Impact of surgeon volume and specialization on short-term outcomes in colorectal cancer surgery

Exploring 6 years of colorectal cancer surgery in rural Italy: insights from 648 consecutive patients unveiling successes and challenges

The multidisciplinary management of patients suffering from colorectal cancer (CRC) has significantly increased survival over the decades and surgery remains the only potentially curative option for it. However, despite the implementation of minimally invasive surgery and ERAS pathway, the overall morbidity and mortality remain quite high, especially in rural populations because of urban - rural disparities. The aim of the study is to analyze the characteristics and the surgical outcomes of a series of unselected CRC patients residing in two similar rural areas in Italy. A total of 648 consecutive patients of a median age of 73 years (IQR 64-81) was enrolled between 2017 and 2022 in a prospective database. Emergency admission (EA) was recorded in 221 patients (34.1%), and emergency surgery (ES) was required in 11.4% of the patients. Tumor resection and laparoscopic resection rates were 95.0% and 63.2%, respectively. The median length of stay was 8 days. The overall morbidity and mortality rates were 23.5% and 3.2%, respectively. EA was associated with increased median age (77.5 vs. 71 ys, p < 0.001), increased mean ASA Score (2.84 vs. 2.59; p = 0.002) and increased IV stage disease rate (25.3% vs. 11.5%, p < 0.001). EA was also associated with lower tumor resection rate (87.3% vs. 99.1%, p < 0.001), restorative resection rate (71.5 vs. 89.7%, p < 0.001), and laparoscopic resection rate (36.2 vs. 72.6%, p < 0.001). Increased mortality rates were associated with EA (7.2% vs. 1.2%, p < 0.001), ES (11.1% vs. 2.0%, p < 0.001) and age more than 80 years (5.8% vs. 1.9%, p < 0.001). In rural areas, high quality oncologic care can be delivered in CRC patients. However, the surgical outcomes are adversely affected by a still too high proportion of emergency presentation of elderly and frail patients that need additional intensive care supports beyond the surgical skill and alternative strategies for earlier detection of the disease.

Influence of hospital-level and surgeon factors on the outcomes after ileo-anal pouch surgery for inflammatory bowel disease: systematic review

BACKGROUND

Ileal pouch-anal anastomosis ('pouch surgery') provides a chance to avoid permanent ileostomy after proctocolectomy, but can be associated with poor outcomes. The relationship between hospital-level/surgeon factors (including volume) and outcomes after pouch surgery is of increasing interest given arguments for increasing centralization of these complex procedures. The aim of this systematic review was to appraise the literature describing the influence of hospital-level and surgeon factors on outcomes after pouch surgery for inflammatory bowel disease.

METHODS

A systematic review was performed of studies reporting outcomes after pouch surgery for inflammatory bowel disease. The MEDLINE (Ovid), Embase (Ovid), and Cochrane CENTRAL databases were searched (1978-2022). Data on outcomes, including mortality, morbidity, readmission, operative approach, reconstruction, postoperative parameters, and pouch-specific outcomes (failure), were extracted. Associations between hospital-level/surgeon factors and these outcomes were summarized. This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD42022352851).

RESULTS

A total of 29 studies, describing 41 344 patients who underwent a pouch procedure, were included; 3 studies demonstrated higher rates of pouch failure in lower-volume centres, 4 studies demonstrated higher reconstruction rates in higher-volume centres, 2 studies reported an inverse association between annual hospital pouch volume and readmission rates, and 4 studies reported a significant association between complication rates and surgeon experience.

CONCLUSION

This review summarizes the growing body of evidence that supports centralization of pouch surgery to specialist high-volume inflammatory bowel disease units. Centralization of this technically demanding surgery that requires dedicated perioperative medical and nursing support should facilitate improved patient outcomes and help train the next generation of pouch surgeons.

Distribution of case volumes in surgery: an analysis of the British Spine Registry

Objectives

To characterize the distribution of case volumes within a surgical field.

Design

An analysis of British Spine Registry.

Setting

295 centers in England that conducted at least one spinal operation either within the NHS or private settings between 1 May 2016 and 27 February 2021.

Participants

644 surgeons.

Main outcome measures

Mathematical descriptions of distributions of cases among surgeons and the extent of workforce-level case-volume concentration as a surrogate marker.

Results

There were wide variations in monthly caseloads between surgeons, ranging from 0 to average monthly high of 81.8 cases. The curves showed that 37.7% of surgeons were required to perform 80% of all spinal operations, which is substantially less than in fields outside of healthcare.With the COVID-19 pandemic, the case volumes of surgeons with the highest volumes dropped dramatically, whereas those with the lowest case numbers remained nearly unchanged. This, along with the relatively low level of case-volume concentration within spinal surgery, may indicate an inevitability of at least some level of surgical care being provided by the relatively lower volume surgeons.

Conclusions

While there is a reasonable degree of workforce-level case volume concentration within spinal surgery, with high volume spinal surgeons providing a large proportion of care, it is not clear whether a further concentration of case volumes into those few hands is possible or desirable.

Short- and long-term outcome after colon cancer resections performed by male and female surgeons: A single-center retrospective cohort study

BACKGROUND AND OBJECTIVE

To assess the effect of surgeon sex on short- and long-term outcomes after colon cancer resections.

METHODS

Clinical data of patients who underwent colon cancer resections between 2010 and 2020 at Helsingborg Hospital, Sweden, were retrospectively obtained from medical records. The sex of the surgeon of each procedure was recorded. Morbidity, mortality, and long-term survival were compared in patients operated by male and female surgeons.

RESULTS

Colon cancer resections were performed by 23 male and 9 female surgeons in 1113 patients (79% elective, 21% emergent). After elective surgery, there was no difference in postoperative complications, 30-day mortality, or long-term survival between patients operated by male and female surgeons. Following emergent resections, the complication rate was significantly lower in patients operated by female surgeons (41.3% vs 58.1%, p = 0.019). Similarly, the rates of R1-resections (0% vs 5.2%, p = 0.039), reoperations (3.8% vs 14.2%, p = 0.014), and intensive care unit (ICU) care (6.3% vs 17.4%, p = 0.018) were significantly lower for patients operated by female surgeons, but there was no difference in 30-day mortality (6.3% vs 5.2%, p = 0.767). Cox regression analysis showed that long-term and cancer-free survival in patients emergently operated by male surgeons was significantly shorter than that of patients operated by female surgeons (hazard ratio = 1.9 (95% confidence interval (CI) = 1.3-2.8), p = 0.001 and hazard ratio = 1.7 (95% CI = 1.1-2.7), p = 0.016).

CONCLUSIONS

The short- and long-term outcome after elective colon cancer resections were similar in patients operated by male and female surgeons. The outcome following emergent resections performed by female surgeons compared favorably with that of male surgeons, with fewer complications and reoperations and better long-term survival.

Cyanoacrylate in Colorectal Surgery: Is It Safe?

Anastomotic leakage (AL) of a gastrointestinal (GI) anastomosis continues to be an important complication in GI surgery. Since its introduction more than 60 years ago, Cyanoacrylate (CA) has gained popularity in colorectal surgery to provide "prophylaxis" against AL. However, although in surgical practice it is increasingly used, evidence on humans is still lacking. The aim of this study is to analyze in humans the safety of CA to seal colorectal anastomosis. All consecutive patients from Jannuary 2022 through December 2022 who underwent minimally invasive colorectal surgery were retrospectively analyzed from a prospectively maintained database. Inclusion criteria were a histological diagnosis of cancer, a totally minimally invasive procedure, and the absence of intraoperative complications. 103 patients were included in the study; N-butyl cyanoacrylate with metacryloxisulfolane (Glubran 2®) was used to seal colorectal anastomosis, no adverse reactions to CA or postoperative complications related to inflammation and adhesions occurred; and only one case of AL (0.9%) was recorded. We can consider this study an important proof of concept on the safety of CA to seal colorectal anastomosis. It opens the possibility of starting prospective and comparative studies in humans to evaluate the effectiveness of CA in preventing colorectal AL.

