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Wilms M, Jenetzky E, Märzheuser S, Busse R, Nimptsch U. Treatment of Anorectal Malformations in German Hospitals: Analysis of National Hospital Discharge Data from 2016 to 2021. Eur J Pediatr Surg 2024. [PMID: 38307106 DOI: 10.1055/a-2260-5124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
BACKGROUND Anorectal malformations (ARMs) are complex congenital anomalies. The corrective operation is demanding and schedulable. Based on complete national data, patterns of care have not been analyzed in Germany yet. METHODS All cases with ARM were analyzed (1) at the time of birth and (2) during the hospital stay for the corrective operation, based on the national hospital discharge data (DRG statistics). Patient's comorbidities, treatment characteristics, hospital structures, and the outcome of corrective operations were analyzed with respect to the hospitals' caseload. RESULTS From 2016 to 2021, 1,726 newborns with ARM were treated at the time of birth in 388 hospitals. Of these hospitals, 19% had neither a pediatric nor a pediatric surgical department. At least one additional congenital anomaly was present in 49% of cases and 7% of the newborns had a birthweight below 1,500 g.In all, 2,060 corrective operations for ARM were performed in 113 hospitals in the same time period. In 24.5% of cases, at least one major complication was documented. One-third of the operations were performed in 56 hospitals, one-third in 20 hospitals, and one-third in 10 hospitals with median annual case numbers of 2, 5, and 10, respectively.Hospitals with the highest caseload operated cloacal defects more often than hospitals with the lowest caseload (7 vs. 2%) and had more early complications than hospitals with the lowest caseload (30 vs. 21%). This difference was not statistically significant after risk adjustment. CONCLUSIONS Children with ARM are multimorbid. Early complications after corrective surgery are common. Considering the large number of hospitals with a very low caseload, centralization of care for the complex and elective corrective surgery for ARM remains a key issue for quality of care.
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Affiliation(s)
- Miriam Wilms
- Patient Organization for People with Anorectal Malformations and Hirschsprung's Disease (SoMA e.V.), Munich, Germany
- Department of General-, Visceral-, Thorax and Pediatric Surgery, Universitätsklinikum Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - Ekkehart Jenetzky
- Department of Research Methodology and Information Systems in the Integrative Medicine, University Witten Herdecke Faculty of Medicine, Witten, Nordrhein-Westfalen, Germany
- Departement of Child and Adolescent Psychiatry, Johannes Gutenberg University Hospital Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Stefanie Märzheuser
- Departement of Pediatric Surgery, Rostock University Medical Center Children and Youth Clinic, Rostock, Mecklenburg-Vorpommern, Germany
| | - Reinhard Busse
- Department of Health Care Management, Technische Universität Berlin, Berlin, Berlin, Germany
| | - Ulrike Nimptsch
- Department of Health Care Management, Technische Universität Berlin, Berlin, Berlin, Germany
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Lippenberger F, Ziegelmayer S, Berlet M, Feussner H, Makowski M, Neumann PA, Graf M, Kaissis G, Wilhelm D, Braren R, Reischl S. Development of an image-based Random Forest classifier for prediction of surgery duration of laparoscopic sigmoid resections. Int J Colorectal Dis 2024; 39:21. [PMID: 38273097 PMCID: PMC10811180 DOI: 10.1007/s00384-024-04593-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 01/27/2024]
Abstract
PURPOSE Sigmoid diverticulitis is a disease with a high socioeconomic burden, accounting for a high number of left-sided colonic resections worldwide. Modern surgical scheduling relies on accurate prediction of operation times to enhance patient care and optimize healthcare resources. This study aims to develop a predictive model for surgery duration in laparoscopic sigmoid resections, based on preoperative CT biometric and demographic patient data. METHODS This retrospective single-center cohort study included 85 patients who underwent laparoscopic sigmoid resection for diverticular disease. Potentially relevant procedure-specific anatomical parameters recommended by a surgical expert were measured in preoperative CT imaging. After random split into training and test set (75% / 25%) multiclass logistic regression was performed and a Random Forest classifier was trained on CT imaging parameters, patient age, and sex in the training cohort to predict categorized surgery duration. The models were evaluated in the test cohort using established performance metrics including receiver operating characteristics area under the curve (AUROC). RESULTS The Random Forest model achieved a good average AUROC of 0.78. It allowed a very good prediction of long (AUROC = 0.89; specificity 0.71; sensitivity 1.0) and short (AUROC = 0.81; specificity 0.77; sensitivity 0.56) procedures. It clearly outperformed the multiclass logistic regression model (AUROC: average = 0.33; short = 0.31; long = 0.22). CONCLUSION A Random Forest classifier trained on demographic and CT imaging biometric patient data could predict procedure duration outliers of laparoscopic sigmoid resections. Pending validation in a multicenter study, this approach could potentially improve procedure scheduling in visceral surgery and be scaled to other procedures.
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Affiliation(s)
- Florian Lippenberger
- Institute of Diagnostic and Interventional Radiology, School of Medicine and Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sebastian Ziegelmayer
- Institute of Diagnostic and Interventional Radiology, School of Medicine and Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maximilian Berlet
- Department of Surgery, School of Medicine, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
- Research Group MITI, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Hubertus Feussner
- Department of Surgery, School of Medicine, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
- Research Group MITI, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Marcus Makowski
- Institute of Diagnostic and Interventional Radiology, School of Medicine and Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Philipp-Alexander Neumann
- Department of Surgery, School of Medicine, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Markus Graf
- Institute of Diagnostic and Interventional Radiology, School of Medicine and Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Georgios Kaissis
- Institute of Diagnostic and Interventional Radiology, School of Medicine and Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Institute for Artificial Intelligence in Medicine and Healthcare, School of Medicine and Faculty of Informatics, Technical University of Munich, Munich, Germany
| | - Dirk Wilhelm
- Department of Surgery, School of Medicine, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
- Research Group MITI, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Rickmer Braren
- Institute of Diagnostic and Interventional Radiology, School of Medicine and Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- German Cancer Consortium (DKTK, Partner Site Munich) and German Cancer Research Center, DKFZ, Heidelberg, Germany
| | - Stefan Reischl
- Institute of Diagnostic and Interventional Radiology, School of Medicine and Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
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Uttinger KL, Brunotte M, Diers J, Lock JF, Jansen-Winkeln B, Seehofer D, Germer CT, Wiegering A. Diverticulitis patient care during the Covid-19 pandemic in Germany-a retrospective nationwide population-based cohort study. Langenbecks Arch Surg 2023; 408:447. [PMID: 38001302 PMCID: PMC10673984 DOI: 10.1007/s00423-023-03184-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023]
Abstract
PURPOSE Coronavirus disease 2019 (COVID-19) impacted health care systems around the world. Despite a decrease in emergency admissions, an increased number of complicated forms of diverticulitis was reported. It was the aim of this study to analyze the pandemic impact on diverticulitis management in Germany. METHODS This is a retrospective population-wide analysis of hospital billing data (2012-2021) of diverticulitis in Germany. Patients were identified based on diagnosis (ICD10) and procedural codes to stratify by conservative and operative management. Primary outcome of interest was admission rates, secondary outcomes were rates of surgical vs conservative treatment and fraction of complicated clinical courses during the pandemic. RESULTS Of a total of 991,579 cases, 66,424 (6.7%) were admitted during pandemic lockdowns. Conservative treatment was the most common overall (66.9%) and higher during lockdowns (70.7%). Overall admissions and population adjusted rates of surgically treated patients decreased, the latter by 12.7% and 11.3%, corrected to estimated rates, in the two lockdowns. Surgery after emergency presentation decreased by 7.1% (p=0.053) and 11.1% (p=0.002) in the two lockdowns with a higher rate of ostomy and/or revision (+5.6%, p=0.219, and +10.2%, p=0.030). In-hospital mortality was increased in lockdown periods (1.64% vs 1.49%). In detail, mortality was identical in case of conservative treatment during lockdown periods (0.5%) but was higher in surgically treated patients (4.4% vs 3.6%). CONCLUSION During lockdowns, there was an overall decrease of admissions for diverticulitis, especially non-emergency admissions in Germany, and treatment was more likely to be conservative. In case of surgery, however, there was increased risk of a complicated course (ostomy, re-surgery), possibly due to patient selection.
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Affiliation(s)
- Konstantin L Uttinger
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany.
