The effect of centralisation on the outcomes of oesophagogastric surgery--a fifteen year audit.

Introduction: Centralisation of oesophagogastric (OG) resectional services has been proposed to improve patient outcomes in terms of perioperative mortality and long-term survival. Centralisation of services occurred in Gloucester 5 years ago. The aim of this paper is to assess if local patient outcomes have benefited from centralisation.

Methods: All oesophagogastric resections performed in our unit over a 15-year period (10-years pre-centralisation and 5-years post-centralisation) were assessed retrospectively. Patient demographics, pathological details and date of death were identified. Perioperative mortality (30 and 90 day) and estimated Kaplan-Meier survival was compared for cases performed pre- and post-centralisation of services.

Results: 456 resections for cancer were performed in the 15-year period; 234 of these were performed pre-centralisation (mean 23.4, range 13-31) and 222 were performed post-centralisation (mean 44.4, range 40-50). Median survival rates for gastric cancer were 1.1 years pre-centralisation and 1.5 years post-centralisation (p = 0.147) and median survival for oesophageal cancer improved from 1.1 years to 2.1 respectively (p = 0.028). Combined OG 30-day mortality rates improved from 10.3% pre-centralisation to 3.6% post-centralisation (p = 0.006, Fisher's exact test).

Discussion: Centralisation of OG services in Gloucester has resulted in twice as many resections being performed locally. Median survival for patients with oesophageal cancer has increased by 1 year and the 30-day mortality rate following resection has reduced by almost two thirds. Although other factors (such as improvements in oncological treatments, staging and critical care management over the 15-year time period) have undoubtedly had roles to play in these improvements, the results of this study support the policy of centralisation of upper GI cancer services.