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Letter to the Editor |
1 Department of Surgery Messolongi General Hospital, Messolongi, Greece
2 Department on Internal Medicine Section of Oncology St. Andrews General Hospital Patras, Greece E-mail: jspil{at}in.gr
To the Editor:
We read with interest the article by Metreveli et al.1 Numerous studies have documented that high-volume hospitals achieve lower operative mortality with selected high-risk procedures.2 On the basis of the number of liver resections per year, hospitals were arbitrarily classified as high-volume providers for >15 per year, medium volume for 7 to 15 per year, and low volume for <7 per year.3 The authors suggest that liver resections can be performed safely with low rates of morbidity and operative mortality with careful selection of patients at low- or medium-volume community hospitals. Recent data from our hospital demonstrate the same results.4 During the last 3 years (2002–2004), 22 liver resections performed in our hospital by the same surgeon(s). The causes of liver resection were 13 malignancies (primary or metastatic), 2 traumatic causes, 6 parasitic cysts, and 1 giant hemangioma. The types of liver resections were lobectomy (n = 3), trisegmentectomy (n = 2), segmentectomy (n = 10), and wedge resection (n = 7). The overall mortality rate was 0%, and the overall morbidity rate was 40%. Estimated blood loss ranged from 250 to 1800 mL, with a mean of 370 mL. Eight patients (36.4%) required blood transfusions. In two patients (9%), there was major complication that demanded reoperation and prolonged hospital stay: an anastomotic leak from a hepatojejunal anastomosis and a large biloma from the main biliary duct after a left extensive hepatectomy.4
Our study supports the authors’ results. More advanced surgical techniques, sophisticated equipment, and increased surgical expertise have led to decreased complications and deaths. The policy of private and public administration of encouraging patients to seek care at high-volume hospitals could have negative effects on patients and hospitals, and this is an international problem in public health. The social problem includes emotional cost for the patients and their families who live in isolated rural areas, and on the other hand, for hospitals, which have difficulty recruiting and retaining residents and surgeons. Our hospital, for the last 3 years, has been trying to organize a surgical oncology section. We performed 1000 operations per year, and 25% of them were cancer cases. Some recent data suggest that ideally, patients who are potential candidates for liver resection should be referred to "centers of excellence" according to hospital performance rather than hospital volume, particularly because some low-volume centers may have favorable outcomes with the lowest cost.5–7 In these centers, the presence of skillful surgeons, along with careful patient selection, advanced equipment, and other support staff, may answer the question of why hospital rather than individual surgeon volume should be the key to the final outcome.
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