- Department of Visceral, Transplant, Thoracic and Vascular Surgery Leipzig University Medical Center, Leipzig, Germany.
| | - Maximilian Brunotte
- Department of Visceral, Transplant, Thoracic and Vascular Surgery Leipzig University Medical Center, Leipzig, Germany
| | - Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany
| | - Johan Friso Lock
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany
| | - Boris Jansen-Winkeln
- Department of General, Visceral and Oncological Surgery, St. Georg Hospital Leipzig, Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplant, Thoracic and Vascular Surgery Leipzig University Medical Center, Leipzig, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg Medical Center, Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg Medical Center, Würzburg, Germany
- Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany
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Brunner M, ElGendy A, Denz A, Weber G, Grützmann R, Krautz C. [Robot-assisted visceral surgery in Germany : Analysis of the current status and trends of the last 5 years using data from the StuDoQ|Robotics registry]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:940-947. [PMID: 37500803 PMCID: PMC10587021 DOI: 10.1007/s00104-023-01940-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 07/29/2023]
Abstract
Robot-assisted systems have been increasingly used in general surgery for several years. Accordingly, the number of systems installed in Germany has also rapidly increased. While around 100 robot-assisted systems were used in German hospitals in 2018, this figure had already risen to more than 200 by 2022. The aim of this article is to present the current state of development and trends in robotic surgery in Germany. For this purpose, data from the StuDoQ|Robotics register were analyzed. Furthermore, a descriptive analysis of concomitant diagnosis-related groups (DRG) data was carried out via the Federal Statistical Office (Destatis), for a better assessment of the representativeness of the StuDoQ|Robotics register data. In both data sets, the annual number of robot-assisted visceral surgery procedures in Germany steadily increased. Compared to the DRG data, only 3.7% up to a maximum of 36.7% of all robot-assisted procedures performed were documented in the StuDoQ|Robotics register, depending on the type of procedure. Colorectal resections were the most frequent robot-assisted procedures (StuDoQ: 32.5% and 36.7% vs. DRG data: 24.2% and 29.7%) and had, for example, low mortality rates (StuDoQ: 1% and 1% vs. DRG data: 2.3% and 1.3%). Due to the low coverage rates of robot-assisted esophageal, gastric, pancreatic and liver interventions, no valid statements could be derived from the StuDoQ data for these areas. With the current coverage rates, the informative value of the StuDoQ|Robotics register is considerably limited for some types of intervention. In the future, measures should therefore be explored that lead to a significant increase in the coverage rates.
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Affiliation(s)
- Maximilian Brunner
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität Erlangen, Krankenhausstraße 12, 91054, Erlangen, Deutschland.
| | - Amr ElGendy
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität Erlangen, Krankenhausstraße 12, 91054, Erlangen, Deutschland
| | - Axel Denz
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität Erlangen, Krankenhausstraße 12, 91054, Erlangen, Deutschland
| | - Georg Weber
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität Erlangen, Krankenhausstraße 12, 91054, Erlangen, Deutschland
| | - Robert Grützmann
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität Erlangen, Krankenhausstraße 12, 91054, Erlangen, Deutschland
| | - Christian Krautz
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität Erlangen, Krankenhausstraße 12, 91054, Erlangen, Deutschland
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Völkel V, Gerken M, Kleihues-van Tol K, Schoffer O, Bierbaum V, Bobeth C, Roessler M, Reissfelder C, Fürst A, Benz S, Rau BM, Piso P, Distler M, Günster C, Hansinger J, Schmitt J, Klinkhammer-Schalke M. Treatment of Colorectal Cancer in Certified Centers: Results of a Large German Registry Study Focusing on Long-Term Survival. Cancers (Basel) 2023; 15:4568. [PMID: 37760537 PMCID: PMC10526771 DOI: 10.3390/cancers15184568] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
(1) Background: The WiZen study is the largest study so far to analyze the effect of the certification of designated cancer centers on survival in Germany. This certification program is provided by the German Cancer Society (GCS) and represents one of the largest oncologic certification programs worldwide. Currently, about 50% of colorectal cancer patients in Germany are treated in certified centers. (2) Methods: All analyses are based on population-based clinical cancer registry data of 47.440 colorectal cancer (ICD-10-GM C18/C20) patients treated between 2009 and 2017. The primary outcome was 5-year overall survival (OAS) after treatment at certified cancer centers compared to treatment at other hospitals; the secondary endpoint was recurrence-free survival. Statistical methods included Kaplan-Meier analysis and multivariable Cox regression. (3) Results: Treatment at certified hospitals was associated with significant advantages concerning 5-year overall survival (HR 0.92, 95% CI 0.89, 0.96, adjusted for a broad range of confounders) for colon cancer patients. Concentrating on UICC stage I-III patients, for whom curative treatment is possible, the survival benefit was even larger (colon cancer: HR 0.89, 95% CI 0.84, 0.94; rectum cancer: HR 0.91, 95% CI 0.84, 0.97). (4) Conclusions: These results encourage future efforts for further implementation of the certification program. Patients with colorectal cancer should preferably be directed to certified centers.
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Affiliation(s)
- Vinzenz Völkel
- Tumor Center Regensburg, Center of Quality Management and Health Services Research, University of Regensburg, 93053 Regensburg, Germany (M.K.-S.)
| | - Michael Gerken
- Tumor Center Regensburg, Center of Quality Management and Health Services Research, University of Regensburg, 93053 Regensburg, Germany (M.K.-S.)
- Bavarian Cancer Registry, Regional Center Regensburg, Bavarian Health and Food Safety Authority, 93053 Regensburg, Germany
| | | | - Olaf Schoffer
- Center for Evidence-Based Healthcare (ZEGV), Faculty of Medicine, University Hospital Carl Gustav Carus and Carl Gustav Carus, Dresden University of Technology (TU Dresden), 01307 Dresden, Germany; (O.S.); (J.S.)
| | - Veronika Bierbaum
- Center for Evidence-Based Healthcare (ZEGV), Faculty of Medicine, University Hospital Carl Gustav Carus and Carl Gustav Carus, Dresden University of Technology (TU Dresden), 01307 Dresden, Germany; (O.S.); (J.S.)
| | - Christoph Bobeth
- Center for Evidence-Based Healthcare (ZEGV), Faculty of Medicine, University Hospital Carl Gustav Carus and Carl Gustav Carus, Dresden University of Technology (TU Dresden), 01307 Dresden, Germany; (O.S.); (J.S.)
| | - Martin Roessler
- Center for Evidence-Based Healthcare (ZEGV), Faculty of Medicine, University Hospital Carl Gustav Carus and Carl Gustav Carus, Dresden University of Technology (TU Dresden), 01307 Dresden, Germany; (O.S.); (J.S.)
| | - Christoph Reissfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Alois Fürst
- Klinik für Allgemein-, Viszeral-, Thoraxchirurgie und Adipositasmedizin, Caritas Krankenhaus St., 93053 Regensburg, Germany
| | - Stefan Benz
- Arbeitsgemeinschaft Deutscher Tumorzentren e.V. (ADT), 14057 Berlin, Germany
- Klinik für Allgemein-, Viszeral-, Thorax- und Kinderchirurgie, 71032 Böblingen, Germany
| | - Bettina M. Rau
- Department of General, Visceral and Thoracic Surgery, Hospital of Neumarkt, 92318 Neumarkt in der Oberpfalz, Germany
| | - Pompiliu Piso
- Klinik für Allgemein- und Viszeralchirurgie, Krankenhaus der Barmherzigen Brüder, 93049 Regensburg, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Dresden, Faculty of Medicine Carl Gustav Carus, Dresden University of Technology (TU Dresden), 01307 Dresden, Germany
| | | | - Judith Hansinger
- Tumor Center Regensburg, Center of Quality Management and Health Services Research, University of Regensburg, 93053 Regensburg, Germany (M.K.-S.)
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare (ZEGV), Faculty of Medicine, University Hospital Carl Gustav Carus and Carl Gustav Carus, Dresden University of Technology (TU Dresden), 01307 Dresden, Germany; (O.S.); (J.S.)
| | - Monika Klinkhammer-Schalke
- Tumor Center Regensburg, Center of Quality Management and Health Services Research, University of Regensburg, 93053 Regensburg, Germany (M.K.-S.)