Significance of surgical first assistant expertise for surgical site infection prevention: Propensity score matching analysis

Surgical site infection (SSI) is one of the most common postoperative complications in patients undergoing major operations, such as spinal fusion surgery, and a major contributor to patient morbidity and mortality. SSI is considered the most preventable type of infection; however, the risk of SSI is multifactorial. This study aimed to determine the extent to which the expertise of the surgical first assistant (SFA) affected SSI rates. We retrospectively reviewed 528 patients at a single institution who underwent lumbar spine fusion surgery via the posterior approach performed by a single surgeon between January 2012 and May 2020. The SFAs participating in the surgeries were classified into 2 groups: a certified neurosurgery specialist and relatively less experienced neurosurgery resident trainees. To reduce potential selection bias and confounding factors, propensity score matching was performed between the 2 groups. In 170 of the 528 lumbar spine fusion surgeries, the SFA was a certified neurosurgery specialist. In the other 358 surgeries, the SFA was a resident trainee. Seventeen patients met the SSI criteria. The SSI rate was significantly different between the 2 groups (0.6% (1 patient) and 4.5% (16 patients) in the certified specialist and resident trainee groups, respectively; P = .02). After propensity score matching, 170 paired patients were selected. After adjusting for confounding factors, SFAs that were certified neurosurgery specialists were associated with a lower likelihood of SSI (adjusted OR 0.09; 95% CI, 0.01 to 0.79; P = .029) than SFAs that were neurosurgery residents. A higher level of SFA expertise was significantly associated with a lower overall SSI rate in lumbar spine fusion surgeries. It is difficult to predict the incidence of SSI; however, this finding suggests the importance of SFA expertise in preventing SSI.

Survival Analysis of Patients with Colorectal Cancer Undergoing Combined Treatment: A Retrospective Cohort Study

BACKGROUND

If colorectal cancer (CRC) is diagnosed in the early stages, the patients will have higher survival rates. Although some other factors might affect the survival rate, the type of treatment available based on existing health and therapeutic facilities is extremely important as well. Accordingly, this study aimed to explore the best type of treatment for CRC patients.

STUDY DESIGN

This study employed a retrospective population-based cohort design.

METHODS

The data of 335 patients with CRC in Kurdistan province were collected through a population-based cancer registry system from March 1, 2009 to 2014. Demographic and clinical-pathologic data of the patients were gathered through their medical records, pathology reports, and reference to patients' homes. The survival rate was calculated using the Kaplan-Meier curve, log-rank test, and univariate and multivariate Cox regression. The data were analyzed using Stata 14 software.

RESULTS

In this study, the mean age±standard deviation at diagnosis was 61.7± 1.05 in men and 60.5± 1.12 in women, respectively, and 203 (60.5%) patients were males. There was less mortality rate among the patients who received both surgical and chemotherapy treatments compared to those who did not receive any treatment (Hazard ratio [HR]=0.57, 95% CI: 0.24-0.93).

CONCLUSION

When CRC patients are treated using both surgical and chemotherapy treatments, they will exhibit a higher survival rate. Therefore, it is suggested to use both treatments for CRC patients.

Kingsnorth's modified score as predictor of complications in open inguinal hernia repair

Purpose

This study aims to analyse the postoperative complications (30 days) on unilateral primary inguinal hernia repair and prove their correlation with the preoperative modified scoring system of Kingsnorth (KN).

Methods

Prospective study design collecting data from patients who underwent surgery for unilateral primary inguinal hernia in a University Hospital. The data were collected in the National Inguinal Hernia Registry (EVEREG). A statistical analysis to assess the association between the presence of postoperative complications and the preoperative and intraoperative variables was performed. The patients were classified depending on their KN score. Surgical complications and their relationship with the classification were specifically analysed. Study design was performed following STROBE statements.

Results

The sample included 403 patients who met the inclusion criteria from which 62 (15.3%) subjects presented postoperative complications. The variables that presented a statistically significant relationship with the appearance of complications were a KN score of 5–8 (OR 2.7; 95% CI 1.07–4.82; P = 0.03) and the involvement of a member of the abdominal wall surgery unit in the procedure (OR 0.28; 95% CI 0.08–0.92; P = 0.03). The KN score correlated with a longer duration of surgery (Pearson's correlation 0.291; P < 0.0001).

Conclusion

The KN classification can predict the onset of surgical wound complications on patients who undergo a primary unilateral inguinal hernia surgery. A KN score of 5–8 has a higher probability of wound complications. When surgery is performed by the abdominal wall surgery unit, the chances of postoperative complications decrease.

Risk factors and economic burden of postoperative anastomotic leakage related events in patients who underwent surgeries for colorectal cancer

Background

Nationwide research about the clinical and economic burden caused by anastomotic leakage (AL) has not been published yet in Korea. This study assessed the AL rate and quantified the economic burden using the nationwide database.

Methods

This real world evidence study used health claims data provided by the Korean Health Insurance Review and Assessment Service (HIRA, which showed that 156,545 patients underwent anterior resection (AR), low anterior resection (LAR), or ultra-low anterior resection (uLAR) for colorectal cancer (CRC) between January 1, 2007 and January 31, 2020. The incidence of AL was identified using a composite operational definition, a composite of imaging study, antibacterial drug use, reoperation, or image-guided percutaneous drainage. Total hospital costs and length of stay (LOS) were evaluated in patients with AL versus those without AL during index hospitalization and within 30 days after the surgery.

Results

Among 120,245 patients who met the eligibility criteria, 7,194 (5.98%) patients had AL within 30 days after surgery. Male gender, comorbidities (diabetes, metastatic disease, ischemic heart disease, ischemic stroke), protective ostomy, and multiple linear stapler use, blood transfusion, and urinary tract injury were associated with the higher odds of AL. Older age, rectosigmoid junction cancer, AR, LAR, and laparoscopic approach were related with the reduced odds of AL. Patients with AL incurred higher costs for index hospitalization compared to those without AL (8,991 vs. 7,153 USD; p<0.0001). Patients with AL also required longer LOS (16.78 vs. 14.22 days; p<0.0001) and readmissions (20.83 vs. 13.93 days; p<0.0001).

Conclusion

Among patients requiring resection for CRC, the occurrence of AL was associated with significantly increased costs and LOS. Preventing AL could not only produce superior clinical outcomes, but also reduce the economic burden for patients and payers.

Diagnostic accuracy of C-reactive protein, procalcitonin and neutrophils for the early detection of anastomotic leakage after colorectal resection: a multicentric, prospective study

AIM

The aim was to determine the accuracy of C-reactive protein (CRP), procalcitonin and neutrophils in the early detection (fourth postoperative day) of anastomotic leakage (AL) after colorectal surgery.

METHODS

We conducted a multicentre, prospective study that included a consecutive series of patients who underwent colorectal resection with anastomosis without ostomy (September 2015 to December 2017). CRP, procalcitonin and neutrophil values on the fourth postoperative day after colorectal resection along with the postoperative outcome (60-day AL, morbidity and mortality) were prospectively included in an online, anonymous database.

RESULTS

The analysis ultimately included 2501 cases. The overall morbidity and mortality was 30.1% and 1.6%, respectively, and the AL rate was 8.6%. The area under the receiver operating characteristic curve values (95% CI) for detecting AL were 0.84 (0.81-0.87), 0.75 (0.72-0.79) and 0.70 (0.66-0.74) for CRP, procalcitonin and neutrophils, respectively. The best cut-off level for CRP was 119 mg/l, resulting in 70% sensitivity, 81% specificity and 97% negative predictive value. After laparoscopic resection, the accuracy for CRP and procalcitonin was increased, compared with open resection. The combination of two or three of these biomarkers did not significantly increase their accuracy.

CONCLUSION

On the fourth postoperative day, CRP was the most reliable marker for excluding AL. Its high negative predictive value, especially after laparoscopic resection, allows for safe hospital discharge on the fourth postoperative day. The routine use of procalcitonin or neutrophil counts does not seem to increase the diagnostic accuracy.

Differences in organization of care are associated with mortality, severe complication and failure to rescue in emergency colon cancer surgery

Background

Emergency colon cancer surgery is associated with increased mortality and complication risk, which can be due to differences in the organization of hospital care. This study aimed.

Objective

To explore which structural factors in the preoperative, perioperative and postoperative periods influence outcomes after emergency colon cancer surgery.

Methods

An observational study was performed in 30 Dutch hospitals. Medical records from 1738 patients operated in the period 2012 till 2015 were reviewed on the type of referral, intensive care unit (ICU) level, surgeon specialization and experience, duration of surgery and operating room time, blood loss, stay on specialized postoperative ward, complication occurrence, reintervention and day of surgery and linked to case-mix data available in the Dutch Colorectal Audit. Multivariate logistic regression analysis was used to estimate the influence of these factors on 30-day mortality, severe complication and failure to rescue (FTR), after adjustment for case-mix.

