Hospital volume following major surgery for gastric cancer determines in-hospital mortality rate and failure to rescue: a nation-wide study based on German billing data (2009–2017)



For many cancer resections, a hospital volume-outcome relationship exists. The data regarding gastric cancer resection—especially in the western hemisphere—are ambiguous. This study analyzes the impact of gastric cancer surgery caseload per hospital on postoperative mortality and failure to rescue in Germany.


All patients diagnosed with gastric cancer from 2009 to 2017 who underwent gastric resection were identified from nation-wide administrative data. Hospitals were grouped into five equal caseload quintiles (I–V in ascending caseload order). Postoperative deaths and failure to rescue were determined.


Forty-six thousand one hundred eighty-seven patients were identified. There was a significant shift from partial resections in low-volume hospitals to more extended resections in high-volume centers. The overall in-house mortality rate was 6.2%. The crude in-hospital mortality rate ranged from 7.9% in quintile I to 4.4% in quintile V, with a significant trend between volume categories (p < 0.001). In the multivariable logistic regression analysis, quintile V hospitals (average of 29 interventions/year) had a risk-adjusted odds ratio of 0.50 (95% CI 0.39–0.65), compared to the baseline in-house mortality rate in quintile I (on average 1.5 interventions/year) (p < 0.001). In an analysis only evaluating hospitals with more than 30 resections per year mortality dropped below 4%. The overall postoperative complication rate was comparable between different volume quintiles, but failure to rescue (FtR) decreased significantly with increasing caseload.


Patients who had gastric cancer surgery in hospitals with higher volume had better outcomes and a reduced failure to rescue rates for severe complications.

This is a preview of subscription content, access via your institution.

Fig. 2


  1. 1.

    Collaborators GBDSC. The global, regional, and national burden of stomach cancer in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Gastroenterol Hepatol. 2020;5(1):42–54. (Epub 2019/10/28; PubMed PMID: 31648970; PubMed Central PMCID: PMCPMC7033564).

    Article  Google Scholar 

  2. 2.

    Yamamoto M, Rashid OM, Wong J. Surgical management of gastric cancer: the East vs. West perspective. J Gastrointest Oncol. 2015;6(1):79–88. (Epub 2015/02/03; PubMed PMID: 25642341; PubMed Central PMCID: PMCPMC4294827).

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Ajani JA, D’Amico TA, Almhanna K, Bentrem DJ, Chao J, Das P, et al. Gastric cancer, Version 3.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2016;14(10):1286–312. (Epub 2016/10/05; PubMed PMID: 27697982).

    Article  PubMed  Google Scholar 

  4. 4.

    Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Med Care. 2011;49(12):1076–81. (Epub 2011/10/18; PubMed PMID: 22002649).

    Article  PubMed  Google Scholar 

  5. 5.

    Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346(15):1128–37. (Epub 2002/04/12; PubMed PMID: 11948273).

    Article  PubMed  Google Scholar 

  6. 6.

    Diers J, Wagner J, Baum P, Lichthardt S, Kastner C, Matthes N, et al. Nationwide in-hospital mortality rate following rectal resection for rectal cancer according to annual hospital volume in Germany. BJS Open. 2020.

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Diers J, Wagner J, Baum P, Lichthardt S, Kastner C, Matthes N, Löb S, Matthes H, Germer C-T, Wiegering A. Nationwide in-hospital mortality following colonic cancer resection according to hospital volume in Germany. 2019. PMID: 31592096  PMCID: PMC6773649.

  8. 8.

    Baum P, Diers J, Haag J, Klotz L, Eichhorn F, Eichhorn M, et al. Nationwide effect of high procedure volume in lung cancer surgery on in-house mortality in Germany. Lung Cancer. 2020.

    Article  PubMed  Google Scholar 

  9. 9.

    Choi H, Yang SY, Cho HS, Kim W, Park EC, Han KT. Mortality differences by surgical volume among patients with stomach cancer: a threshold for a favorable volume-outcome relationship. World J Surg Oncol. 2017;15(1):134. (Epub 2017/07/19; PubMed PMID: 28716145; PubMed Central PMCID: PMCPMC5513131).

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Mukai Y, Kurokawa Y, Takiguchi S, Mori M, Doki Y. Are treatment outcomes in gastric cancer associated with either hospital volume or surgeon volume? Ann Gastroenterol Surg. 2017;1(3):186–92. (Epub 2018/06/05. PubMed PMID: 29863147; PubMed Central PMCID: PMCPMC5881359).

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Dikken JL, Dassen AE, Lemmens VE, Putter H, Krijnen P, van der Geest L, et al. Effect of hospital volume on postoperative mortality and survival after oesophageal and gastric cancer surgery in The Netherlands between 1989 and 2009. Eur J Cancer. 2012;48(7):1004–13. (Epub 2012/03/30. PubMed PMID: 22456179).

    Article  PubMed  Google Scholar 

  12. 12.

    Song Y, Tieniber AD, Roses RE, Fraker DL, Kelz RR, Karakousis GC. National trends in centralization and perioperative outcomes of complex operations for cancer. Surgery. 2019;166(5):800–11. (Epub 2019/06/25. PubMed PMID: 31230839).

    Article  PubMed  Google Scholar 

  13. 13.