- Arbeitsgemeinschaft Deutscher Tumorzentren e.V. (ADT), 14057 Berlin, Germany
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Peeters NWL, Vreman RA, Cirkel GA, Kersten MJ, van Laarhoven HWM, Timmers L. Systemic anticancer treatment in the Netherlands: Few hospitals treat many patients, many hospitals treat few patients. Health Policy 2023; 135:104865. [PMID: 37459745 DOI: 10.1016/j.healthpol.2023.104865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 05/10/2023] [Accepted: 06/24/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION The correlation between patient volume and clinical outcomes is well known for various oncological treatments, especially in the surgical field. The current level of centralisation of systemic treatment of (hemato-)oncology indications in Dutch hospitals is unknown. OBJECTIVES The aim of this study was to gain insight in patient volumes per hospital of patients treated with systemic anticancer treatment in the Netherlands. METHODS National claims data (Vektis) of all 73 Dutch hospitals that provide systemic anticancer medication in the Netherlands for the time period 2019 were used. The distribution of volumes of patients treated with anticancer medication for 38 different haematological or oncological indications was analysed. Hospitals were categorized into academic/specialised, general, and top clinical. Two volume cut off points (10 and 30 patients) were used to identify hospitals treating relatively few patients with anticancer medication. Four indications were investigated in more detail. RESULTS A wide distribution in patient volumes within hospitals was observed. Top clinical hospitals generally treated the most patients per hospital, followed by general and academic/specialised oncology hospitals. The volume cut off points showed that in 19 indications (50%) the majority (>50%) of all hospitals treated less than 10 patients and in 25 indications (66%) the majority of all hospitals treated less than 30 patients with anticancer medication. Four case studies demonstrated that relatively few hospitals treat many patients while many hospitals treat few patients with anticancer medication. CONCLUSION In the majority of oncology indications, a large proportion of Dutch hospitals treat small numbers of unique patients with anticancer medication. The high level of fragmentation gives ground for further exploration and discussion on how the organisation of care can support optimization of the efficiency and quality of care. Professional groups, policy makers, patients, and healthcare insurers should consider per indication whether centralisation is warranted.
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Affiliation(s)
| | - Rick A Vreman
- Zorginstituut Nederland (ZIN), Diemen, the Netherlands; Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Geert A Cirkel
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Medical Oncology, Meander Medical Center, Amersfoort, the Netherlands
| | - Marie José Kersten
- Department of Hematology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Medical Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
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Pietryga S, Lock JF, Diers J, Baum P, Uttinger KL, Baumann N, Flemming S, Wagner JC, Germer CT, Wiegering A. Nationwide volume-outcome relationship concerning in-hospital mortality and failure-to-rescue in surgery of sigmoid diverticulitis. Int J Colorectal Dis 2023; 38:203. [PMID: 37522984 DOI: 10.1007/s00384-023-04495-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE A correlation between the hospital volume and outcome is described for multiple entities of oncological surgery. To date, this has not been analyzed for the surgical treatment of sigmoid diverticulitis. The aim of this study was to explore the impact of the annual caseload per hospital of colon resection on the postoperative incidence of complications, failure to rescue, and mortality in patients with diverticulitis. METHODS Patients receiving colorectal resection independent from the diagnosis from 2012 to 2017 were selected from a German nationwide administrative dataset. The hospitals were grouped into five equal caseload quintiles (Q1-Q5 in ascending caseload order). The outcome analysis was focused on patients receiving surgery for sigmoid diverticulitis. RESULTS In total, 662,706 left-sided colon resections were recorded between 2012 and 2017. Of these, 156,462 resections were performed due to sigmoid diverticulitis and were included in the analysis. The overall in-house mortality rate was 3.5%, ranging from 3.8% in Q1 (mean of 9.5 procedures per year) to 3.1% in Q5 (mean 62.8 procedures per year; p < 0.001). Q5 hospitals revealed a risk-adjusted odds ratio of 0.85 (95% CI 0.78-0.94; p < 0.001) for in-hospital mortality compared to Q1 during multivariable logistic regression analysis. High-volume centers showed overall lower complication rates, whereas the failure-to-rescue did not differ significantly. CONCLUSION Surgical treatment of sigmoid diverticulitis in high-volume colorectal centers shows lower postoperative mortality rates and fewer postoperative complications.
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Affiliation(s)
- Sebastian Pietryga
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at, Würzburg University Hospital, Würzburg, Germany
| | - Johan Friso Lock
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at, Würzburg University Hospital, Würzburg, Germany
| | - Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at, Würzburg University Hospital, Würzburg, Germany
| | - Philip Baum
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at, Würzburg University Hospital, Würzburg, Germany
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Konstantin L Uttinger
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at, Würzburg University Hospital, Würzburg, Germany
| | - Nikolas Baumann
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at, Würzburg University Hospital, Würzburg, Germany
| | - Sven Flemming
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at, Würzburg University Hospital, Würzburg, Germany
| | - Johanna C Wagner
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at, Würzburg University Hospital, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at, Würzburg University Hospital, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg Medical Center, Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at, Würzburg University Hospital, Würzburg, Germany.
- Comprehensive Cancer Center Mainfranken, University of Würzburg Medical Center, Würzburg, Germany.
- Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany.
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, Medical Center Julius Maximilians, University of Würzburg, Oberduerrbacherstrasse 6, 97080, Würzburg, Germany.
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8
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Uttinger KL, Diers J, Baum P, Hankir M, Germer CT, Wiegering A. Impact of the COVID pandemic on major abdominal cancer resections in Germany: a retrospective population-based cohort study. Int J Surg 2023; 109:670-678. [PMID: 36917131 PMCID: PMC10132304 DOI: 10.1097/js9.0000000000000202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 12/30/2022] [Indexed: 03/15/2023]
Abstract
BACKGROUND The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is estimated to have claimed more than 6 million lives globally since it started in 2019. Germany was exposed to two waves of coronavirus disease 2019 in 2020, one starting in April and the other in October. To ensure sufficient capacity for coronavirus disease 2019 patients in intensive care units, elective medical procedures were postponed. The fraction of major abdominal cancer resections affected by these measures remains unknown, and the most affected patient cohort has yet to be identified. METHODS This is a register-based, retrospective, nationwide cohort study of anonymized 'diagnosis-related group' billing data provided by the Federal Statistical Office in Germany. Cases were identified using diagnostic and procedural codes for major cancer resections. Population-adjusted cancer resection rates as the primary endpoint were compared at baseline (2012-2019) to those in 2020. RESULTS A change in resection rates for all analyzed entities (esophageal, gastric, liver, pancreatic, colon, rectum, and lung cancer) was observed from baseline to 2020. Total monthly oncological resections dropped by 7.4% (8.7% normalized to the annual German population, P =0.011). Changes ranged from +3.7% for pancreatic resections ( P =0.277) to -19.4% for rectal resections ( P <0.001). Reductions were higher during lockdown periods. During the first lockdown period (April-June), the overall drop was 14.3% (8.58 per 100 000 vs. 7.35 per 100 000, P <0.001). There was no catch-up effect during the summer months except for pancreatic cancer resections. In the second lockdown period, there was an overall drop of 17.3%. In subgroup analyses, the elderly were most affected by the reduction in resection rates. There was a significant negative correlation between regional SARS-CoV-2 incidences and resections rates. This correlation was strongest for rectal cancer resections (Spearman's r : -0.425, P <0.001). CONCLUSIONS The pandemic lockdowns had a major impact on the oncological surgical caseload in Germany in 2020. The elderly were most affected by the reduction. There was a clear correlation between SARS-CoV-2 incidences regionally and the reduction of surgical resection rates. In future pandemic circumstances, oncological surgery has to be prioritized with an extra focus on the most vulnerable patients.
