Minimally invasive esophagectomy, or MIE, replaces the large incisions of conventional open surgery with thoracoscopic and laparoscopic techniques, aiming to reduce trauma to the chest and abdominal wall while still removing the esophagus and reconstructing the digestive tract. Since the first reported case by Cuschieri and colleagues in 1992, the approach has spread rapidly around the world. In Japan, where esophageal cancer remains one of the more common and lethal malignancies, the proportion of esophagectomies performed minimally invasive rose from just 2 percent in 1996 to 57 percent by 2016, according to national surgical registries. That steep adoption curve reflects advances in instrumentation, the widespread uptake of the prone position for the thoracic phase, and insurance coverage introduced in 2002.

Yet esophagectomy in any form remains one of the most demanding operations in gastrointestinal surgery, and MIE demands even greater technical skill. The operation requires mobilizing the esophagus deep within the mediastinum, performing extensive lymph node dissection near the recurrent laryngeal nerves and airway, and then fashioning a new conduit from the stomach. Given these challenges, the question of whether hospitals that rarely perform the procedure achieve comparable results has been a persistent concern for surgeons and policymakers alike.

The scientific lineage of the volume-outcome question stretches back to 1979, when Luft and colleagues first documented that surgical mortality declines as hospital case volume rises across a range of procedures. Begg and colleagues focused specifically on esophagectomy in 1998, followed by Swisher, van Lanschot, and Birkmeyer, each using different volume thresholds but each reaching the same directional conclusion: the lowest-volume hospitals consistently posted the highest death rates. Japanese investigators, including Kazui and later Nishigori, confirmed similar patterns in national data. What remained unknown was whether these findings, based on open surgery or mixed populations, applied to MIE performed exclusively.

To answer that question, the research team turned to the National Clinical Database, a rigorously audited nationwide registry developed in cooperation with Japan’s surgical board certification system. The database enforces standardized definitions of morbidity and mortality and maintains continuous data verification. The investigators included patients with thoracic esophageal cancer who underwent transthoracic subtotal esophagectomy with reconstruction, defining MIE as either a totally thoracoscopic and laparoscopic approach or a hybrid combining thoracoscopy with open laparotomy. Of the 22,712 eligible cases, 9,739, or 42.9 percent, were performed minimally invasively.

Hospitals were stratified into five categories by their average annual esophagectomy volume, counting both open and minimally invasive operations to capture total institutional experience: very low (1 to 5 cases per year), low (6 to 10), medium (11 to 20), high (21 to 40), and very high (41 or more). The distribution was heavily skewed. Nearly three quarters of all hospitals fell into the very low category, while only 26 institutions performed 41 or more esophagectomies annually. Meanwhile, MIE adoption rose steadily with volume, from 27.9 percent of operations at very low-volume hospitals to roughly 45 to 50 percent at the higher-volume tiers, suggesting that minimally invasive techniques concentrated early in busier centers.

The raw outcomes were unambiguous. Overall operative mortality for MIE across the study period was 2.1 percent, but it ranged from 1.2 percent at very high-volume hospitals to 3.9 percent at very low-volume centers. After adjusting for patient age, comorbidities, American Society of Anesthesiologists class, preoperative therapy, and tumor stage using hierarchical logistic regression, patients at very low-volume hospitals faced 2.70 times the odds of death compared with those at very high-volume hospitals, a difference that was highly statistically significant. Medium-volume hospitals also showed a modest but significant elevation in risk, with an odds ratio of 1.70, while the differences at low and high-volume hospitals did not reach statistical significance.

Intriguingly, the overall complication rate, which averaged 40.9 percent, varied far less across hospital tiers, from 38.7 percent at the busiest centers to 44.2 percent at the least busy, and the adjusted analysis found no significant volume effect on total complications. This dissociation between complications and mortality points toward what surgical health services researchers call failure to rescue: the capacity of an institution to recognize and effectively manage a complication once it arises. Prior work by Abdelsattar and colleagues found that 21.2 percent of patients with major complications died before discharge at low-volume hospitals, compared with 13.4 percent at high-volume hospitals, a gap attributed to differences in evidence-based care processes and structural resources such as dedicated surgical intensive care units and multidisciplinary teams.

