Where to have complex surgery: why the hospital matters

Anyone facing a major planned operation on the pancreas, oesophagus, liver or lung usually asks first who the best surgeon is. The more important question is often: which hospital? For complex operations, the chance of survival depends measurably on how often a hospital performs that procedure. In Germany this has led to binding minimum volumes. Disclosure: the author heads liver surgery and transplantation at a large university hospital (LMU Klinikum München) and therefore works in exactly this kind of centre.

The volume–outcome relationship

The best-known study comes from John Birkmeyer and colleagues (2002). Using US Medicare data, they found that for all 14 operations studied, mortality fell as hospital volume rose, but to very different degrees. After pancreatic resection, 16.3% of patients died in hospitals doing very few such operations and 3.8% in those doing very many. For oesophagectomy, the gap was 11.9 percentage points. For carotid endarterectomy, by contrast, it was barely measurable (1.7% versus 1.5%). The rarer and more complex an operation, the more experience matters.

German data confirm this. Ulrike Nimptsch and Thomas Mansky analysed all hospital cases from 2009 to 2014. For 20 of 25 treatments, higher volume was associated with lower mortality. After pancreatic resection for cancer, risk-adjusted in-hospital mortality was 11.7% in the lowest-volume group and 6.4% in the highest. For complex oesophageal surgery it was 10.5% versus 5.8%. A dedicated analysis of 60,858 pancreatic operations found 11.5% versus 6.5%.

Why experience works: “failure to rescue”

Good hospitals do not necessarily have fewer complications; they manage them better. In a US study of 84,730 patients in 186 hospitals, the rate of major complications was 16.2% in the hospitals with the lowest mortality and 18.2% in those with the highest. But after a major complication, 12.5% died versus 21.4%. Surgeons call this “failure to rescue”. Rescue means recognising a leak, bleeding or sepsis early and treating it at once. That takes intensive care, interventional radiology and endoscopy around the clock, experienced nurses, and a team that will reoperate at night.

Surgeon or hospital?

Both matter. In 2003, Birkmeyer and colleagues showed that the individual surgeon's experience explains about half of the hospital effect: 55% for pancreatic resection and 46% for oesophagectomy. The rest lies in the system around the surgeon. The ideal is an experienced surgeon in an experienced hospital.

Minimum volumes: the rules in Germany

The Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) is the top decision-making body of Germany's self-governing health system. It sets minimum volumes for certain planned procedures. A hospital may provide these services at the expense of statutory health insurance (GKV) only if it is expected to reach the minimum. The thresholds apply per hospital site and year, not per surgeon. Status: version of 18 June 2026.

• Liver transplantation (including living donation): 20
• Kidney transplantation: 25 · Heart transplantation: 10 (new from 2026)
• Complex oesophageal surgery: 26. In the transition years 2021 and 2022 it was still 10.
• Complex pancreatic surgery: 20. The threshold rose in steps from 10 to 15 to 20. As a result, eligible sites fell from 327 (2025) to 286 (2026).
• Lung cancer surgery: 75 · Breast cancer surgery: 100
• Bowel cancer (decided in 2024): colon 20 (2027), 25 (2028), 30 (from 2029). Rectum 15 (2027 and 2028), 20 (from 2029).

Further thresholds apply to stem cell transplantation, very small premature infants and knee replacement. There is no separate minimum volume for liver resection for tumours.

Certified cancer centres

The German Cancer Society (Deutsche Krebsgesellschaft, DKG) certifies centres for individual tumour types such as bowel, pancreatic, lung or breast cancer. At the end of 2025 there were 2,294 certified centres at 2,429 sites. Each year they must show in an audit that they meet guideline-based requirements. Patients can use the “OncoMap” search by tumour type and postcode. The WiZen study linked data from AOK, Germany's largest statutory insurer, for 2009 to 2017 with clinical cancer registries and examined eleven cancer types. Patients whose first treatment took place in a certified hospital lived longer. Depending on the cancer, the survival advantage ranged from 3% (lung) to 23% (breast). Being observational, it cannot rule out bias. Notably, except for breast cancer, most patients were treated in non-certified hospitals.

The Bundes-Klinik-Atlas and quality reports

Since May 2024, Germany has had a government hospital portal, the Bundes-Klinik-Atlas, covering about 1,700 hospitals. The federal states, medical societies and the German Hospital Federation criticised errors and a presentation too complex for lay readers; the portal was simplified, and its future has been under review since 2025. It remains online, but its case numbers lag behind (as of mid-2026: data year 2024). Behind it lie the hospitals' legally required quality reports (Qualitätsberichte). Every hospital publishes one each year, and the full reports are available in the G-BA's reference database. They are unwieldy, but often the most precise source of case numbers by procedure.

Why distance usually matters less

Many people want surgery close to home. For a planned high-risk operation, though, proximity should not decide. For the new bowel cancer minimum volumes, the G-BA estimated that the average travel time to the nearest hospital would rise only from 11 to 15 minutes (colon) and from 12 to 18 minutes (rectum). For the pancreas or oesophagus, journeys are often longer, but they are a one-off and can be planned. Follow-up care, such as chemotherapy, can often be organised close to home. An emergency is a different situation: then the nearest suitable hospital counts.

Your right to a second opinion

Under § 27b of the German Social Code Book V, people with statutory insurance are entitled to a structured second opinion for certain planned procedures. The insurer pays for it. The list includes gallbladder removal, knee and hip replacement, spinal surgery, hysterectomy, cardiac catheterisation, procedures on aortic aneurysms and the carotid artery and, since 2025, surgery for localised prostate cancer. Your doctor must normally tell you about this right at least ten days before the operation and hand over your records on request. The second opinion may not come from the hospital that is to operate. Second-opinion doctors can be found through the doctor search at 116117.de. Major cancer operations on the pancreas, oesophagus or liver are not on the list. You can still seek one; ask your insurer what it offers.

Questions to ask

• How many of these operations does the hospital perform each year? How many of them does the surgeon who will operate on me perform?
• Does the site reach the minimum volume, if one applies? Is the centre certified by the DKG for my tumour type?
• What have the complication rate, readmissions and 30- and 90-day mortality been in recent years?
• Will my case be discussed before surgery at an interdisciplinary tumour board, with surgery, oncology, radiotherapy, radiology and pathology?
• Are intensive care, interventional radiology and endoscopy available on site around the clock?
• Who is my contact after discharge if a complication occurs?

Evasive answers are information in themselves. For what should happen after a worrying finding, see “When a screening test finds something”.

This article is general information and not individual medical advice. Decisions about tests and treatment belong in a conversation with your own physician.