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Affiliation(s)
- Konstantin L. Uttinger
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, Leipzig University Hospital, Leipzig
| | - Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg
| | - Philip Baum
- Department of Thoracic Surgery, Thoraxklinik Heidelberg University Hospital, Heidelberg
| | - Mohammed Hankir
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg
- Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg
- Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre
- Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany
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Willis MA, Keller PS, Sommer N, Koch F, Ritz JP, Beyer K, Reißfelder C, Hardt J, Herold A, Buhr HJ, Emmanuel K, Kalff JC, Vilz TO. Adherence to fast track measures in colorectal surgery-a survey among German and Austrian surgeons. Int J Colorectal Dis 2023; 38:80. [PMID: 36964828 PMCID: PMC10039823 DOI: 10.1007/s00384-023-04379-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 03/26/2023]
Abstract
PURPOSE The effectiveness of modern perioperative treatment concepts has been demonstrated in several studies and meta-analyses. Despite good evidence, limited implementation of the fast track (FT) concept is still a widespread concern. To assess the status quo in Austrian and German hospitals, a survey on the implementation of FT measures was conducted among members of the German Society of General and Visceralsurgery (DGAV), the German Society of Coloproctology (DGK) and the Austrian Society of Surgery (OEGCH) to analyze where there is potential for improvement. METHODS Twenty questions on perioperative care of colorectal surgery patients were sent to the members of the DGAV, DGK and OEGCH using the online survey tool SurveyMonkey®. Descriptive data analysis was performed using Microsoft Excel. RESULTS While some of the FT measures have already been routinely adopted in clinical practice (e.g. minimally invasive surgical approach, early mobilization and diet buildup), for other components there are discrepancies between current recommendations and present implementation (e.g. the use of local nerve blocks to provide opioid-sparing analgesia or the use of abdominal drains). CONCLUSION The implementation of the FT concept in Austria and Germany is still in need of improvement. Particularly regarding the use of abdominal drains and postoperative analgesia, there is a tendency to stick to traditional structures. To overcome the issues with FT implementation, the development of an evidence-based S3 guideline for perioperative care, followed by the founding of a surgical working group to conduct a structured education and certification process, may lead to significant improvements in perioperative patient care.
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Affiliation(s)
- Maria A Willis
- Department of Surgery, University Hospital Bonn, Campus 1, 53127, Bonn, Germany
| | - Peter S Keller
- Department of Surgery, University Hospital Bonn, Campus 1, 53127, Bonn, Germany
| | - Nils Sommer
- Department of Surgery, University Hospital Bonn, Campus 1, 53127, Bonn, Germany
| | - Franziska Koch
- Department of General and Abdominal Surgery, Helios Hospital Schwerin, Schwerin, Germany
| | - Jörg-Peter Ritz
- Department of General and Abdominal Surgery, Helios Hospital Schwerin, Schwerin, Germany
| | - Katharina Beyer
- Department of Surgery, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Christoph Reißfelder
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Heidelberg, Germany
| | - Julia Hardt
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Heidelberg, Germany
| | | | - Heinz J Buhr
- German Society of General- and Abdominal Surgeons, Germany, Berlin, Germany
| | - Klaus Emmanuel
- Department of Surgery, University Hospital Salzburg, Salzburg, Austria
| | - Joerg C Kalff
- Department of Surgery, University Hospital Bonn, Campus 1, 53127, Bonn, Germany
| | - Tim O Vilz
- Department of Surgery, University Hospital Bonn, Campus 1, 53127, Bonn, Germany.
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10
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Uttinger KL, Reibetanz J, Diers J, Baum P, Pietryga S, Hendricks A, Schütze L, Baumann N, Wiegering V, Lock J, Dischinger U, Seyfried F, Fassnacht M, Germer CT, Wiegering A. Volume-outcome relationship in adrenal surgery from 2009-2017 in Germany-a retrospective study. Eur J Endocrinol 2023; 188:6979716. [PMID: 36651160 DOI: 10.1093/ejendo/lvac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/30/2022] [Accepted: 12/08/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Adrenal resections are rare procedures of a heterogeneous nature. While recent European guidelines advocate a minimum annual caseload for adrenalectomies (6 per surgeon), evidence for a volume-outcome relationship for this surgery remains limited. DESIGN A retrospective analysis of all adrenal resections in Germany between 2009 and 2017 using hospital billing data was performed. Hospitals were grouped into three tertiles of approximately equal patient volume. METHODS Descriptive, univariate, and multivariate analyses were applied to identify a possible volume-outcome relationship (complications, complication management, and mortality). RESULTS Around 17 040 primary adrenal resections were included. Benign adrenal tumors (n = 8,213, 48.2%) and adrenal metastases of extra-adrenal malignancies (n = 3582, 21.0%) were the most common diagnoses. Six hundred and thirty-two low-volume hospitals performed an equal number of resections as 23 high-volume hospitals (median surgeries/hospital/year 3 versus 31, P < .001). Complications were less frequent in high-volume hospitals (23.1% in low-volume hospitals versus 17.3% in high-volume hospitals, P < .001). The most common complication was bleeding in 2027 cases (11.9%) with a mortality of 4.6% (94 patients). Overall in-house mortality was 0.7% (n = 126). Age, malignancy, an accompanying resection, complications, and open surgery were associated with in-house mortality. In univariate analysis, surgery in high-volume hospitals was associated with lower mortality (OR: 0.47, P < .001). In a multivariate model, the tendency remained equal (OR: 0.59, P = .104). Regarding failure to rescue (death in case of complications), there was a trend toward lower mortality in high-volume hospitals. CONCLUSIONS The annual caseload of adrenal resections varies considerably among German hospitals. Our findings suggest that surgery in high-volume centers is advantageous for patient outcomes although fatal complications are rare.
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Affiliation(s)
- Konstantin L Uttinger
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
- Department of Visceral, Transplant, Thoracic and Vascular Surgery at Leipzig University Hospital, 04103 Leipzig, Germany
| | - Joachim Reibetanz
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Johannes Diers
- Department of Internal Medicne, Marienkrankenhaus, 22087 Hamburg, Germany
| | - Philip Baum
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, 62196 Heidelberg, Germany
| | - Sebastian Pietryga
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Anne Hendricks
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Leon Schütze
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Nikolas Baumann
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Verena Wiegering
- Department of Pediatrics, Ped. Hematology, Oncology and Stem Cell Transplantation, at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Johann Lock
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Ulrich Dischinger
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg Medical Center, 97080 Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg Medical Center, 97080 Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg Medical Center, 97080 Würzburg, Germany
- Department of Biochemistry and Molecular Biology, University of Würzburg, 97080 Würzburg, Germany
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11
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Flemming S, Kelm M, Germer CT, Wiegering A. [Ileal pouch after restorative coloproctectomy]. CHIRURGIE (HEIDELBERG, GERMANY) 2022; 93:1030-1036. [PMID: 36036850 DOI: 10.1007/s00104-022-01708-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 06/15/2023]
Abstract
The continuous development of pouch surgery has enabled continence-preserving treatment after coloproctectomy. The ileoanal J‑pouch is nowadays the standard reconstruction after restorative coloproctectomy with excellent functional long-term results. Taking the relative contraindications and a suitable patient selection into consideration, pouch placement can be indicated not only for ulcerative colitis and familial adenomatous polyposis, but also for patients with nonfistular Crohn's disease. Due to a high treatment density with immunosuppressants, the surgical treatment regimen should be subdivided into a multistage procedure, whereby according to current data a modified two-stage procedure should be favored.
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Affiliation(s)
- S Flemming
- Klinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - M Kelm
- Klinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - C-T Germer
- Klinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - A Wiegering
- Klinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
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12
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Mortality during In-Hospital Treatment for Head and Neck Cancer in Germany: A Diagnosis-Related Group-Based Nationwide Analysis, 2005–2018. JOURNAL OF ONCOLOGY 2022; 2022:1387860. [PMID: 36164347 PMCID: PMC9509216 DOI: 10.1155/2022/1387860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 08/30/2022] [Indexed: 11/18/2022]
Abstract
Background Data on in-hospital MR (IHMR) of head and neck cancer (HNC) are sparse. Methods IHMR was determined in Germany between 2005 and 2018 using nationwide population-based diagnosis-related group (DRG) data of 1,090,596 HNC. Results The overall average IHMR was 0.04 ± 0.02. IHMR increased with older age to 0.04 ± 0.01 for patients of 65-79 years of age (relative risk [RR] in relation to patients of 35-49 years of age = 1.767; 95%confidence interval [CI] = 1.040 to3.001) to a maximum of 0.07 ± 0.01 for patients of 80 years and older (RR = 2.826; CI = 1.663 to 4.803). IHMR was the highest when no HNC-specific treatment, i.e., best supportive and palliative care, was applied (0.11 ± 0.01; RR in relation to tumor biopsy surgery = 7.241; CI = 3.447 to 5.211). IHMR was not different between surgery, radiotherapy, or chemotherapy/biologicals. Conclusions IHMR did not change over time. Efforts are needed to decrease the IHMR for HNC.