The complication-specific analyses sharpened this picture. Anastomotic leakage, one of the most feared complications of esophageal reconstruction, was significantly more likely at very low-volume hospitals, with an adjusted odds ratio of 2.23 relative to very high-volume centers, and remained elevated at both low and high-volume tiers. Atelectasis was also significantly more common at very low-volume hospitals. By contrast, rates of postoperative pneumonia, recurrent laryngeal nerve paralysis, and chylothorax showed no significant volume association, hinting that the core technical execution of MIE has become fairly standardized across Japan. Consistent with that interpretation, operative time and intraoperative blood loss were broadly similar across hospital tiers, while postoperative length of tellingly fell from a median of 30 days at very low-volume hospitals to 21 days at very high-volume centers, a difference the authors attribute partly to more effective perioperative management.

The study period itself was a deliberate choice. Between 2012 and 2015, Japanese esophageal surgery was undergoing its steepest transition toward minimally invasive techniques, with institutional experience varying enormously. The authors argue this transitional window makes the volume effect especially visible. Their analysis also situates the findings within an international debate over volume thresholds. The Leapfrog Group in the United States progressively raised its recommended minimum to 20 esophagectomies per year by 2018, while Japanese researcher Fujita and colleagues identified fewer than 5 cases per year as the risky threshold in an earlier national analysis, a figure closely matching the present study’s definition of very low-volume hospitals.

The implications for policy are nuanced rather than simplistic. Centralizing all MIE to a handful of high-volume centers could save lives, but it would impose geographic burdens on patients in rural regions and may be impractical in a country with a dispersed hospital network. The authors suggest alternative safeguards: paying close attention to surgeon-level volume, which Birkmeyer and colleagues showed explains nearly half of the hospital volume effect on mortality, and ensuring that operations and perioperative care are led by board-certified esophageal surgery specialists. In Japan, senior surgeons at high-volume hospitals frequently supervise less experienced colleagues, and multidisciplinary conferences may spread expertise beyond the operating surgeon, which could explain why earlier Japanese studies found hospital volume mattered while individual surgeon volume did not.

The authors acknowledge important limitations. The registry did not capture institutional factors such as hospital size, intensive care staffing, or the presence of certified esophageal surgeons, any of which could mediate the volume-outcome relationship. Long-term survival, the ultimate measure of cancer care, was not assessed, although prior meta-analytic work by Brusselaers and colleagues suggests high-volume settings confer an 18 to 25 percent survival advantage that persists even after excluding early postoperative deaths. Residual confounding from patient frailty and nutritional status also cannot be excluded despite extensive risk adjustment.

Even with those caveats, the central message lands with force. Patients facing minimally invasive esophagectomy at hospitals that perform the operation only a handful of times a year, roughly once every two to three months, carry a substantially elevated risk of dying from the procedure itself. As minimally invasive esophagectomy continues its global march toward becoming the default approach for esophageal cancer, this study of nearly ten thousand Japanese patients offers a data-driven benchmark: somewhere around five cases a year, institutional experience appears to cross a line separating acceptable outcomes from avoidable deaths.

Subject of Research: The relationship between hospital surgical volume and postoperative outcomes of minimally invasive esophagectomy for esophageal cancer

Article Title: Relationship Between Hospital Volume and Outcomes of Minimally Invasive Esophagectomy for Esophageal Cancer: Analysis of the National Clinical Database in Japan

Article References: Ozawa, S., Kumamaru, H., Kitagawa, Y., Koyanagi, K., Oguma, J., Udagawa, H., Miyata, H., Toh, Y., & Matsubara, H. (2026). Relationship Between Hospital Volume and Outcomes of Minimally Invasive Esophagectomy for Esophageal Cancer: Analysis of the National Clinical Database in Japan. Annals of Gastroenterological Surgery, 10(5), 1518-1526. https://doi.org/10.1002/ags3.70229

