere.…”