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13
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Widder A, Kelm M, Reibetanz J, Wiegering A, Matthes N, Germer CT, Seyfried F, Flemming S. Robotic-Assisted versus Laparoscopic Left Hemicolectomy-Postoperative Inflammation Status, Short-Term Outcome and Cost Effectiveness. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191710606. [PMID: 36078317 PMCID: PMC9517740 DOI: 10.3390/ijerph191710606] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/20/2022] [Accepted: 08/21/2022] [Indexed: 05/09/2023]
Abstract
Robotic-assisted colon surgery may contain advantages over the laparoscopic approach, but clear evidence is sparse. This study aimed to analyze postoperative inflammation status, short-term outcome and cost-effectiveness of robotic-assisted versus laparoscopic left hemicolectomy. All consecutive patients who received minimal-invasive left hemicolectomy at the Department of Surgery I at the University Hospital of Wuerzburg in 2021 were prospectively included. Importantly, no patient selection for either procedure was carried out. The robotic-assisted versus laparoscopic approaches were compared head to head for postoperative short-term outcomes as well as cost-effectiveness. A total of 61 patients were included, with 26 patients having received a robotic-assisted approach. Baseline characteristics did not differ among the groups. Patients receiving a robotic-assisted approach had a significantly decreased length of hospital stay as well as lower rates of complications in comparison to patients who received laparoscopic surgery (n = 35). In addition, C-reactive protein as a marker of systemic stress response was significantly reduced postoperatively in patients who were operated on in a robotic-assisted manner. Consequently, robotic-assisted surgery could be performed in a cost-effective manner. Thus, robotic-assisted left hemicolectomy represents a safe and cost-effective procedure and might improve patient outcomes in comparison to laparoscopic surgery.
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Affiliation(s)
- Anna Widder
- Department of General, Visceral, Transplantat, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Matthias Kelm
- Department of General, Visceral, Transplantat, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Joachim Reibetanz
- Department of General, Visceral, Transplantat, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplantat, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
- Department of Biochemistry and Molecular Biology, University of Wuerzburg, 97070 Wuerzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Wuerzburg Medical Centre, 97080 Wuerzburg, Germany
| | - Niels Matthes
- Department of General, Visceral, Transplantat, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
- Department of Biochemistry and Molecular Biology, University of Wuerzburg, 97070 Wuerzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantat, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Wuerzburg Medical Centre, 97080 Wuerzburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplantat, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Sven Flemming
- Department of General, Visceral, Transplantat, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
- Correspondence:
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Low-grade mucinous neoplasms (LAMN) of the appendix in Germany between 2011 and 2018: a nationwide analysis based on data provided by the German Center for Cancer Registry Data (ZfKD) at the Robert Koch Institute (RKI). Langenbecks Arch Surg 2022; 407:3615-3622. [PMID: 35962281 DOI: 10.1007/s00423-022-02639-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/31/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Low-grade appendiceal mucinous neoplasms (LAMN) are semi-malignant tumors of the appendix which are incidentally found in up to 1% of appendectomy specimen. To this day, no valid descriptive analysis on LAMN is available for the German population. METHODS Data of LAMN (ICD-10: D37.3) were collected from the population-based cancer registries in Germany, provided by the German Center for Cancer Registry Data (Zentrum für Krebsregisterdaten-ZfKD). Data was anonymized and included gender, age at diagnosis, tumor staging according to the TNM-classification, state of residence, information on the performed therapy, and survival data. RESULTS A total of 612 cases were reported to the ZfKD between 2011 and 2018. A total of 63.07% were female and 36.93% were male. Great inhomogeneity in reporting cases was seen in the federal states of Germany including the fact that some federal states did not report any cases at all. Age distribution showed a mean age of 62.03 years (SD 16.15) at diagnosis. However, data on tumor stage was only available in 24.86% of cases (n = 152). A total of 49.34% of these patients presented with a T4-stage. Likewise, information regarding performed therapy was available in the minority of patients: 269 patients received surgery, 22 did not and for 312 cases no information was available. Twenty-four patients received chemotherapy, 188 did not, and for 400 cases, no information was available. Overall 5-year survival was estimated at 79.52%. Patients below the age of 55 years at time of diagnosis had a significantly higher 5-year survival rate compared to patients above the age of 55 years (85.77% vs. 73.27%). DISCUSSION In this study, we observed an incidence of LAMN in 0.13% of all appendectomy specimen in 2018. It seems likely that not all cases were reported to the ZfKD; therefore, case numbers may be considered underestimated. Age and gender distribution goes in line with international studies with females being predominantly affected. Especially regarding tumor stage and therapy in depth information cannot be provided through the ZfKD-database. This data analysis emphasizes the need for further studies and the need for setting up a specialized registry for this unique tumor entity to develop guidelines for the appropriate treatment and follow-up.
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15
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Correction to: Differences in morbidity and mortality between unilateral adrenalectomy for adrenal Cushing's syndrome and bilateral adrenalectomy for therapy refractory extra-adrenal Cushing's syndrome. Langenbecks Arch Surg 2022; 407:3895. [PMID: 35829817 DOI: 10.1007/s00423-022-02601-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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16
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Reibetanz J, Kelm M, Uttinger KL, Reuter M, Schlegel N, Hankir M, Wiegering V, Germer CT, Fassnacht M, Lock JF, Wiegering A. Differences in morbidity and mortality between unilateral adrenalectomy for adrenal Cushing's syndrome and bilateral adrenalectomy for therapy refractory extra-adrenal Cushing's syndrome. Langenbecks Arch Surg 2022; 407:2481-2488. [PMID: 35633419 PMCID: PMC9467939 DOI: 10.1007/s00423-022-02568-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/21/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE In selected cases of severe Cushing's syndrome due to uncontrolled ACTH secretion, bilateral adrenalectomy appears unavoidable. Compared with unilateral adrenalectomy (for adrenal Cushing's syndrome), bilateral adrenalectomy has a perceived higher perioperative morbidity. The aim of the current study was to compare both interventions in endogenous Cushing's syndrome regarding postoperative outcomes. METHODS We report a single-center, retrospective cohort study comparing patients with hypercortisolism undergoing bilateral vs. unilateral adrenalectomy during 2008-2021. Patients with adrenal Cushing's syndrome due to adenoma were compared with patients with ACTH-dependent Cushing's syndrome (Cushing's disease and ectopic ACTH production) focusing on postoperative morbidity and mortality as well as long-term survival. RESULTS Of 83 patients with adrenalectomy for hypercortisolism (65.1% female, median age 53 years), the indication for adrenalectomy was due to adrenal Cushing's syndrome in 60 patients (72.2%; 59 unilateral and one bilateral), and due to hypercortisolism caused by Cushing's disease (n = 16) or non-pituitary uncontrolled ACTH secretion of unknown origin (n = 7) (27.7% of all adrenalectomies). Compared with unilateral adrenalectomy (n = 59), patients with bilateral adrenalectomy (n = 24) had a higher rate of severe complications (0% vs. 33%; p < 0.001) and delayed recovery (median: 10.2% vs. 79.2%; p < 0.001). Using the MTL30 marker, patients with bilateral adrenalectomy fared worse than patients after unilateral surgery (MTL30 positive: 7.2% vs. 25.0% p < 0.001). Postoperative mortality was increased in patients with bilateral adrenalectomy (0% vs. 8.3%; p = 0.081). CONCLUSION While unilateral adrenalectomy for adrenal Cushing's syndrome represents a safe and definitive therapeutic option, bilateral adrenalectomy to control ACTH-dependent extra-adrenal Cushing's syndrome or Cushing's disease is a more complicated intervention with a mortality of nearly 10%.
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Affiliation(s)
- Joachim Reibetanz
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany
| | - Matthias Kelm
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany
| | - Konstantin L Uttinger
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany.,Department of Visceral, Transplant, Thoracic and Vascular Surgery at Leipzig University Hospital, Leipzig, Germany
| | - Miriam Reuter
- Division of Endocrinology and Diabetes, Department of Medicine I, University Hospital, University of Würzburg, 97080, Würzburg, Germany
| | - Nicolas Schlegel
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany
| | - Mohamed Hankir
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany
| | - Verena Wiegering
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Children's Hospital, University of Wuerzburg, Josef-Schneiderstr. 2, 97080, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany.,Comprehensive Cancer Center Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Medicine I, University Hospital, University of Würzburg, 97080, Würzburg, Germany.,Comprehensive Cancer Center Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany
| | - Johan Friso Lock
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany. .,Comprehensive Cancer Center Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany. .,Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany. .,Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, Medical Centre, Julius Maximilians University of Würzburg, Oberduerrbacher Strasse 6, 97080, Würzburg, Germany.
