Operative Volume of Newborn Surgery in German University Hospitals: High Volume Versus Low Volume Centers

Abstract

Introduction Adequate patient volume is essential for the maintenance of quality, meaningful research, and training of the next generation of pediatric surgeons. The role of university hospitals is to fulfill these tasks at the highest possible level. Due to decentralization of pediatric surgical care during the last decades, there is a trend toward reduction of operative caseloads. The aim of this study was to assess the operative volume of the most relevant congenital malformations at German academic pediatric surgical institutions over the past years.

Methods Nineteen chairpersons representing university-chairs in pediatric surgery in Germany submitted data on 10 index procedures regarding congenital malformations or neonatal abdominal emergencies over a 3-year period (2015 through 2017). All institutions were categorized according to the total number of respective cases into “high,” “medium,” and “low” volume centers by terciles. Some operative numbers were verified using data from health insurance companies, when available. Finally, the ratio of cumulative case load versus prevalence of the particular malformation was calculated for the study period.

Results From 2015 through 2017, a total 2,162 newborns underwent surgery for congenital malformations and neonatal abdominal emergencies at German academic medical centers, representing 51% of all expected newborn cases nationwide. The median of cases per center within the study period was 101 (range 18–258). Four institutions (21%) were classified as “high volume” centers, four (21%) as “medium volume” centers, and 11 (58%) as “low volume” centers. The proportion of patients operated on in high-volume centers varied per disease category: esophageal atresia/tracheoesophageal fistula: 40%, duodenal atresia: 40%, small and large bowel atresia: 39%, anorectal malformations: 40%, congenital diaphragmatic hernia: 56%, gastroschisis: 39%, omphalocele: 41%, Hirschsprung disease: 45%, posterior urethral valves: 39%, and necrotizing enterocolitis (NEC)/focal intestinal perforation (FIP)/gastric perforation (GP): 45%.

Conclusion This study provides a national benchmark for neonatal surgery performed in German university hospitals. The rarity of these cases highlights the difficulties for individual pediatric surgeons to gain adequate clinical and surgical experience and research capabilities. Therefore, a discussion on the centralization of care for these rare entities is necessary.

Keywords

newborn surgery - pediatric surgery - Germany - centralization

Publication History

Received: 13 July 2021

Accepted: 05 October 2021

Article published online:
13 January 2022

• References

• 1 Schmedding A, Rolle U. Decentralized rather than centralized pediatric surgery care in Germany. Eur J Pediatr Surg 2017; 27 (05) 399-406
• 2 Lalchandani P, Dunn JCY. Global comparison of pediatric surgery workforce and training. J Pediatr Surg 2015; 50 (07) 1180-1183
• 3 Rolle U. Centralization of pediatric surgery: European perspective. Eur J Pediatr Surg 2017; 27 (05) 387
• 4 Peycelon M, Faraj S, Leclair MD, Bonnard A. French connection between specialized and routine pediatric surgical care. Eur J Pediatr Surg 2017; 27 (05) 410-415
• 5 Sfeir R, Bonnard A, Khen-Dunlop N. et al. Esophageal atresia: data from a national cohort. J Pediatr Surg 2013; 48 (08) 1664-1669
• 6 Long AM, Tyraskis A, Allin B, Burge DM, Knight M. Oesophageal atresia with no distal tracheoesophageal fistula: management and outcomes from a population-based cohort. J Pediatr Surg 2017; 52 (02) 226-230
• 7 Schmiedeke E, de Blaauw I, Lacher M. et al. Towards the perfect ARM center: the European Union's criteria for centers of expertise and their implementation in the member states. A report from the ARM-Net. Pediatr Surg Int 2015; 31 (08) 741-745
• 8 Pakarinen M, Bjørland K, Qvist N, Wester T. Centralized pediatric surgery in the Nordic countries: a role model for Europe?. Eur J Pediatr Surg 2017; 27 (05) 395-398
• 9 Wijnen MHWA. Centralization of pediatric surgery in the Netherlands. Eur J Pediatr Surg 2017; 27 (05) 407-409
• 10 Tumiene B, Graessner H, Mathijssen IM. et al. European reference networks: challenges and opportunities. J Community Genet 2021; 12 (02) 217-229
• 11 Schmedding A, Wittekind B, Salzmann-Manrique E, Schloesser R, Rolle U. Decentralized surgery of abdominal wall defects in Germany. Pediatr Surg Int 2020; 36 (05) 569-578
• 12 European Platform on Rare Diseases Registration. Eur Platf Rare Dis Regist. Available at: https://eu-rd-platform.jrc.ec.europa.eu/eurocat/eurocat-data/prevalence
• 13 Dingemann C, Dietrich J, Zeidler J. et al. Early complications after esophageal atresia repair: analysis of a German health insurance database covering a population of 8 million. Dis Esophagus 2016; 29 (07) 780-786
• 14 Elhattab A, Ali L, Rousseau V. et al. Thoracoscopy versus thoracotomy in the repair of esophageal atresia with distal tracheoesophageal fistula. J Laparoendosc Adv Surg Tech A 2020; 30 (12) 1289-1294
• 15 Koivusalo AI, Rintala RJ, Pakarinen MP. Outcomes of fundoplication in oesophageal atresia associated gastrooesophageal reflux disease. J Pediatr Surg 2018; 53 (02) 230-233
• 16 Malakounides G, Lyon P, Cross K. et al. Esophageal atresia: improved outcome in high-risk groups revisited. Eur J Pediatr Surg 2016; 26 (03) 227-231
• 17 Jenetzky E, van Rooij IALM, Aminoff D. et al. The challenges of the European anorectal malformations-net registry. Eur J Pediatr Surg 2015; 25 (06) 481-487
• 18 Siega-Riz AM, Herring AH, Olshan AF, Smith J, Moore C. National Birth Defects Prevention Study. The joint effects of maternal prepregnancy body mass index and age on the risk of gastroschisis. Paediatr Perinat Epidemiol 2009; 23 (01) 51-57
• 19 Hoff N, Wester T, Granström AL. Classification of short-term complications after transanal endorectal pullthrough for Hirschsprung's disease using the Clavien-Dindo-grading system. Pediatr Surg Int 2019; 35 (11) 1239-1243