Results

Patients operated by a non-Gastro intestinal/oncology specialized surgeon have significantly increased mortality (Odds Ratio (OR) 2.28 [95% confidence interval (95% CI) 1.23–4.23]) and severe complication risk (OR 1.61 [95% CI 1.08–2.39]). Also, duration of stay in the operating room was significantly associated with increased risk on severe complication (OR 1.03 [95% CI 1.01–1.06]). Patients admitted to a non-specialized ward have significantly increased mortality (OR 2.25 [95% CI 1.46–3.47]) and FTR risk (OR 2.39 [95% CI 1.52–3.75]). A low ICU level (basic ICU) was associated with a lower severe complication risk (OR 0.72 [95% CI 0.52–1.00]). Surgery on Tuesday was associated with a higher mortality risk (OR 2.82 [95% CI 1.24–6.40]) and a severe complication risk (OR 1.77, [95% CI 1.19–2.65]).

Conclusion

This study identified a non-specialized surgeon and ward, operating room, time and day of surgery to be risk factors for worse outcomes in emergency colon cancer surgery.

Textbook outcome after rectal cancer surgery as a composite measure for quality of care: A population-based study

BACKGROUND

Textbook outcome is a composite measure of combined outcome indicators, which has been suggested to be of additional value over single outcome parameters in clinical auditing of surgical treatment. This study aimed to assess textbook outcome after rectal cancer surgery as short-term marker for quality of care.

MATERIALS AND METHODS

Patients who underwent elective rectal cancer surgery between 2012 and 2019 and registered in the Dutch ColoRectal Audit were included. Textbook outcome was achieved when the following criteria were met: 30-day and primary hospital admission survival, no reintervention, tumour-free margins, no postoperative complications, a hospital stay of less than 14 days and no readmission. Hospital variation was evaluated in case-mix corrected funnel-plots. A multilevel logistic regression analysis was performed to identify associated factors with textbook outcome.

RESULTS

The study population consisted of 20,521 patients who underwent primary rectal cancer surgery, of whom 56.3% achieved textbook outcome. Postoperative complications were the main contributor to not achieving textbook outcome. Case-mix corrected funnel plots demonstrated that underperforming hospitals in 2012-2015 were no underperformers in 2016-2019 anymore. Female sex, laparoscopic surgery, and rectal resection without defunctioning stoma creation were positively associated with textbook outcome.

CONCLUSION

Textbook outcome after rectal cancer resection is mainly driven by postoperative complications. Although textbook outcome showed some discriminating value for identifying underperforming hospitals, it does not fit the plan-do-check-act cycle of clinical auditing. In our opinion, textbook outcome has little added value to the current outcome indicators for rectal cancer surgery.

Does Fragmentation of Care in Locally Advanced Rectal Cancer Increase Patient Mortality?

OBJECTIVE

To evaluate health care fragmentation in patients with stage II and III rectal cancers.

BACKGROUND

Fragmentation of care among multiple hospitals may worsen outcomes for cancer patients.

METHODS

National Cancer Database was queried for adult patients who underwent radiation and surgery for locally advanced (stage II-III) rectal adenocarcinoma from 2006 to 2015. Fragmented care was defined as receiving radiation at a different hospital from surgery. Descriptive statistics characterized patients, and survival probability was plotted using the Kaplan-Meier method and a Cox proportional hazards model.

RESULTS

A total of 37,081 patients underwent surgery and radiation for stage II-III rectal cancer from 2006 to 2015 (24,102 integrated care vs. 12,979 fragmented care). Patients who received fragmented care (hazard ratio [HR] 1.105; 95% CI 1.045-1.169) had a higher risk of mortality. Patients who received at least surgery (HR 0.84; 95% CI 0.77-0.92) at academic hospitals had a lower risk of mortality. Academic hospitals had a higher proportion of patients with fragmented care (38.0 vs. comprehensive community 32.8% vs. community 33.8%, p < 0.001). Within academic hospitals, fragmented care portended worse survival (integrated academic 80.0% vs. fragmented academic 76.7%, p = 0.0002). Fragmented care at academic hospitals had increased survival over integrated care at community hospitals (fragmented academic 76.7 vs. integrated community 72.2%, p = 0.00039).

CONCLUSIONS

In patients with stage II-III rectal cancer, patients who have integrated care at academic hospitals or at least surgery at academic centers had better survival. All efforts should be made to reduce care fragmentation and surgery at academic centers should be prioritized.

Association of certification, improved quality and better oncological outcomes for rectal cancer in a specialized colorectal unit

PURPOSE

Centralization of cancer care is expected to yield superior results. In Germany, the national strategy is based on a voluntary certification process. The effect of centre certification is difficult to prove because quality data are rarely available prior to certification. This observational study aims to assess outcomes for rectal cancer patients before and after implementation of a certified cancer centre.

PATIENTS AND METHODS

All consecutive patients treated for rectal cancer in our certified centre from 2009 to 2017 were retrieved from a prospective database. The dataset was analyzed according to a predefined set of 19 quality indicators comprising 36 quality goals. The results were compared to an identical cohort of patients, treated from 2000 to 2008 just before centre implementation.

RESULTS

In total, 1059 patients were included, 481 in the 2009-2017 interval and 578 in the 2000-2008 interval. From 2009 to 2017, 25 of 36 quality goals were achieved (vs. 19/36). The proportion of anastomotic leaks in low anastomoses was improved (13.5% vs. 22.1%, p = 0.018), as was the local 5-year recurrence rate for stage (y)pIII rectal cancers (7.7% vs. 17.8%, p = 0.085), and quality of mesorectal excision (0.3% incomplete resections vs. 5.5%, p = 0.002). Furthermore, a decrease of abdominoperineal excisions was noted (47.1% vs. 60.0%, p = 0.037). For the 2009-2017 interval, local 5-year recurrence rate in stages (y)p0-III was 4.6% and 5-year overall survival was 80.2%.

CONCLUSIONS

Certification as specialized centre and regular audits were associated with an improvement of various quality parameters. The formal certification process has the potential to enhance quality of care for rectal cancer patients.

Guideline-Recommended Chemoradiation for Patients With Rectal Cancer at Large Hospitals: A Trend in the Right Direction

BACKGROUND

Many patients with rectal cancer are treated at small, low-volume hospitals despite evidence that better outcomes are associated with larger, high-volume hospitals.

OBJECTIVES

This study aims to examine trends of patients with rectal cancer who are receiving care at large hospitals, to determine the patient characteristics associated with treatment at large hospitals, and to assess the relationships between treatment at large hospitals and guideline-recommended therapy.

DESIGN

This study was a retrospective cohort analysis to assess trends in rectal cancer treatment.

SETTINGS

Data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Patterns of Care studies were used.

PATIENTS

The study population consisted of adults diagnosed with stages II/III rectal cancer in 1990/1991, 1995, 2000, 2005, 2010, and 2015.

MAIN OUTCOME MEASURES

The primary outcome was treatment at large hospitals (≥500 beds). The receipt of guideline-recommended preoperative chemoradiation therapy and postoperative chemotherapy was assessed for patients diagnosed in 2005+.

RESULTS

Two thousand two hundred thirty-one patients were included. The proportion treated at large hospitals increased from 19% in 1990/1991 to 27% in 2015 (ptrend < 0.0001). Black race was associated with treatment at large hospitals (vs white) (OR, 1.73; 95% CI, 1.30-2.31), as was being 55 to 64 years of age (vs 75+), and diagnosis in 2015 (vs 1990/1991). Treatment in large hospitals was associated with twice the odds of preoperative chemoradiation, as well as younger age and diagnosis in 2010 or 2015 (vs 2005).

LIMITATIONS

The study did not account for the change in the number of large hospitals over time.

CONCLUSIONS

Results suggest that patients with rectal cancer are increasingly being treated in large hospitals where they receive more guideline-recommended therapy. Although this trend is promising, patients receiving care at larger, higher-volume facilities are still the minority. Initiatives increasing patient and provider awareness of benefits of specialized care, as well as increasing referrals to large centers may improve the use of recommended treatment and ultimately improve outcomes. See Video Abstract at http://links.lww.com/DCR/A994. QUIMIORRADIACIÓN RECOMENDADA EN GUÍAS PARA PACIENTES CON CÁNCER RECTAL EN HOSPITALES DE GRAN TAMAÑO: UNA TENDENCIA EN LA DIRECCIÓN CORRECTA: Muchos pacientes con cáncer rectal se tratan en hospitales pequeños y de bajo volumen a pesar de evidencia de que los mejores resultados se asocian con hospitales más grandes y de gran volumen.

OBJETIVOS

Examinar las tendencias en los pacientes con cáncer rectal que reciben atención en hospitales de gran tamaño, determinar las características de los pacientes asociadas con el tratamiento en hospitales grandes y evaluar la relación entre el tratamiento en hospitales grandes y la terapia recomendada en guías. DISEÑO:: Este estudio fue un análisis de cohorte retrospectivo para evaluar las tendencias en el tratamiento del cáncer de recto.