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Radiotherapy for Pediatric Adrenocortical Carcinoma – Review of the Literature. Clin Transl Radiat Oncol 2022; 35:56-63. [PMID: 35601796 PMCID: PMC9121070 DOI: 10.1016/j.ctro.2022.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 12/18/2022] Open
Abstract
Radiotherapy (RT) is mostly performed for curative intent, only few cases in palliative setting are reported. The site of RT was predominantly tumor bed, abdominal cavity, and/or metastases. Adjuvant RT has to be discussed—even in the context of TPSs—especially for patients with high risk factors. Evidence regarding RT in in pediatric adrenocortical carcinoma is too limited to give any general recommendation. However, we suggest to consider adjuvant radiotherapy in individual patients with high risk of recurrence. A systematic international study with a common data platform is needed to establish evidence. on the role of RT in the treatment of children with adrenocortical carcinoma and to improve the outcome in this rare disease.
Background and purpose Pediatric adrenocortical carcinoma (pACC) is a rare disease with poor prognosis. Publications on radiotherapy (RT) are scarce. This review summarizes the current data on RT for pACC and possibly provides first evidence to justify its use in this setting. Materials and methods We searched the PubMed and Embase database for manuscripts regarding RT for pACC. Results We included 17 manuscripts reporting on 76 patients treated with RT, after screening 2961 references and 269 full articles. In addition, we added data of 4 unreported pACC patients treated by co-authors. All reports based on retrospective data. Median age at first diagnosis was 11.1 years (70% female); 78% of patients presented with hormonal activity. RT was mostly performed for curative intent (78%). 88% of RT were administered during primary therapy. The site of RT was predominantly the local tumor bed (76%). Doses of RT ranged from 15 to 62 Gy (median 50 Gy). Information on target volumes or fractionation were lacking. Median follow-up was 6,9 years and 64% of the patients died of disease, with 33% alive without disease. In 16 of 48 patients with available follow-up data after adjuvant RT (33%) no recurrence was reported and in 3 of 9 patients palliative RT seemed to induce some benefit for the patient. Conclusions Our first systematic review on RT for pACC provides too few data for any general recommendation, but adjuvant RT in patients with high risk might be considered. International collaborative studies are urgently needed to establish better evidence on the role of RT in this rare malignancy.
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Diers J, Baum P, Lehmann K, Uttinger K, Baumann N, Pietryga S, Hankir M, Matthes N, Lock JF, Germer CT, Wiegering A. Disproportionately high failure to rescue rates after resection for colorectal cancer in the geriatric patient population - A nationwide study. Cancer Med 2022; 11:4256-4264. [PMID: 35475597 DOI: 10.1002/cam4.4784] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 04/07/2022] [Accepted: 04/16/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Colorectal cancer incidence increases with patient age. The aim of this study was to assess, at the nationwide level, in-hospital mortality, and failure to rescue in geriatric patients (≥ 80 years old) with colorectal cancer arising from postoperative complications. METHODS All patients receiving surgery for colorectal cancer in Germany between 2012 and 2018 were identified in a nationwide database. Association between age and in-hospital mortality following surgery and failure to rescue, defined as death after complication, were determined in univariate and multivariate analyses. RESULTS Three lakh twenty-eight thousands two hundred and ninety patients with colorectal cancer were included of whom 77,287 were 80 years or older. With increasing age, a significant relative increase in right hemicolectomy was observed. In general, these patients had more comorbid conditions and higher frailty. In-hospital mortality following colorectal cancer surgery was 4.9% but geriatric patients displayed a significantly higher postoperative in-hospital mortality of 10.6%. The overall postoperative complication rate as well as failure to rescue increased with age. In contrast, surgical site infection (SSI) and anastomotic leakage (AL) did not increase in geriatric patients, whereas the associated mortality increased disproportionately (13.3% for SSI and 29.9% mortality for patients with AI, both p < 0.001). Logistic regression analysis adjusting for confounders showed that geriatric patients had almost five-times higher odds for death after surgery than the baseline age group below 60 (OR 4.86; 95%CI [4.45-5.53], p < 0.001). CONCLUSION Geriatric patients have higher mortality after colorectal cancer surgery. This may be partly due to higher frailty and disproportionately higher rates of failure to rescue arising from postoperative complications.
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Affiliation(s)
- Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Philip Baum
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Kai Lehmann
- Department of General, Visceral and Vascular Surgery, Charité University Hospital Berlin Campus Benjamin Franklin, Berlin, Germany
| | - Konstatin Uttinger
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Nikolas Baumann
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Sebastian Pietryga
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Mohammed Hankir
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Niels Matthes
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Johann F Lock
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany.,Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany.,Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany.,Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany
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Baum P, Lenzi J, Diers J, Rust C, Eichhorn ME, Taber S, Germer CT, Winter H, Wiegering A. Risk-Adjusted Mortality Rates as a Quality Proxy Outperform Volume in Surgical Oncology-A New Perspective on Hospital Centralization Using National Population-Based Data. J Clin Oncol 2022; 40:1041-1050. [PMID: 35015575 DOI: 10.1200/jco.21.01488] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Despite a long-known association between annual hospital volume and outcome, little progress has been made in shifting high-risk surgery to safer hospitals. This study investigates whether the risk-standardized mortality rate (RSMR) could serve as a stronger proxy for surgical quality than volume. METHODS We included all patients who underwent complex oncologic surgeries in Germany between 2010 and 2018 for any of five major cancer types, splitting the data into training (2010-2015) and validation sets (2016-2018). For each surgical group, we calculated annual volume and RSMR quintiles in the training set and applied these thresholds to the validation set. We studied the overlap between the two systems, modeled a market exit of low-performing hospitals, and compared effectiveness and efficiency of volume- and RSMR-based rankings. We compared travel distance or time that would be required to reallocate patients to the nearest hospital with low-mortality ranking for the specific procedure. RESULTS Between 2016 and 2018, 158,079 patients were treated in 974 hospitals. At least 50% of high-volume hospitals were not ranked in the low-mortality group according to RSMR grouping. In an RSMR centralization model, an average of 32 patients undergoing complex oncologic surgery would need to relocate to a low-mortality hospital to save one life, whereas 47 would need to relocate to a high-volume hospital. Mean difference in travel times between the nearest hospital to the hospital that performed surgery ranged from 10 minutes for colorectal cancer to 24 minutes for pancreatic cancer. Centralization on the basis of RSMR compared with volume would ensure lower median travel times for all cancer types, and these times would be lower than those observed. CONCLUSION RSMR is a promising proxy for measuring surgical quality. It outperforms volume in effectiveness, efficiency, and hospital availability for patients.
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Affiliation(s)
- Philip Baum
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christoph Rust
- Department of Econometrics, University of Regensburg, Regensburg, Germany.,Department of Finance, Accounting and Statistics, Vienna University of Economics and Business, Vienna, Austria
| | - Martin E Eichhorn
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Samantha Taber
- Department of Thoracic Surgery, Heckeshorn Lung Clinic, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.,Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany
| | - Hauke Winter
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.,Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany.,Theodor Boveri Institute, Biocenter, University of Wuerzburg, Am Hubland, Würzburg, Germany
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20
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Roessler M, Walther F, Eberlein-Gonska M, Scriba PC, Kuhlen R, Schmitt J, Schoffer O. Exploring relationships between in-hospital mortality and hospital case volume using random forest: results of a cohort study based on a nationwide sample of German hospitals, 2016-2018. BMC Health Serv Res 2022; 22:1. [PMID: 34974828 PMCID: PMC8722027 DOI: 10.1186/s12913-021-07414-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 12/14/2021] [Indexed: 01/12/2023] Open
Abstract
Background Relationships between in-hospital mortality and case volume were investigated for various patient groups in many empirical studies with mixed results. Typically, those studies relied on (semi-)parametric statistical models like logistic regression. Those models impose strong assumptions on the functional form of the relationship between outcome and case volume. The aim of this study was to determine associations between in-hospital mortality and hospital case volume using random forest as a flexible, nonparametric machine learning method. Methods We analyzed a sample of 753,895 hospital cases with stroke, myocardial infarction, ventilation > 24 h, COPD, pneumonia, and colorectal cancer undergoing colorectal resection treated in 233 German hospitals over the period 2016–2018. We derived partial dependence functions from random forest estimates capturing the relationship between the patient-specific probability of in-hospital death and hospital case volume for each of the six considered patient groups. Results Across all patient groups, the smallest hospital volumes were consistently related to the highest predicted probabilities of in-hospital death. We found strong relationships between in-hospital mortality and hospital case volume for hospitals treating a (very) small number of cases. Slightly higher case volumes were associated with substantially lower mortality. The estimated relationships between in-hospital mortality and case volume were nonlinear and nonmonotonic. Conclusion Our analysis revealed strong relationships between in-hospital mortality and hospital case volume in hospitals treating a small number of cases. The nonlinearity and nonmonotonicity of the estimated relationships indicate that studies applying conventional statistical approaches like logistic regression should consider these relationships adequately. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07414-z.