Image Credits: AI Generated

DOI: 10.1002/ags3.70229

Keywords: esophageal cancer, minimally invasive esophagectomy, hospital volume, surgical mortality, National Clinical Database, failure to rescue, anastomotic leakage, postoperative complications, thoracic surgery, Japan, volume-outcome relationship, surgical outcomes

The analysis included 19,054 people who underwent minimally invasive esophagectomy for esophageal or esophagogastric junction cancer in Japan between 2019 and 2022. Of these patients, 4,599—24.1 percent—received a feeding enterostomy during their cancer operation. The procedure creates a small opening, or stoma, through the abdominal wall into part of the digestive tract. A gastrostomy connects the opening to the stomach, while a jejunostomy connects it to the jejunum, the section of small intestine beyond the stomach. Through this access, clinicians can deliver liquid nutrition when swallowing is unsafe or oral intake is insufficient after surgery. The approach was particularly important during the era of open esophagectomy, when recovery was often slower and postoperative nutritional problems were common. But minimally invasive surgery, enhanced-recovery protocols and earlier oral feeding have changed the balance between potential benefit and procedural risk.

Esophagectomy remains one of the most demanding operations in cancer care. Surgeons remove part or all of the esophagus and reconstruct the food pathway, usually by pulling the stomach upward to connect it with the remaining esophagus or throat. The operation can disrupt normal swallowing, breathing and gastrointestinal function at the same time. Even when the tumor is successfully removed, patients may experience pneumonia, leakage at the surgical connection, infection, prolonged ventilator dependence, delayed movement of food through the reconstructed stomach or an inability to consume enough calories. A feeding enterostomy is intended to provide a reliable nutritional route during this vulnerable period. Yet creating it requires an additional surgical maneuver, and any incision into the bowel or stomach can potentially lead to infection, leakage, adhesions or obstruction. The clinical challenge is therefore not simply whether enteral feeding is beneficial, but whether the access route itself improves outcomes enough to justify its risks.

To examine that trade-off, the investigators used Japan’s National Clinical Database, which captures more than 95 percent of esophagectomy cases nationwide. They restricted the study to minimally invasive procedures, including thoracoscopic and robot-assisted operations, and excluded open thoracotomy cases. Patients who had both a gastrostomy and a jejunostomy, duplicate records or incomplete key information were also excluded. Because patients selected for enterostomy may differ systematically from those who are not—for example, in illness severity, nutritional status or surgical complexity—the researchers used inverse probability of treatment weighting. This statistical technique estimates each patient’s probability of receiving an enterostomy based on measured characteristics, then weights the observations so the comparison groups more closely resemble one another. The team also used g-computation to estimate adjusted risks, average outcomes and differences between groups, reducing the chance that simple differences in patient characteristics would be mistaken for effects of the feeding procedure.

The primary endpoint was postoperative bowel obstruction, a complication that can occur when surgery, inflammation or scar tissue interferes with the passage of intestinal contents. After adjustment, the difference between patients with and without an enterostomy was only 0.2 percentage points and was not statistically significant, with a p value of 0.132. In other words, the study did not show convincing evidence that creating the feeding access either increased or reduced bowel obstruction overall. That result is important because obstruction is one of the main concerns surrounding a procedure that manipulates the gastrointestinal tract. However, the absence of a statistically significant difference does not prove that the two strategies are identical in every patient. Bowel-related events were rare, and the researchers did not perform adjusted comparisons for those uncommon outcomes. The study therefore provides reassurance against a large increase in obstruction risk, but it cannot exclude smaller effects or risks concentrated in particular high-risk subgroups.