ESCENARIO

Se utilizaron datos de los estudios del programa Patrones de Atención, Vigilancia, Epidemiología y Resultados Finales (SEER) del Instituto Nacional de Cáncer (NIH).

PACIENTES

La población de estudio consistió en adultos diagnosticados con cáncer rectal en estadio II / III en 1990/1991, 1995, 2000, 2005, 2010 y 2015.

PRINCIPALES MEDIDAS DE RESULTADO

El resultado primario fue el tratamiento en hospitales grandes (≥500 camas). La recepción de quimiorradiación preoperatoria recomendada según las guías y la quimioterapia posoperatoria se evaluaron para los pacientes diagnosticados en 2005 y posteriormente.

RESULTADOS

Se incluyeron 2,231 pacientes. La proporción tratada en los hospitales grandes aumentó del 19% en 1990/1991 al 27% en 2015 (ptrend < 0.0001). La raza afroamericana se asoció con el tratamiento en hospitales grandes (vs. blanca) (OR, 1.73; IC 95%, 1.30-2.31), al igual que 55-64 años de edad (vs ≥75) y diagnóstico en 2015 (vs 1990/1991). El tratamiento en los hospitales grandes se asoció con el doble de probabilidad de quimiorradiación preoperatoria, así como con una edad más temprana y diagnóstico en 2010 o 2015 (vs 2005).

LIMITACIONES

El estudio no tomó en cuenta el cambio en el número de hospitales grandes a lo largo del tiempo.

CONCLUSIONES

Los resultados sugieren que los pacientes con cáncer rectal reciben cada vez más tratamiento en hospitales grandes donde reciben terapia recomendada por las guías mas frecuentemente. Aunque esta tendencia es prometedora, los pacientes que reciben atención en hospitales más grandes y de mayor volumen siguen siendo una minoría. Las iniciativas que aumenten la concientización del paciente y del proveedor de servicios médicos sobre los beneficios de la atención especializada, así como el aumento de las referencias a centros grandes podrían mejorar el uso del tratamiento recomendado y, en última instancia, mejorar los resultados. Vea el Resumen en video en http://links.lww.com/DCR/A994.

Outcomes After Elective Colorectal Surgery by 2 Surgeons Versus 1 Surgeon in a Low-Volume Hospital

Background. Improved patient outcomes after colorectal surgery in high-volume hospitals are leading to centralization of colorectal surgery. However, it is desirable to strive for optimal quality of colorectal surgery in low-volume hospitals. This study aimed to assess the effect of the number of surgeons involved in the surgical procedure on patient outcomes in a low-volume hospital. Methods. All patients who underwent elective colorectal surgery with construction of a primary anastomosis between January 1, 2007, and December 31, 2015, were included in this retrospective cohort. The propensity score was used to adjust for confounding. Results. A total of 429 patients were included. One hundred forty-three patients (33.3%) were operated by 1 surgeon and 286 patients (66.7%) were operated by 2 surgeons. Patients operated by 2 surgeons were younger, more often male, and had a higher body mass index. A multivariate analysis with propensity scores revealed that surgery with 2 surgeons was associated with fewer reoperations (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2-0.9, P = .038). Colorectal anastomotic leakage (OR = 0.6, 95% CI = 0.2-1.3, P = .204) and mortality (OR = 0.8, 95% CI = 0.2-3.7, P = .807) were not associated with the number of surgeons involved in the surgical procedure. Conclusion. The present study shows that elective colorectal surgery in a low-volume hospital performed by 2 surgeons resulted in fewer reoperations. This might positively influence patient outcomes and might be related to increased surgical quality as compared with procedures performed by only 1 surgeon.

Incisional hernia recurrence after open elective repair: expertise in abdominal wall surgery matters

BACKGROUND

Recurrence after incisional hernia repair is one of the major problems related with this operation. Our objective is to analyze the influence of abdominal wall surgery expertise in the results of the open elective repair of incisional hernia.

METHODS

We have compiled the data of a cohort of patients who received surgery for an incisional hernia from July 2012 to December 2015 in a University Hospital. Data were collected prospectively and registered in the Spanish Register of Incisional Hernia (EVEREG). The short- and long-term complications between the groups of patients operated on by the Abdominal Wall Surgery (AWS) unit and groups operated on by surgeons outside of the specialized abdominal wall group (GS) were compared.

RESULTS

During the study period, a total of 237 patients were operated on by the open approach (114 AWS; 123 GS). One hundred seventy-five patients completed a median follow-up of 36.6 months [standard deviation (SD) = 6]. Groups were comparable in terms of age, sex, body mass index (BMI), comorbidities, and complexity of hernia. Complications were similar in both groups. Patients in the AWS group presented fewer recurrences (12.0% vs. 28.9%; P = 0.005). The cumulative incidence of recurrence was higher in the GS group [log rank 13.370; P < 0.001; odds ratio (OR) = 37.8; 95% confidence interval (CI) = 30.3-45.4]. In the multivariate analysis, surgery performed by the AWS unit was related to fewer recurrences (OR = 0.19; 95%CI = 0.07-0.58; P < 0.001).

CONCLUSION

Incisional hernia surgery is associated with better results in terms of recurrence when it is performed in a specialized abdominal wall unit.

Racial Differences in Complication Risk Following Emergency General Surgery: Who Your Surgeon Is May Matter

BACKGROUND

Understanding the mechanisms that lead to health-care disparities is necessary to create robust solutions that ensure all patients receive the best possible care. Our objective was to quantify the influence of the individual surgeon on disparate outcomes for minority patients undergoing an emergency general surgery (EGS).

MATERIALS AND METHODS

Using the Florida State Inpatient Database, we analyzed patients who underwent one or more of seven EGS procedures from 2010 to 2014. The primary outcome was development of a major postoperative complication. To determine the individual surgeon effect on complications, we performed multilevel mixed effects modeling, adjusting for clinical and hospital factors, such as diagnosis, comorbidities, and hospital teaching status and volume.

RESULTS

215,745 cases performed by 5816 surgeons at 198 hospitals were included. The overall unadjusted complication rate was 8.6%. Black patients had a higher adjusted risk of having a complication than white patients (odds ratio 1.12, 95% confidence interval 1.03-1.22). Surgeon random effects, when hospital fixed effects were held constant, accounted for 27.2% of the unexplained variation in complication risk among surgeons. This effect was modified by patient race; for white patients, surgeon random effects explained only 12.4% of the variability, compared to 52.5% of the variability in complications among black patients.

CONCLUSIONS

This multiinstitution analysis within a single large state demonstrates that not only do black patients have a higher risk of developing a complication after undergoing EGS than white patients but also surgeon-level effects account for a larger proportion of the between-surgeon variation. This suggests that the individual surgeon contributes to racial disparities in EGS.

With widespread adoption of MIS colectomy for colon cancer, does hospital type matter?

BACKGROUND

Recent studies have shown that hospital type impacts patient outcomes, but no studies have examined hospital differences in outcomes for patients undergoing minimally invasive surgery (MIS) for segmental colectomies.

METHODS

The 2010-2014 National Cancer Data Base was queried for patients undergoing segmental colectomy for non-metastatic colon adenocarcinoma. Descriptive statistics characterized MIS utilization by hospital type. Multivariable models were used to examine the effect of hospital type on outcomes after MIS. Survival probability was plotted using the Kaplan-Meier method.

RESULTS

80,922 patients underwent MIS segmental colectomy for colon cancer from 2010 to 2014. From 2010 to 2014, the number of MIS segmental colectomies increased by 157% at academic hospitals, 151% at comprehensive hospitals, and 153% at community hospitals. Compared to academic hospitals, community and comprehensive hospitals had greater adjusted odds of positive margins (Community OR 1.525, 95% Confidence Interval 1.233-1.885; Comprehensive OR 1.216, 95% CI 1.041-1.42), incomplete number of lymph nodes analyzed (< 12 LNs) from surgery (Community OR 2.15, 95% CI 1.98-2.32; Comprehensive OR 1.42, 95% CI 1.34-1.51), and greater 30-day mortality (Community OR 1.43, 95% CI 1.14-1.78; Comprehensive OR 1.36, 95% CI 1.17-1.59). Patient survival probability was higher at academic hospitals at 5 years (Academic 69% vs. Comprehensive 66% vs. Community 63%, p < 0.001). Community hospitals and comprehensive hospitals had significantly higher risk of adjusted long-term mortality (Community HR 1.28; 95% CI 1.19-1.37; p < 0.001; Comprehensive HR 1.14; 95% CI 1.09-1.20; p < 0.001).