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Affiliation(s)
- Martin Roessler
- Center for Evidence-based Healthcare, University Hospital Carl Gustav Carus and Medical Faculty at the Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - Felix Walther
- Center for Evidence-based Healthcare, University Hospital Carl Gustav Carus and Medical Faculty at the Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.,Quality and Medical Risk Management, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Maria Eberlein-Gonska
- Quality and Medical Risk Management, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | | | - Ralf Kuhlen
- IQM Initiative Qualitätsmedizin e.V., Berlin, Germany
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, University Hospital Carl Gustav Carus and Medical Faculty at the Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Olaf Schoffer
- Center for Evidence-based Healthcare, University Hospital Carl Gustav Carus and Medical Faculty at the Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
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21
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Uttinger KL, Riedmeier M, Reibetanz J, Meyer T, Germer CT, Fassnacht M, Wiegering A, Wiegering V. Adrenalectomies in children and adolescents in Germany - a diagnose related groups based analysis from 2009-2017. Front Endocrinol (Lausanne) 2022; 13:914449. [PMID: 35966067 PMCID: PMC9363694 DOI: 10.3389/fendo.2022.914449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/05/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Adrenalectomies are rare procedures especially in childhood. So far, no large cohort study on this topic has been published with data on to age distribution, operative procedures, hospital volume and operative outcome. METHODS This is a retrospective analysis of anonymized nationwide hospital billing data (DRG data, 2009-2017). All adrenal surgeries (defined by OPS codes) of patients between the age 0 and 21 years in Germany were included. RESULTS A total of 523 patient records were identified. The mean age was 8.6 ± 7.7 years and 262 patients were female (50.1%). The majority of patients were between 0 and 5 years old (52% overall), while 11.1% were between 6 and 11 and 38.8% older than 12 years. The most common diagnoses were malignant neoplasms of the adrenal gland (56%, mostly neuroblastoma) with the majority being younger than 5 years. Benign neoplasms in the adrenal gland (D350) account for 29% of all cases with the majority of affected patients being 12 years or older. 15% were not defined regarding tumor behavior. Overall complication rate was 27% with a clear higher complication rate in resection for malignant neoplasia of the adrenal gland. Bleeding occurrence and transfusions are the main complications, followed by the necessary of relaparotomy. There was an uneven patient distribution between hospital tertiles (low volume, medium and high volume tertile). While 164 patients received surgery in 85 different "low volume" hospitals (0.2 cases per hospital per year), 205 patients received surgery in 8 different "high volume" hospitals (2.8 cases per hospital per year; p<0.001). Patients in high volume centers were significant younger, had more extended resections and more often malignant neoplasia. In multivariable analysis younger age, extended resections and open procedures were independent predictors for occurrence of postoperative complications. CONCLUSION Overall complication rate of adrenalectomies in the pediatric population in Germany is low, demonstrating good therapeutic quality. Our analysis revealed a very uneven distribution of patient volume among hospitals.
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Affiliation(s)
- Konstantin L. Uttinger
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg, Germany
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, Leipzig University Hospital, Leipzig, Germany
| | - Maria Riedmeier
- Department of Pediatrics, Ped. Hematology, Oncology and Stem Cell Transplantation, Würzburg University Hospital, Würzburg, Germany
| | - Joachim Reibetanz
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg, Germany
| | - Thomas Meyer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg, Germany
| | - Christoph Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg, Germany
- Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany
| | - Martin Fassnacht
- Department of Endocrine Medicine, Würzburg University Hospital, Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg, Germany
- Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany
- Department of Biochemistry and Molecular Biology , University of Würzburg, Würzburg, Germany
| | - Verena Wiegering
- Department of Pediatrics, Ped. Hematology, Oncology and Stem Cell Transplantation, Würzburg University Hospital, Würzburg, Germany
- *Correspondence: Verena Wiegering,
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22
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Anger F, Lichthardt S, Haubitz I, Wagner J, Löb S, Buhr HJ, Germer CT, Wiegering A. Is there a weekend effect in emergency surgery for colorectal carcinoma? Analysis from the German StuDoQ registry. PLoS One 2022; 17:e0277050. [PMID: 36327244 PMCID: PMC9632786 DOI: 10.1371/journal.pone.0277050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Higher postoperative mortality has been observed among patients who received emergency colorectal surgery on the weekend compared to during the week. The aim of this study was to determine whether the weekday of emergency surgery affects the 30-day mortality and postoperative course in emergency colorectal surgery. METHODS Prospectively acquired data from the 2010-2017 German StuDoQ|Colorectal surgery registries were analysed. Differences in 30-day mortality, transfer and length of stay (MTL30) (primary endpoints), postoperative complications, length of stay and pathological results of resected specimens (secondary endpoints) were assessed. Multivariable analysis was performed to identify independent risk factors for postoperative outcome. RESULTS In total, 1,174 patients were included in the analysis. Major postoperative complications and the need for reoperation were observed more frequently for emergency colorectal surgery performed during the week compared to the weekend (23.01 vs. 15.28%, p = 0.036 and 17.96% vs. 11.11%, p = 0.040, respectively). In contrast, patients who received emergency surgery on the weekend presented with significantly higher UICC tumour stages (UICC III 44.06 vs. 34.15%, p = 0.020) compared to patients with emergency colorectal surgery on a weekday. Emergency surgery performed during the week was an independent risk factor for the development of severe postoperative complications (OR 1.69 [1.04-2.74], p = 0.033) and need for reoperation (OR 1.79 [1.02-3.05], p = 0.041) in the multivariable analysis. CONCLUSION Emergency surgery for colorectal carcinoma in Germany is performed with equal postoperative MTL30 and mortality throughout the entire week. However, emergency surgery during the week seems to be associated with a higher rate of severe postoperative complications and reoperation.
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Affiliation(s)
- Friedrich Anger
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
- * E-mail: (FA); (AW)
| | - Sven Lichthardt
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
| | - Imme Haubitz
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
| | - Johanna Wagner
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
| | - Stefan Löb
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
| | | | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
- Comprehensive Cancer Centre Mainfranken, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
- Comprehensive Cancer Centre Mainfranken, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
- Department of Biochemistry and Molecular Biology, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
- * E-mail: (FA); (AW)
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23
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Uttinger KL, Diers J, Baum P, Pietryga S, Baumann N, Hankir M, Germer CT, Wiegering A. Mortality, complications and failure to rescue after surgery for esophageal, gastric, pancreatic and liver cancer patients based on minimum caseloads set by the German Cancer Society. Eur J Surg Oncol 2021; 48:924-932. [PMID: 34893362 DOI: 10.1016/j.ejso.2021.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/21/2021] [Accepted: 12/02/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The German Cancer Society (DKG) board certifies hospitals in treating esophageal, gastric, liver and pancreatic cancer among others. There has been no systematic verification of the number of major surgical resections set by DKG certification with regards to in-house mortality and failure to rescue (FtR). METHODS This is a retrospective analysis of anonymized nationwide hospital billing data (DRG data, 2009-2017). Inclusion criteria were based on the annual surgical minimum caseload (SMC) in accordance with DKG certification. RESULTS 171,429 datasets were identified, including 31,140 esophageal, 54,155 gastric, 57,343 pancreatic and 28,791 liver resections. In-house mortality ranged from 6.2% for gastric resections to 8.1% for pancreatic resections. Differences in in-house mortality between hospitals which fulfilled SMC on average and those which did not fulfill SMC on average were 40.8% (5.3% vs 8.2%) for esophageal, 32.3% (4.8% vs 6.8%) for gastric and 45.7% (6.1% vs 9.8%) for pancreatic resections, while it was 8.2% higher in SMC-hospitals (7.6% vs 7.0%) for liver resections. Complication occurrence rates for esophageal, gastric and pancreatic resections were similar in SMC- and non-SMC-hospitals while FtR in hospitals fulfilling SMC was significantly lower. Data for liver resections demonstrated the same trends only in a sub-analysis of complex procedures. CONCLUSION This study demonstrates an association between caseload threshold defined by DKG and lower mortality in esophageal, gastric, pancreatic and complex liver surgery. In these resections, FtR was reduced if SMC was fulfilled.
