Antireflux Sugery: Practice Makes Perfect

Nissen fundoplication, often called simply antireflux procedure, has been performed since 1956. Between 1990 and 1999, the number of these surgeries has tripled, and then declined through 2006 due to the success of proton pump inhibitors and questions about the procedure’s long-term effectiveness. Throughout the last few decades, one fact was unquestioned: Patients who undergo Nissen fundoplication at high-volume centers (38 or more procedures annually) have better outcomes. However, a recent study reports that in the last 10 years, the number of antireflux surgeries performed at high-volume centers has fallen. Low-volume centers (14 or fewer procedures annually) have increased their proportion of antireflux operations, with urban non-teaching hospitals experiencing the greatest gains.

The study used data from the Nationwide Inpatient Sample, which is considered representative of all US hospital practice. Researchers compared 1998-1999 data with 2008-2009 data. The researchers presumed there would be increased regionalization (use of larger regional centers with a greater volume of surgeries) of antireflux surgery since consistent evidence has demonstrated outcomes are better at centers where it is performed most frequently. They did not prove the hypothesis, instead finding the opposite true.

From 1998-1999, about one-third of antireflux operations were performed at low-volume centers. It increased to greater than 40% in 2008-2009. High-volume centers performed only 25% of the procedures in 2008-2009, falling from 33% in the earlier time period. Researchers also found that although fewer surgeries were performed, patients tended to be older and have greater comorbidities and experience more complications.

Mortality was the same in low- and high-volume centers, but almost every other outcome (procedure cost, length of stay, and complications) was better in centers with the highest volumes. Risk for complications was almost twice as high in low-volume centers regardless of time period, and average hospital charges per procedure were about $3,000 higher in low volume centers.

The researchers speculate that antireflux procedures may not have undergone regionalization because surgical programs frequently train residents in laparoscopy, and antireflux procedures are part of this training. Consequently, general surgeons often consider antireflux procedures a basic skill and do not refer patients to high volume centers. Additionally, patients may prefer having surgery close to home.