Studies regarding volume outcomes are ongoing. There is no consensus regarding whether hospital volume or surgeon volume affects the long-term outcomes of cancer treatment, but Birkmeyer et al reported lower operative mortality and a better survival rate in high-volume hospitals with selected cancer resection (13). For gastric cancer, Coupland et al reported lower short-term and long-term mortality in rates high-volume hospitals for esophageal and gastric cancer (7). Thus, based on the evidence, the centralization of gastric cancer treatment in high-volume centers is performed, as well as in South Korea. However, others report no positive effect of volume (14–18). There are a limited number of studies concerning the relationship between individual surgeon volume and long-term outcomes of gastric cancer.
Regarding the size of the hospital in terms of the number of beds, Dong-rae Paik Hospital is a small-sized hospital with a total of 220 beds, 14 medical departments including internal medicine and surgery, and 10 beds in the intensive care unit. Our study analyzed the outcomes of 10 years of gastric cancer treatment performed in this hospital, and when these 10 years were divided into two periods, P2 showed the outcome of accumulated surgeon volume compared to P1 since all the surgeries were performed by one surgeon. Our study offers a result of the relationship between individual surgeon volume and long-term outcomes of gastric cancer.
Compared with studies conducted in large-sized hospitals with more than 1000 beds, Hyung et al. reviewed 5374 patients who underwent gastric cancer surgery from 1989 to 1999. The 5-year overall survival rate was 94.2% for stage I cancer, 73.4% for stage II, and 44.7% for stage III. The postoperative overall mortality rate was 0.7% (19). Park et al. reviewed 933 patients from 1997 to 2001 and reported a 5-year overall survival rate of 96% for stage Ia, 92% for stage Ib, 72% for stage II, 54% for stage IIIa, and 34% for stage IIIb. The total postoperative morbidity rate was 3.9% and the postoperative mortality rate was 0.6% (20). In our study, the total postoperative morbidity and major complication rates, as well as the postoperative mortality rate, were 11.9%, 4.1%, and 0.36%, respectively. For the long-term results, the 5-year overall survival rate at each stage was 97.8% for stage I, 82.6% for stage II, and 43.4% for stage III. Our results were comparable with those of large-sized hospitals.
Given the changes between the two periods, less PNI and LVI were detected in P2 than in P1. This lower detection of PNI and LVI may be related to the difference in the distribution of T stage (21). PNI has been regarded as an independent prognostic factor for overall survival and relapse-free survival in other studies (22–24), as well as LVI (25). In our multivariate analysis, T stage, N stage, VNI, PNI, and LVI were independent factors related to relapse-free survival, which corresponded to previous studies (20, 24–26). Although those factors may have influenced relapse-free survival over the entire period, it is difficult to determine that those factors had a significant effect on the reduction in relapse-free survival between the two periods. BMI was higher in P2 than in P1, and some studies report that BMI could be an independent factor for long-term survival after surgical treatment for gastric cancer (27, 28). In our study, the average BMI difference between the two periods was only 0.5, and Voglino et al. suggested that BMI does not affect postoperative complications or long-term survival (29).
Since LADG was first introduced by Kitano in 1994, LADG for early gastric cancer has increased in South Korea (30, 31). Dong-rae Paik Hospital began implementing LADG in 2003 and the rate of LADG rose to 18% in P2. This led to a shortening of hospital stay (32). At the beginning of LADG implementation, extended D2 lymph node dissection was not a standard procedure. Therefore, the proportion of D1 lymph node dissection seems to have been increased as LADG increased. Although LADG started mainly in P2, You et al. reported that the short-term outcomes of LADG for gastric cancer by a trained beginner surgeon were comparable with those of open surgery performed by an experienced surgeon (33), which was also seen in our study. There was a significant difference between the two periods in terms of the number of harvested lymph nodes (27.2 vs 41.4, p < 0.001). This seems to be the contribution of the development in pathology and the replacement of pathologists, rather than an increase in the number of lymph nodes actually harvested.
Mamidanna et al. reported that postoperative morbidity and mortality decreased as the surgeon volume increased (9), but in our study, there was no significant difference in postoperative morbidity or major complications as the individual surgeon volume accumulated.
There was no significant difference in the overall survival rate between the two periods, but the relapse-free survival rate was higher in P2 than in P1. Park et al. analyzed 12 years of gastric cancer treatment in a single center and reported that increasing the early detection of gastric cancer increased the overall survival rate (20). However, in our study, there was no difference in the distribution of the total stage between the two periods. We presumed that accumulated surgeon volume was associated with lower relapse-free survival rates in P2.
In South Korea, the standardization of management and assessment of treatment are being performed based on hospital volume as well (34). However, regarding these efforts, hospital size, not volume, tends to be the major factor for Koreans in terms of hospital selection, which led to large-sized and capital concentration despite gastric cancer occurring evenly in all geographical areas in Korea. This led to the distortion of the medical delivery system and delay of surgical treatment (16). In our study, even in the small-sized hospital, the well-trained surgeon showed good results in gastric cancer treatment, and as the surgeon volume accumulated over time, the long-term outcomes improved. It is hard to say that the accumulated surgeon volume directly affects long-term outcomes, but it seems to have been combined with the improvement in surgical skills and technical development as well as the introduction of adjuvant chemotherapy. Nevertheless, our study may have implications for the current Korean social atmosphere. Rather than focusing on the expansion of hospital size for attracting patients, improving the quality of treatment through the training of experienced surgeons and the intensive management of patients should be considered.
Our study has some limitations. First, this study was a retrospective study in a single center, in which there may have been information bias due to errors in information collection. Second, this study was not a head-to-head comparison study but a single-arm study with reviewing of other articles that did not include standardization or control of patients; in addition, the definition of terms was different. Third, the last follow-up was 2013, and the follow-up duration was shorter in P2 than in P1. Because there were patients lost to follow-up, Dong-rae Paik Hospital was absorbed into another hospital. Fourth, although there is a consensus for adjuvant chemotherapy based on oral S-1 or capecitabine plus oxaliplatin in advanced gastric cancer after gastrectomy recently (35, 36), standardization of adjuvant chemotherapy for gastric cancer was not established before 2010. The lack of evidence-based adjuvant chemotherapy in our study did not provide information on how long-term outcomes were affected.