    Anderson O, Ni Z, Moller H, Coupland VH, Davies EA, Allum WH, et al. Hospital volume and survival in oesophagectomy and gastrectomy for cancer. Eur J Cancer. 2011;47(16):2408–14. (Epub 2011/08/13. PubMed PMID: 21835609).

    Article  PubMed  Google Scholar 

  14. 14.

    Baum P, Diers J, Lichthardt S, Kastner C, Schlegel N, Germer CT, et al. Mortality and Complications Following Visceral Surgery. Dtsch Arztebl Int. 2019;116(44):739–46. (Epub 2019/11/28. PubMed PMID: 31774053; PubMed Central PMCID: PMCPMC6912125).

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Nimptsch U, Haist T, Gockel I, Mansky T, Lorenz D. Complex gastric surgery in Germany-is centralization beneficial? Observational study using national hospital discharge data. Langenbecks Arch Surg. 2019;404(1):93–101. (Epub 2018/12/16. PubMed PMID: 30552508).

    Article  PubMed  Google Scholar 

  16. 16.

    Hendricks A, Diers J, Baum P, Weibel S, Kastner C, Müller S, Lock JF, Köhler F, Meybohm P, Kranke P, Germer CT, Wiegering A. Systematic review and meta-analysis on volume-outcome relationship of abdominal surgical procedures in Germany. Int J Surg. 2021;9(86):24–31. Online ahead of print. PMID: 33429078 Review.

  17. 17.

    Information DIfMDu. Available from:

  18. 18.

    Stausberg J, Hagn S. New morbidity and comorbidity scores based on the structure of the ICD-10. PLoS ONE. 2015;10(12):e0143365. (Epub 2015/12/15. PubMed PMID: 26656501; PubMed Central PMCID: PMCPMC4677989).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Cuzick J. A Wilcoxon-type test for trend. Stat Med. 1985;4(1):87–90. (Epub 1985/01/01. PubMed PMID: 3992076).

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Lenzi J, Pildava S. Tips for calculating and displaying risk-standardized hospital outcomes in Stata. Stata J. 2019;19(2):477–96. (PubMedPMID: WOS:000486589100008).

    Article  Google Scholar 

  21. 21.

    Benchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med. 2015;12(10):e1001885. (Epub 2015/10/07; PubMed PMID: 26440803; PubMed Central PMCID: PMCPMC4595218).

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Claassen YHM, van Sandick JW, Hartgrink HH, Dikken JL, De Steur WO, van Grieken NCT, et al. Association between hospital volume and quality of gastric cancer surgery in the CRITICS trial. Br J Surg. 2018;105(6):728–35. (Epub 2018/04/14. PubMed PMID: 29652082).

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Dikken JL, Stiekema J, van de Velde CJ, Verheij M, Cats A, Wouters MW, et al. Quality of care indicators for the surgical treatment of gastric cancer: a systematic review. Ann Surg Oncol. 2013;20(2):381–98. (Epub 2012/10/12. PubMed PMID: 23054104).

    Article  PubMed  Google Scholar 

  24. 24.

    Coupland VH, Lagergren J, Luchtenborg M, Jack RH, Allum W, Holmberg L, et al. Hospital volume, proportion resected and mortality from oesophageal and gastric cancer: a population-based study in England, 2004–2008. Gut. 2013;62(7):961–6. (Epub 2012/10/23. PubMed PMID: 23086798).

    Article  PubMed  Google Scholar 

  25. 25.

    Gabriel E, Narayanan S, Attwood K, Hochwald S, Kukar M, Nurkin S. Disparities in major surgery for esophagogastric cancer among hospitals by case volume. J Gastrointest Oncol. 2018;9(3):503–16. (Epub 2018/07/13. PubMed PMID: 29998016; PubMed Central PMCID: PMCPMC6006045).

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Nomura E, Tsukuma H, Ajiki W, Oshima A. Population-based study of relationship between hospital surgical volume and 5-year survival of stomach cancer patients in Osaka. Japan Cancer Sci. 2003;94(11):998–1002. (Epub 2003/11/13. PubMed PMID: 14611678).

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Dikken JL, Wouters MW, Lemmens VE, Putter H, van der Geest LG, Verheij M, et al. Influence of hospital type on outcomes after oesophageal and gastric cancer surgery. Br J Surg. 2012;99(7):954–63. (Epub 2012/05/10. PubMed PMID: 22569956).

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Damhuis RA, Wijnhoven BP, Plaisier PW, Kirkels WJ, Kranse R, van Lanschot JJ. Comparison of 30-day, 90-day and in-hospital postoperative mortality for eight different cancer types. Br J Surg. 2012;99(8):1149–54. (Epub 2012/06/22. PubMed PMID: 22718521).

    CAS  Article  PubMed  Google Scholar 

Download references


The authors thank Dr. Mohammed Hankir for language editing.


No funding.

Author information



Corresponding author

Correspondence to A. Wiegering.

Ethics declarations

Conflict of interest

The authors declare no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 18 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Diers, J., Baum, P., Wagner, J.C. et al. Hospital volume following major surgery for gastric cancer determines in-hospital mortality rate and failure to rescue: a nation-wide study based on German billing data (2009–2017). Gastric Cancer (2021).

Download citation


  • Gastric cancer
  • Volume outcome
  • Mortality
  • Failure to rescue