CONCLUSIONS

Despite widespread use of laparoscopic oncologic surgery, short- and long-term outcomes from MIS for segmental colectomy are superior at academic hospitals. This difference may be due to superior perioperative oncologic technique and surgical outcomes at academic hospitals. Our data provide important information for patients, referring physicians, and surgeons about the significance of hospital type in management of colon cancer.

Physicians' attitudes towards the media and peer-review selection of the 'best cancer doctor': comparison of two different selection methods

OBJECTIVES

The choice of doctor is an important issue for patients with cancer, and the reputation of the doctor is the single most important factor for patients to choose a doctor. Media are providing information about the 'best cancer doctor', but they vary widely in their selection methodology. We investigated cancer physicians' attitudes towards the selection of the 'best cancer doctor' by the media, by comparing two different selection methodologies: selection by media personnel or selection through peer-review system.

DESIGN

Nationwide, cross-sectional survey.

SETTING

National Cancer Center and 12 Regional Cancer Centers across Korea.

PARTICIPANTS

A total of 680 cancer care physicians participated in the survey (75.5% participation rate), and two were excluded due to incomplete response.

MAIN OUTCOME MEASURES

Physicians' opinions on the credibility, fairness, validity, helpfulness to patients, their intention to use the information and helpfulness to improve the quality of cancer care of the two different methods.

RESULTS

Only a few physicians believed that the selection method of the 'best cancer doctor' by the media personnel was credible (9.1%), fair (6.1%) or valid (10.0%). In contrast, the majority agreed that the peer-selection method of the 'best doctor' is credible (74.7%), fair (64.7%) and valid (67.4%). More physicians believed the latter methods would be useful for patients when selecting their doctor (38.5% vs 82.2%) and may lead to improvement of the quality of cancer care from the perspective of the healthcare system (12.6% vs 59.8%). The need for ensuring objectiveness and transparency was also raised.

CONCLUSION

Physicians showed different attitudes towards two different selection methods. Regulations or guidelines for selecting the 'best cancer doctor' and for disclosing the information should be considered in order to control the quality of the information and to protect the customers.

Pouch failures following ileal pouch-anal anastomosis for ulcerative colitis

AIM

Ileal pouch-anal anastomosis is a procedure offered to patients with ulcerative colitis who opt for restoration of bowel continuity. The aim of this study was to determine the risk of pouch failure and ascertain the risk factors associated with failure.

METHOD

The study included 1991 patients with ulcerative colitis who underwent ileal pouch-anal anastomosis in Denmark in the period 1980-2013. Pouch failure was defined as excision of the pouch or presence of an unreversed stoma within 1 year after its creation. We used Cox proportional hazards regression to explore the association between pouch failure and age, gender, synchronous colectomy, primary faecal diversion, annual hospital volume (very low, 1-5 cases per year; low, 6-10; intermediate 11-20; high > 20), calendar year, laparoscopy and primary sclerosing cholangitis.

RESULTS

Over a median 11.4 years, 295 failures occurred, corresponding to 5-, 10- and 20-year cumulative risks of 9.1%, 12.1% and 18.2%, respectively. The risk of failure was higher for women [adjusted hazard ratio (aHR) 1.39, 95% CI 1.10-1.75]. Primary non-diversion (aHR 1.63, 95% CI 1.11-2.41) and a low hospital volume (aHR, very low volume vs high volume 2.30, 95% CI 1.26-4.20) were also associated with a higher risk of failure. The risk of failure was not associated with calendar year, primary sclerosing cholangitis, synchronous colectomy or laparoscopy.

CONCLUSION

In a cohort of patients from Denmark (where pouch surgery is centralized) with ulcerative colitis and ileal pouch-anal anastomosis, women had a higher risk of pouch failure. Of modifiable factors, low hospital volume and non-diversion were associated with a higher risk of pouch failure.

Predicting opportunities to increase utilization of laparoscopy for rectal cancer

BACKGROUND

Despite proven safety and efficacy, rates of laparoscopy for rectal cancer in the US are low. With reports of inferiority with laparoscopy compared to open surgery, and movements to develop accredited centers, investigating utilization and predictors of laparoscopy are warranted. Our goal was to evaluate current utilization and identify factors impacting use of laparoscopic surgery for rectal cancer.

METHODS

The Premier™ Hospital Database was reviewed for elective inpatient rectal cancer resections (1/1/2010-6/30/2015). Patients were identified by ICD-9-CM diagnosis codes, and then stratified into open or laparoscopic approaches by ICD-9-CM procedure codes or billing charge. Logistic multivariable regression identified variables predictive of laparoscopy. The Cochran-Armitage test assessed trend analysis. The main outcome measures were trends in utilization and factors independently associated with use of laparoscopy.

RESULTS

3336 patients were included-43.8% laparoscopic (n = 1464) and 56.2% open (n = 1872). Use of laparoscopy increased from 37.6 to 55.3% during the study period (p < 0.0001). General surgeons performed the majority of all resections, but colorectal surgeons were more likely to approach rectal cancer laparoscopically (41.31 vs. 36.65%, OR 1.082, 95% CI [0.92, 1.27], p < 0.3363). Higher volume surgeons were more likely to use laparoscopy than low-volume surgeons (OR 3.72, 95% CI [2.64, 5.25], p < 0.0001). Younger patients (OR 1.49, 95% CI [1.03, 2.17], p = 0.036) with minor (OR 2.13, 95% CI [1.45, 3.12], p < 0.0001) or moderate illness severity (OR 1.582, 95% CI [1.08, 2.31], p < 0.0174) were more likely to receive a laparoscopic resection. Teaching hospitals (OR 0.842, 95% CI [0.710, 0.997], p = 0.0463) and hospitals in the Midwest (OR 0.69, 95% CI [0.54, 0.89], p = 0.0044) were less likely to use laparoscopy. Insurance status and hospital size did not impact use.

CONCLUSIONS

Laparoscopy for rectal cancer steadily increased over the years examined. Patient, provider, and regional variables exist, with hospital status, geographic location, and colorectal specialization impacting the likelihood. However, surgeon volume had the greatest influence. These results emphasize training and surgeon-specific outcomes to increase utilization and quality in appropriate cases.

Patterns of Specialty-Based Referral and Perioperative Outcomes for Women With Endometrial Cancer Undergoing Hysterectomy

OBJECTIVE

To examine patterns of referral to gynecologic oncologists and perioperative outcomes based on surgeon specialty for women with endometrial cancer and hyperplasia.

METHODS

The National Surgical Quality Improvement Program database was used to perform a retrospective cohort study of women with endometrial cancer and hyperplasia who underwent hysterectomy from 2014 to 2015. Patients were stratified based on treatment by a gynecologic oncologist or other health care provider. Patterns of referral to a gynecologic oncologist was the primary outcome, and mode of hysterectomy and complications were secondary outcomes.

RESULTS

A total of 6,510 women were identified. Gynecologic oncologists performed 90.9% (95% confidence interval [CI] 90.1-91.7) of the hysterectomies for endometrial cancer, 66.8% (95% CI 63.1-70.4) for complex atypical endometrial hyperplasia, and 49.3% (95% CI 44.7-53.8) for endometrial hyperplasia without atypia. Older women and those with a higher American Society of Anesthesiology score were more likely to be treated by an oncologist. Minimally invasive hysterectomy was performed in 73.6% (95% CI 72.1-75.1) of women with endometrial cancer operated on by gynecologic oncologists compared with 73.8% (95% CI 68.8-78.2) of those treated by other physicians (odds ratio [OR] 0.99, 95% CI 0.80-1.23); lymphadenectomy was performed in 56.3% of women treated by gynecologic oncologists compared with 34.8% of those treated by other specialists (OR 2.42, 95% CI 1.99-2.94). Severe complications were uncommon and there was no difference in complication rates based on specialty, 2.6% (95% CI 2.2-3.1) compared with 2.0% (95% CI 0.8-3.3).

CONCLUSION

Gynecologic oncologists provide care for the majority of women with endometrial cancer who undergo hysterectomy in the United States and are also involved in the care of a large percentage of women with endometrial hyperplasia.

