ORIGINAL SCIENTIFIC REPORT
Antireﬂux Surgery in the USA: Inﬂuence of Surgical Volume
on Perioperative Outcomes and Costs—Time for Centralization?
Paula D. Strassle
Marco G. Patti
Published online: 30 December 2017
Internationale de Chirurgie 2017
Background Few studies have analyzed the relationship between surgical volume and outcomes after antireﬂux
procedures. The aim of this study was to determine the effect of surgical volume on postoperative results and costs
for patients undergoing surgery for gastroesophageal reﬂux disease.
Methods We analyzed the National Inpatient Sample (period 2000–2013). Adult patients (C18 years old) with
gastroesophageal reﬂux disease who underwent fundoplication were included. Hospital surgical volume was deter-
mined using the 30th and 60th percentile cut points using weighted discharges and categorized as low (\10 oper-
ations/year), intermediate (10–25 operations/year), or high ([25 operations/year). We performed multivariable
logistic regression models to assess the effect of surgical volume on patient outcomes.
Results The studied cohort comprised 75,544 patients who had antireﬂux surgery. When operations performed at
low-volume hospitals, postoperative bleeding, cardiac failure, renal failure, respiratory failure, and inpatient mor-
tality were more common. In intermediate-volume hospitals, patients were more likely to have postoperative
infection, esophageal perforation, bleeding, cardiac failure, renal failure, and respiratory failure. The length of
hospital stay was longer at low- and intermediate-volume hospitals (1.08 and 0.55 days longer, respectively). There
was an increase in charges of 5120 dollars per patient at low-volume centers, and 4010 dollars per patient at
Conclusions When antireﬂux surgery is performed at high-volume hospitals, morbidity is lower, length of hospital
stay is shorter, and costs for the healthcare system are decreased.
Gastroesophageal reﬂux disease (GERD) is the most
common gastrointestinal disorder in the USA . While
most patients do well with lifestyle modiﬁcations and acid-
reducing medications, others will need an antireﬂux oper-
ation because they have only partial control of symptoms,
or experience complications related to the medications.
The most commonly performed antireﬂux operation is the
Nissen fundoplication (360°), which has long-term success
in about 80–90% of patients [2–4].
Previous reports analyzed the beneﬁt of centralizing high-
risk surgical procedures, showing a decrease in postoperative
Oral presentation nominated for Grassi Prize during 47th World
Congress of Surgery, Basel, Switzerland, August 13–17, 2017.
& Francisco Schlottmann
Department of Surgery, University of North Carolina at
Chapel Hill, 4030 Burnett Womack Building, 101 Manning
Drive, CB 7081, Chapel Hill, NC 27599-7081, USA
Department of Epidemiology, Gillings School of Global
Public Health, University of North Carolina at Chapel Hill,
Chapel Hill, NC, USA
Department of Medicine and Surgery, University of North
Carolina at Chapel Hill, Chapel Hill, NC, USA
World J Surg (2018) 42:2183–2189