The clearest warning signal was reoperation. After adjustment, patients who received a feeding enterostomy had a 2.5-percentage-point higher rate of reoperation within 30 days than those who did not, with a reported p value of 0.012. A difference of that size may be clinically meaningful after a major cancer operation, even though the database analysis cannot establish precisely why the additional procedures occurred in every case. Reoperations can be triggered by leaks, infections, bleeding, obstruction or other postoperative problems, and the enterostomy may be directly responsible in some patients or simply more common among patients already at elevated risk. The investigators also found a higher overall burden of postoperative complications in the enterostomy group. These results underscore a central limitation of routine preventive procedures: an intervention designed to protect against nutritional decline may introduce a new source of surgical morbidity.

The findings were not uniformly negative. Delayed gastric emptying occurred 0.9 percentage points less often among patients with an enterostomy, a difference that reached statistical significance with a p value of 0.028. Deep-vein thrombosis was also less frequent in the enterostomy group. Delayed gastric emptying can cause nausea, vomiting, abdominal distension and prolonged dependence on tubes or intravenous support after the stomach is repositioned to serve as a new esophagus. The lower rate observed with enterostomy may reflect more reliable nutritional management, altered postoperative care or differences that were not fully captured by the available data; the study cannot determine the biological mechanism. Similarly, the association with fewer thrombotic events should not automatically be interpreted as proof that the feeding tube prevents clots. Patients receiving enteral nutrition may mobilize or recover differently, but residual confounding remains possible even after statistical adjustment. The overall message is therefore one of trade-offs rather than a simple benefit-risk verdict.

The researchers also investigated which type of feeding enterostomy might be preferable when the reconstructed digestive tract was routed behind the breastbone, a technique known as retrosternal reconstruction. This subgroup was necessary because the choice between gastrostomy and jejunostomy is strongly constrained by anatomy. Jejunostomy is used almost exclusively when reconstruction passes through the posterior mediastinum, the central space in the chest, whereas both options can be considered for a retrosternal route. Among 2,723 patients with retrosternal reconstruction and an enterostomy, jejunostomy was associated with an 11.2-minute shorter operation than gastrostomy. Gastrostomy, however, was associated with a hospital stay 2.3 days shorter than jejunostomy. The investigators did not compare the two techniques across all reconstruction routes because gastrostomy was extremely uncommon in posterior mediastinal reconstruction, creating severe imbalance and making such a comparison unreliable.

The study’s conclusions are likely to resonate beyond Japan because the underlying clinical dilemma is shared by esophageal cancer centers worldwide. Modern minimally invasive esophagectomy reduces surgical trauma, but it does not eliminate the physiological stress of removing and reconstructing the esophagus. Some patients—particularly those with severe preoperative malnutrition, anticipated swallowing impairment or a high likelihood of prolonged recovery—may still benefit from dependable enteral access. Others may recover quickly enough to eat early, making a prophylactic stoma unnecessary. The national scale of the Japanese database gives the analysis considerable statistical power, but its retrospective design means that treatment was not assigned randomly. Surgeons may have chosen enterostomy for patients they judged more vulnerable, and not every factor influencing that decision can be measured in a database. The results should therefore guide individualized decision-making rather than dictate a universal rule.

Taken together, the evidence argues against routine or uniform feeding-enterostomy placement during minimally invasive esophagectomy. The procedure did not significantly alter postoperative bowel obstruction, was linked to more reoperations, and nevertheless coincided with lower rates of delayed gastric emptying and deep-vein thrombosis. In the specific setting of retrosternal reconstruction, gastrostomy may offer a shorter hospital stay, while jejunostomy may modestly reduce operative time. These differences are not large enough to replace clinical judgment, but they offer surgeons a framework for discussing options with patients before surgery. The most appropriate choice will depend on nutritional status, expected swallowing recovery, reconstruction route, institutional practice and the patient’s tolerance for additional postoperative risk. Rather than treating a feeding enterostomy as an automatic component of minimally invasive esophagectomy, the findings support a selective strategy: preserve the option for patients most likely to need it, while avoiding an extra procedure when its benefits are unlikely to outweigh its complications.