Volume-outcome relationship for colorectal cancer in primary care: a prospective cohort study

Purpose Higher caseloads are associated with better outcomes for many conditions treated in secondary and tertiary care settings, including colorectal cancer (CRC). There is little known whether such volume-outcome relationship exist in primary care settings. The purpose of this paper is to examine general practitioner (GP) CRC-specific caseload for possible associations with referral pathways, disease stage and CRC patients' overall survival. Design/methodology/approach The paper retrospectively analyses a prospectively maintained CRC database for 2009-2014 in a single district hospital providing bowel cancer screening and tertiary rectal cancer services. Findings Of 1,145 CRC patients, 937 (81.8 per cent) were diagnosed as symptomatic cancers. In total, 210 GPs from 44 practices were stratified according to their CRC caseload over the study period into low volume (LV, 1-4); medium volume (MV, 5-7); and high volume (HV, 8-21 cases). Emergency presentation (LV: 49/287 (17.1 per cent); MV: 75/264 (28.4 per cent); HV: 105/386 (27.2 per cent); p=0.007) and advanced disease at presentation (LV: 84/287 (29.3 per cent); MV: 94/264 (35.6 per cent); HV: 144/386 (37.3 per cent); p=0.034) was more common amongst HV GPs. Three-year mortality risk was significantly higher for HV GPs (MV: (hazard ratio) HR 1.185 (confidence interval=0.897-1.566), p=0.231, and HV: HR 1.366 (CI=1.061-1.759), p=0.016), but adjustment for emergency presentation and advanced disease largely accounted for this difference. There was some evidence that HV GPs used elective cancer pathways less frequently (LV: 166/287 (57.8 per cent); MV: 130/264 (49.2 per cent); HV: 182/386 (47.2 per cent); p=0.007) and more selectively (CRC/referrals: LV: 166/2,743 (6.1 per cent); MV: 130/2,321 (5.6 per cent); HV: 182/2,508 (7.3 per cent); p=0.048). Originality/value Higher GP CRC caseload in primary care may be associated with advanced disease and poorer survival; more work is required to determine the reasons and to develop targeted intervention at local level to improve elective referral rates.

Short-term outcomes after surgical resection for colorectal cancer in South Australia

RATIONALE, AIMS AND OBJECTIVE

Short-term outcomes (unplanned readmission, post-surgical complication rates, 30-day and 90-day post-surgical mortality) are often used as indicators of quality of surgical care for colorectal cancer (CRC). Differences in these immediate outcomes can highlight disparities in care across patient subpopulations. This study aimed to document short-term outcomes following major surgery for CRC and to identify whether there were any sociodemographic differences across South Australia (SA).

METHODS

This population-based study included all CRC resections among SA residents diagnosed with CRC aged 50-79 years in 2003-2008 (n = 3940). Clinical, treatment, comorbidity and outcomes data were compiled through linkage of administrative and surveillance datasets across SA. A retrospective cohort design was used to examine short-term outcomes including post-operative complications, 28-day emergency readmission and 30-day and 90-day mortality. We used multivariable logistic regression to identify factors associated with each outcome.

RESULTS

Post-operative complications occurred in 28% of cases. Thirty-day and ninety-day mortality were 1.3% and 3%, respectively. Later stage, older age, multiple comorbidities and emergency admissions were associated with poorer short-term outcomes. Risk of complications was lower among patients from higher socio-economic areas (OR = 0.77, 95%CI 0.62-0.98). Risk of 30-day mortality was higher among non-metropolitan patients (OR = 2.33, 95%CI 1.22-4.46). Post-operative complications increased the risk of emergency readmission and short-term mortality.

CONCLUSIONS

Short-term outcomes following CRC surgery may be improved through strategies to increase earlier detection and reduce emergency admissions. Socioeconomic and regional disparities require further examination of health system factors.

Prospective multicenter registration study of colorectal cancer: significant variations in radicality and oncosurgical quality-Swiss Group for Clinical Cancer Research Protocol SAKK 40/00

PURPOSE

This study aimed to investigate in a multicenter cohort study the radicality of colorectal cancer resections, to assess the oncosurgical quality of colorectal specimens, and to compare the performance between centers.

METHODS

One German and nine Swiss hospitals agreed to prospectively register all patients with primary colorectal cancer resected between September 2001 and June 2005. The median number of eligible patients with one primary tumor included per center was 95 (range 12-204).

RESULTS

The following variations of median values or percentages between centers were found: length of bowel specimen 20-39 cm (25.8 cm), maximum height of mesocolon 6.5-12.5 cm (9.0 cm), number of examined lymph nodes 9-24 (16), distance to nearer bowel resection margin in colon cancer 4.8-12 cm (7 cm), and in rectal cancer 2-3 cm (2.5 cm), central ligation of major artery 40-97 % (71 %), blood loss 200-500 ml (300 ml), need for perioperative blood transfusion 5-40 % (19 %), tumor opened during mobilization 0-11 % (5 %), T4-tumors not en-bloc resected 0-33 % (4 %), inadvertent perforation of mesocolon/mesorectum 0-8 % (4 %), no-touch isolation technique 36-86 % (67 %), abdominoperineal resection for rectal cancer 0-30 % (17 %), rectal cancer specimen with circumferential margin ≤1 mm 0-19 % (10 %), in-hospital mortality 0-6 % (2 %), anastomotic leak or intra-abdominal abscess 0-17 % (7 %), re-operation 0-17 % (8 %).

CONCLUSION

In colorectal cancer, surgery considerable variations between different centers were found with regard to radicality and oncosurgical quality, suggesting a potential for targeted improvement of surgical technique.

Conversations for providers caring for patients with rectal cancer: Comparison of long-term patient-centered outcomes for patients with low rectal cancer facing ostomy or sphincter-sparing surgery

For some patients with low rectal cancer, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter-sparing surgery. Sphincter-sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients who are eligible for sphincter-sparing surgery may not be well served by the surgery, and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries or to help physicians elicit long-term surgical outcomes. Furthermore, comparison of long-term outcomes and late effects after the two surgeries has not been synthesized. Therefore, this systematic review summarizes controlled studies that compared long-term survivorship outcomes between these two surgical groups. The goals are: 1) to improve understanding and shared decision-making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) to increase the patient's participation in the decision; 3) to alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, to improve patients' long-term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter-sparing surgery as well as questions to ask during follow-up examinations to ascertain any long-term challenges facing the patient. CA Cancer J Clin 2016;66:387-397. © 2016 American Cancer Society.

Colorectal surgery in Italy. Criteria to identify the hospital units and the tertiary referral centers entitled to perform it

Improving the quality and effectiveness of care is a key priority of any health policy. The outcomes of health care can be considered as indicators of effectiveness or quality. The scientific literature that evaluates the association between the volume of activity and the outcome of health interventions has greatly developed over the past decade, but, for practical reasons, ethical and social issues, a few randomized controlled studies were made to evaluate this association, although there are numerous observational studies of outcome and systematic reviews of the studies themselves. The colorectal surgery is the most studied area and it represents the ideal testing ground to determine the effectiveness of the quality indicators because of the high incidence of the disease and the wide spread in the territory of the structures that aim to tackle these issues. Numerous studies have documented an association between the large number of colo-rectal surgical procedures and the quality of results. In particular, the volume of activity is one of the characteristics of measurable process that can have a significant impact on the outcome of health care. In conclusion, the ability to use volume thresholds as a proxy for quality is very tempting but it is only part of reality. Infact, the volume-outcome relationship strictly depends on the type of cancer (colon vs rectum) and it appears somehow stronger for the individual surgeon than for the hospital; especially for the 5-year overall survival, operative mortality and number of permanent stoma.

Anastomotic leakage after colon cancer resection: does the individual surgeon matter?

AIM

Anastomotic leakage is one of the most feared complications after colonic resection. Many risk factors for anastomotic leakage have been reported, but the impact of an individual surgeon as a risk factor has scarcely been reported. The aim of this study was to assess if the individual surgeon is an independent risk factor for anastomotic leakage in colonic cancer surgery.

METHOD

This was a retrospective analysis of prospectively collected data from patients who underwent elective resection for colon cancer with anastomosis at a specialized colorectal unit from January 1993 to December 2010. Anastomotic leaks were diagnosed according to standardized criteria. Patient and tumour characteristics, surgical procedure and operating surgeons were analysed. A logistic regression model was used to discriminate statistical variation and identify risk factors for anastomotic leakage.

RESULTS

A total of 1045 patients underwent elective colon cancer resection with primary anastomosis. Anastomotic leakage occurred in 6.4% of patients. Ileocolic anastomosis had an anastomotic leakage rate of 7.2%, colo-colonic/colorectal anastomosis 5.2% and ileorectal anastomosis 12.7%, with intersurgeon variability. The independent risk factors associated with anastomotic leakage were the use of perioperative blood transfusion (OR 2.83, CI 1.59-5.06, P < 0.0001) and the individual surgeon performing the procedure (OR up to 8.44, P < 0.0001).

CONCLUSION

In addition to perioperative blood transfusion, the individual surgeon was identified as an important risk factor for anastomotic leakage. Efforts should be made to reduce performance variability amongst surgeons.

Experience of a specialist emergency bariatric surgical service

BACKGROUND

Bariatric surgery is associated with late and procedure-specific acute surgical complications. There is very little evidence available regarding the volume, nature, and outcomes of acute surgical admissions directly stemming from bariatric surgery. Centralization of bariatric elective services in the United Kingdom may have an adverse impact on the ability of local services to manage such unpredictable complications. To address this potential problem, we set up a comprehensive and specialist emergency bariatric service.

OBJECTIVES

The aim of this study was to quantify and characterize the workload of a specialist emergency surgical bariatric service.

SETTING

University National Health Service hospital.

METHODS

Over 2 years, we prospectively collected data on demographic characteristics, management, and outcomes of all acute surgical admissions related directly to previous bariatric surgery.

RESULTS

Between December 2011 and November 2013, 69 patients had 71 emergency admissions due to a surgical emergency directly related to previous bariatric surgery. Thirty-seven (54%) had undergone primary bariatric surgery at our institution, 13 (19%) at a different National Health Service hospital, 16 (23%) at private U.K. hospitals, and 3 (4%) at private overseas hospitals. Forty-four endoscopic or surgical interventions were required, of which 17 (39%) were performed on nights or weekends and within 12 hours of admission. Of 27 operations, 25 (93%) were completed laparoscopically. Median length of stay was 2 days, there were no mortalities, and there was 1 readmission within 30 days.

CONCLUSIONS

There is a significant volume of late bariatric surgical emergencies, many requiring urgent intervention. These may be effectively managed by a specialist bariatric service.

Colorectal specialization and survival in colorectal cancer

AIM

It is recognized that higher surgeon volume is associated with improved survival in colorectal cancer. However, there is a paucity of national studies that have evaluated the relationship between surgical specialization and survival.

METHOD

We used the Surveillance, Epidemiology, and End Results Medicare cancer registry to examine the association between colorectal specialization (CRS) and disease-specific survival (DSS) between 2001 and 2009. A total of 21,432 colon cancer and 5893 rectal cancer patients who underwent elective surgical resection between 2001 and 2009 were evaluated. Univariate and multivariate Cox survival analysis was used to identify the association between surgical specialization and cancer-specific survival.

RESULTS

Colorectal specialists performed 16.3% of the colon and 27% of the rectal resections. On univariate analysis, specialization was associated with improved survival in Stage II and Stage III colon cancer and Stage II rectal cancer. In multivariate analysis, however, CRS was associated with significantly improved DSS only in Stage II rectal cancer [hazard ratio (HR) 0.70, P = 0.03]. CRS was not significantly associated with DSS in either Stage I (colon HR 1.14, P = 0.39; rectal HR 0.1.26, P = 0.23) or Stage III (colon HR 1.06, P = 0.52; rectal HR 1.08, P = 0.55) disease. When analysis was limited to high volume surgeons only, the relationship between CRS and DSS was unchanged.

CONCLUSIONS

CRS is associated with improved DSS following resection of Stage II rectal cancer. A combination of factors may contribute to long-term survival in these patients, including appropriate surgical technique, multidisciplinary treatment decisions and guideline-adherent surveillance. CRS probably contributes positively to these factors resulting in improved survival.

Surgical Unit volume and 30-day reoperation rate following primary resection for colorectal cancer in the Veneto Region (Italy)

BACKGROUND

The aim of this study was to evaluate the impact of Surgical Unit volume on the 30-day reoperation rate in patients with CRC.

METHODS

Data were extracted from the regional Hospital Discharge Dataset and included patients who underwent elective resection for primary CRC in the Veneto Region (2005-2013). The primary outcome measure was any unplanned reoperation performed within 30 days from the index surgery. Independent variables were: age, gender, comorbidity, previous abdominal surgery, site and year of the resection, open/laparoscopic approach and yearly Surgical Unit volume for colorectal resections as a whole, and in detail for colonic, rectal and laparoscopic resections. Multilevel multivariate regression analysis was used to evaluate the impact of variables on the outcome measure.

RESULTS

During the study period, 21,797 elective primary colorectal resections were performed. The 30-day reoperation rate was 5.5% and was not associated with Surgical Unit volume. In multivariate multilevel analysis, a statistically significant association was found between 30-day reoperation rate and rectal resection volume (intermediate-volume group OR 0.75; 95% CI 0.56-0.99) and laparoscopic approach (high-volume group OR 0.69; 95% CI 0.51-0.96).

CONCLUSIONS

While Surgical Unit volume is not a predictor of 30-day reoperation after CRC resection, it is associated with an early return to the operating room for patients operated on for rectal cancer or with a laparoscopic approach. These findings suggest that quality improvement programmes or centralization of surgery may only be required for subgroups of CRC patients.

The association between county-level surgeon density and esophageal and gastric cancer mortality

BACKGROUND

Surgical resection plays an integral part in the curative treatment of esophageal (EC) and gastric cancer (GC). The impact of the allocation of surgeons at the county level on these cancer outcomes is unclear. Our aims were to examine the effect of surgeon density on EC and GC mortality and to compare the relative roles of thoracic and general surgeons on outcomes.

METHODS

Using county-level data from the Area Resource File, we constructed multivariate regression models to explore the effect of thoracic and general surgeon density on EC and GC mortality, adjusting for cancer incidence rate, county-level, socioeconomic factors and health care resource metrics.

RESULTS

In total, 663 and 539 counties were analyzed for EC and GC, respectively: Mean EC and GC mortality rates were 4.95 and 4.07; mean thoracic and general surgeon density were 6 and 50 per 100,000 people, respectively. When compared to counties with no thoracic surgeons, those with at least one thoracic surgeon had reduced EC mortality. For GC, counties with one or more general surgeons also had decreased deaths when compared with those without any general surgeons. While increasing the density of surgeons beyond ten only yielded minimal improvements in EC mortality, this resulted in significant further reductions in GC mortality.

CONCLUSIONS

Mortality from GC appears to be more susceptible to the benefits of increased surgeon density. For EC, a strategic policy of allocating health resources and distributing the surgical workforce proportionally across counties will be best able to optimize outcomes at the population-based level.

Risk Factors for Anastomotic Leakage After Intersphincteric Resection Without a Protective Defunctioning Stoma for Lower Rectal Cancer

BACKGROUND

Intersphincteric resection (ISR) is performed as an alternative to abdominoperineal resection for super-low rectal cancer. The purpose of this study was to evaluate risk factors for anastomotic leakage (AL) after ISR without a defunctioning stoma for lower rectal cancer.

METHODS

Between 1995 and 2012, 135 consecutive patients with lower rectal cancer underwent curative ISR without a protective defunctioning stoma. Univariate and multivariate analyses were performed to determine the risk factors for AL.

RESULTS

The radiological and symptomatic AL rate was 17.0 % (23/135). Univariate analysis demonstrated that male sex (P = 0.030), preoperative chemotherapy (P = 0.016), partial ISR (P < 0.001), lateral lymph-node dissection (P = 0.042), distal tumor distance from the dentate line (P = 0.007), and straight reconstruction (P < 0.001) were significantly associated with AL. Severe AL requiring re-laparotomy developed in 13 (9.6 %) patients. Univariate analysis demonstrated that male sex (P = 0.006), partial ISR (P < 0.001), distal tumor distance from the dentate line (P = 0.002), and straight reconstruction (P < 0.001) were significantly associated with AL requiring relaparotomy. Multivariate analysis demonstrated that partial ISR [odds ratio (OR) 6.701; P = 0.001] and straight reconstruction (OR 5.552; P = 0.002) were independently predictive of AL.

CONCLUSIONS

Partial ISR and straight reconstruction increased the risk of AL after ISR without a protective defunctioning stoma. A defunctioning stoma might be mandatory in patients with the risk factors identified in this analysis.

Self-reported practice patterns and knowledge of rectal cancer care among Canadian general surgeons

BACKGROUND

Our objective was to examine the knowledge and treatment decision practice patterns of Canadian surgeons who treat patients with rectal cancer.

METHODS

A mail survey with 6 questions on staging investigations, management of low rectal cancer, lymph node harvest, surgical margins and use of adjuvant therapies was sent to all general surgeons in Canada. Appropriate responses to survey questions were defined a priori. We compared survey responses according to surgeon training (colorectal/surgical oncology v. others) and geographic region (Atlantic, Central, West).

RESULTS

The survey was sent to 2143 general surgeons; of the 1312 respondents, 703 treat patients with rectal cancer. Most surgeons responded appropriately to the questions regarding staging investigations (88%) and management of low rectal cancer (88%). Only 55% of surgeons correctly identified the recommended lymph node harvest as 12 or more nodes, 45% identified 5 cm as the recommended distal margin for upper rectal cancer, and 70% appropriately identified which patients should be referred for adjuvant therapy. Surgeons with subspecialty training were significantly more likely to provide correct responses to all of the survey questions than other surgeons. There was limited variation in responses according to geographic region. Subspecialty-trained surgeons and recent graduates were more likely to answer all of the survey questions correctly than other surgeons.

CONCLUSION

Initiatives are needed to ensure that all surgeons who treat patients with rectal cancer, regardless of training, maintain a thorough and accurate knowledge of rectal cancer treatment issues.

The impact of surgical specialisation on survival following elective colon cancer surgery

PURPOSE

Reorganisation of cancer services in the UK and across Europe has led to elective surgery for colon cancer being increasingly, but not exclusively, delivered by specialist colorectal surgeons. This study examines survival after elective colon cancer surgery performed by specialist compared to non-specialist surgeons.

METHOD

Patients undergoing elective surgery for colon cancer in 16 hospitals between 2001 and 2004 were identified from a prospectively maintained regional audit database. Post-operative mortality (<30 days) and 5-year relative survival in those receiving surgery under the care of a specialist or non-specialist surgeon were compared.

RESULTS

A total of 1,856 patients were included, of which, 1,367 (73.7%) were treated by a specialist and 489 (26.4%) by a non-specialist surgeon. Those treated by a specialist were more likely to be deprived, undergo surgery in a high volume unit and have higher lymph node yields than those treated by a non-specialist. Post-operative mortality was lower (4.5 versus 7.0%; P = 0.032) and 5-year relative survival was higher (72.2 versus 65.6%; P = 0.012) among those treated by a specialist surgeon. In multivariate analysis, surgery by non-specialists was independently associated with increased post-operative mortality (adjusted odds ratio (OR) 1.69; P < 0.001) and poorer 5-year relative survival (adjusted relative excess risk (RER) 1.17; P = 0.045). After exclusion of post-operative deaths, there was no difference in long-term survival (adjusted RER 1.08; P = 0.505).

CONCLUSION

Five-year relative survival after elective colon cancer surgery was higher among those treated by specialist colorectal surgeons due to increased post-operative mortality among those treated by non-specialists.

Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference

BACKGROUND AND AIM

The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome.

METHOD

An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM).

RESULTS AND CONCLUSION

The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.

Patterns of colorectal cancer care in Europe, Australia, and New Zealand

Colorectal cancer is the second most common cancer in women and the third most common in men worldwide. In this study, we used MEDLINE to conduct a systematic review of existing literature published in English between 2000 and 2010 on patterns of colorectal cancer care. Specifically, this review examined 66 studies conducted in Europe, Australia, and New Zealand to assess patterns of initial care, post-diagnostic surveillance, and end-of-life care for colorectal cancer. The majority of studies in this review reported rates of initial care, and limited research examined either post-diagnostic surveillance or end-of-life care for colorectal cancer. Older colorectal cancer patients and individuals with comorbidities generally received less surgery, chemotherapy, or radiotherapy. Patients with lower socioeconomic status were less likely to receive treatment, and variations in patterns of care were observed by patient demographic and clinical characteristics, geographical location, and hospital setting. However, there was wide variability in data collection and measures, health-care systems, patient populations, and population representativeness, making direct comparisons challenging. Future research and policy efforts should emphasize increased comparability of data systems, promote data standardization, and encourage collaboration between and within European cancer registries and administrative databases.

Surgery for rectal cancer-what is on the horizon?

The management of rectal cancer has improved considerably in recent decades. Surgery remains the cornerstone of the treatment. However, the role of preoperative imaging has made it possible to optimize the treatment plan in rectal patients. Neoadjuvant treatment may be indicated in efforts to sterilize possible tumor deposits outside the surgical field, or may be used to downsize and downstage the tumor itself. The optimal sequence of treatment modalities can be determined by a multidisciplinary team, who not only use pretreatment imaging, but also review pathologic results after surgery. The pathologist plays a pivotal role in providing feedback about the success of surgery, i.e., the distance between the tumor and the circumferential resection margin, the quality of surgery, and the effect of neoadjuvant treatment. Registry and auditing of all treatment variables can further improve outcomes. In this century, rectal cancer treatment has become a team effort.

Evolving treatment strategies for colorectal cancer: A critical review of current therapeutic options

Management of rectal cancer has markedly evolved over the last two decades. New technologies of staging have allowed a more precise definition of tumor extension. Refinements in surgical concepts and techniques have resulted in higher rates of sphincter preservation and better functional outcome for patients with this malignancy. Although, preoperative chemoradiotherapy followed by total mesorectal excision has become the standard of care for locally advanced tumors, many controversial matters in management of rectal cancer still need to be defined. These include the feasibility of a non-surgical approach after a favorable response to neoadjuvant therapy, the ideal margins of surgical resection for sphincter preservation and the adequacy of minimally invasive techniques of tumor resection. In this article, after an extensive search in PubMed and Embase databases, we critically review the current strategies and the most debatable matters in treatment of rectal cancer.

Hierarchical multilevel analysis of increased caseload volume and postoperative outcome after elective colorectal surgery

BACKGROUND

The study aimed to explore the impact of surgeon and institution volume on outcome following colorectal surgery in England using multilevel hierarchical analysis.

METHODS

An observational study design was used. All patients undergoing primary elective colorectal resection between 2000 and 2008 were included from the Hospital Episode Statistics database. Consultant surgeons and hospitals were divided into tertiles (low, medium and high volume) according to their mean annual colorectal cancer resection caseload. Outcome measures examined were postoperative 30-day mortality, 28-day readmission and reoperation, and length of stay. Hierarchical multiple regression analysis adjusted for age, sex, co-morbidity, social deprivation, year of surgery, operation type and surgical approach.

RESULTS

A total of 109 261 elective cancer colorectal resections were included. High-volume consultant surgeons and hospitals were defined as performing more than 20·7 and 103·5 elective colorectal cancer procedures per year respectively. Consultant and hospital operative volumes increased throughout the study period. In hierarchical regression models, greater surgeon and institutional volume independently predicted only shorter length of hospital stay. No statistical association was observed between higher provider volume and postoperative mortality, 28-day reoperation or readmission rates.

CONCLUSION

Increasing elective colorectal cancer caseload alone may have marginal postoperative benefit.

Surgical specialization

The evolution of surgery

The economic impact of anastomotic leakage after anterior resections in English NHS hospitals: are we adequately remunerating them?

AIM

Our aim was to determine the frequency and economic impact of anastomotic leakage (AL) at local and national levels in England.

METHOD

All patients who underwent AR in Oxford between 2007 and 2009 were evaluated for AL. Hospital Episode Statistics (HES) data were used to determine reoperation rates after elective AR (n = 23 388) in England between 2000 and 2008. Hospital episode remuneration costs were calculated by the local commissioning department and compared with Department of Health (DH) reference index costs.

RESULTS

The frequency of AL following anterior resection was 10.9% (31 out of 285) in Oxford. Laparotomy for leakage was performed in 5.6% of cases. The 30-day hospital mortality rate for all ARs was 2.1%, compared with 3.2% after AL. The national relaparotomy rate (within 28 days) and 30-day hospital mortality in English National Health Service (NHS) trusts following AR were 5.9% and 2.9%, respectively. Institutional remunerated tariffs (£6233 (SD ± 965)) were similar to DH reference costs (£6319 (SD ± 1830)) after uncomplicated AR. However, there was a significant (P = 0.008) discrepancy between the remunerated tariff for AL (£9605 (SD ± 6908)) and the actual cost (£17 220 (SD ± 9642)). AL resulted in an additional annual cost of approximately £1.1 million to £3.5 million when extrapolated nationally.

CONCLUSION

The estimated economic burden of anastomotic leakage following AR is approximately double that of the remunerated tariff.

Multimodal treatment strategies for locally advanced rectal cancer

This review outlines the important multimodal treatment issues associated with locally advanced rectal cancer. Changes to chemotherapy and radiation schema, as well as modern surgical approaches, have led to a revolution in the management of this disease but the morbidity and mortality remains high. Adequate treatment is dependent on precise preoperative staging modalities. Advances in staging via endorectal ultrasound, computed tomography, MRI and PET have improved pretreatment triage and management. Important prognostic factors and their impact for this disease are under investigation. Here we discuss the different treatment options including modern tumor-related surgical approaches, neoadjuvant as well as adjuvant therapies. Further clinical progress will largely depend on the broader implementation of multidisciplinary treatment strategies following the principles of evidence-based medicine.