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Affiliation(s)
- Konstantin L Uttinger
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany; Department of Visceral, Transplant, Thoracic and Vascular Surgery at Leipzig University Hospital, Leipzig, Germany
| | | | - Philip Baum
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian Pietryga
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany
| | - Nikolas Baumann
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany
| | - Mohamed Hankir
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany; Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, Würzburg, Germany; Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany; Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany.
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Riedmeier M, Decarolis B, Haubitz I, Müller S, Uttinger K, Börner K, Reibetanz J, Wiegering A, Härtel C, Schlegel PG, Fassnacht M, Wiegering V. Adrenocortical Carcinoma in Childhood: A Systematic Review. Cancers (Basel) 2021; 13:5266. [PMID: 34771430 PMCID: PMC8582500 DOI: 10.3390/cancers13215266] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/13/2021] [Accepted: 10/14/2021] [Indexed: 01/01/2023] Open
Abstract
Adrenocortical tumors are rare in children. This systematic review summarizes the published evidence on pediatric adrenocortical carcinoma (ACC) to provide a basis for a better understanding of the disease, investigate new molecular biomarkers and therapeutic targets, and define which patients may benefit from a more aggressive therapeutic approach. We included 137 studies with 3680 ACC patients (~65% female) in our analysis. We found no randomized controlled trials, so this review mainly reflects retrospective data. Due to a specific mutation in the TP53 gene in ~80% of Brazilian patients, that cohort was analyzed separately from series from other countries. Hormone analysis was described in 2569 of the 2874 patients (89%). Most patients were diagnosed with localized disease, whereas 23% had metastasis at primary diagnosis. Only 72% of the patients achieved complete resection. In 334 children (23%), recurrent disease was reported: 81%-local recurrence, 19% (n = 65)-distant metastases at relapse. Patients < 4 years old had a different distribution of tumor stages and hormone activity and better overall survival (p < 0.001). Although therapeutic approaches are typically multimodal, no consensus is available on effective standard treatments for advanced ACC. Thus, knowledge regarding pediatric ACC is still scarce and international prospective studies are needed to implement standardized clinical stratifications and risk-adapted therapeutic strategies.
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Affiliation(s)
- Maria Riedmeier
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Children’s Hospital, University of Wuerzburg, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany; (M.R.); (I.H.); (C.H.); (P.-G.S.)
| | - Boris Decarolis
- Department of Pediatric Oncology and Hematology, Medical Faculty, University Children’s Hospital of Cologne, 50937 Cologne, Germany;
| | - Imme Haubitz
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Children’s Hospital, University of Wuerzburg, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany; (M.R.); (I.H.); (C.H.); (P.-G.S.)
| | - Sophie Müller
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany; (S.M.); (K.U.); (K.B.); (J.R.); (A.W.)
| | - Konstantin Uttinger
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany; (S.M.); (K.U.); (K.B.); (J.R.); (A.W.)
| | - Kevin Börner
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany; (S.M.); (K.U.); (K.B.); (J.R.); (A.W.)
| | - Joachim Reibetanz
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany; (S.M.); (K.U.); (K.B.); (J.R.); (A.W.)
| | - Armin Wiegering
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany; (S.M.); (K.U.); (K.B.); (J.R.); (A.W.)
- Department of Biochemistry and Molecular Biology, University of Wuerzburg, Am Hubland, 97074 Wuerzburg, Germany
- Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Centre, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany;
| | - Christoph Härtel
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Children’s Hospital, University of Wuerzburg, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany; (M.R.); (I.H.); (C.H.); (P.-G.S.)
- Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Centre, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany;
| | - Paul-Gerhardt Schlegel
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Children’s Hospital, University of Wuerzburg, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany; (M.R.); (I.H.); (C.H.); (P.-G.S.)
- Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Centre, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany;
| | - Martin Fassnacht
- Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Centre, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany;
- Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany
| | - Verena Wiegering
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Children’s Hospital, University of Wuerzburg, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany; (M.R.); (I.H.); (C.H.); (P.-G.S.)
- Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Centre, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany;
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Sahm M, Schneider C, Gretschel S, Kube R, Becker A, Günther M, Loew A, Jahnke K, Mantke R. [Reality of care of colorectal cancer in the State of Brandenburg : With special consideration of the number of hospital cases and certification as a colorectal cancer center]. Chirurg 2021; 93:274-285. [PMID: 34374822 DOI: 10.1007/s00104-021-01468-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 11/30/2022]
Abstract
Analysis of the quality of care for colorectal cancer is an essential foundation for further development and is based on the comparison of the goals set and the actual quality of care. This publication presents the reality of care in the State of Brandenburg covering the complete spectrum of treating clinics based on the data of the clinical cancer register. This study analyzed the number of resected and examined lymph nodes, the quality of total mesorectal excision (TME), the residual tumor (R0) resection rate and the proportion of adjuvant therapy of colon cancer in Union internationale contre le cancer (UICC) stage III depending on the operation quota of hospitals and the certification as bowel cancer center according to Onkozert. Apart from the R status, the analyses showed no differences in the qualitative operation data from the clinical cancer register depending on the hospital volume.
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Affiliation(s)
- Maik Sahm
- Medizinische Hochschule Brandenburg Theodor Fontane, Hochstraße 29, 14770, Brandenburg, Deutschland.
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Hospital volume following major surgery for gastric cancer determines in-hospital mortality rate and failure to rescue: a nation-wide study based on German billing data (2009-2017). Gastric Cancer 2021; 24:959-969. [PMID: 33576929 DOI: 10.1007/s10120-021-01167-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/31/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND For many cancer resections, a hospital volume-outcome relationship exists. The data regarding gastric cancer resection-especially in the western hemisphere-are ambiguous. This study analyzes the impact of gastric cancer surgery caseload per hospital on postoperative mortality and failure to rescue in Germany. METHODS All patients diagnosed with gastric cancer from 2009 to 2017 who underwent gastric resection were identified from nation-wide administrative data. Hospitals were grouped into five equal caseload quintiles (I-V in ascending caseload order). Postoperative deaths and failure to rescue were determined. RESULTS Forty-six thousand one hundred eighty-seven patients were identified. There was a significant shift from partial resections in low-volume hospitals to more extended resections in high-volume centers. The overall in-house mortality rate was 6.2%. The crude in-hospital mortality rate ranged from 7.9% in quintile I to 4.4% in quintile V, with a significant trend between volume categories (p < 0.001). In the multivariable logistic regression analysis, quintile V hospitals (average of 29 interventions/year) had a risk-adjusted odds ratio of 0.50 (95% CI 0.39-0.65), compared to the baseline in-house mortality rate in quintile I (on average 1.5 interventions/year) (p < 0.001). In an analysis only evaluating hospitals with more than 30 resections per year mortality dropped below 4%. The overall postoperative complication rate was comparable between different volume quintiles, but failure to rescue (FtR) decreased significantly with increasing caseload. CONCLUSION Patients who had gastric cancer surgery in hospitals with higher volume had better outcomes and a reduced failure to rescue rates for severe complications.
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Hendricks A, Diers J, Baum P, Weibel S, Kastner C, Müller S, Lock JF, Köhler F, Meybohm P, Kranke P, Germer CT, Wiegering A. Systematic review and meta-analysis on volume-outcome relationship of abdominal surgical procedures in Germany. Int J Surg 2021; 86:24-31. [PMID: 33429078 DOI: 10.1016/j.ijsu.2020.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/11/2020] [Accepted: 12/28/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the past, for a number of abdominal surgical interventions a correlation between treatment volume of a hospital and the patient's outcome was shown in national and international studies. METHODS Based on a systematic literature search we analyzed the absolute and risk-adjusted in-house lethality as well as the rate of complications and the failure to rescue after abdominal surgery in Germany. The hospitals were grouped in quintiles according to the volume of treatment. RESULTS 11 studies including more than 2 million patients were identified and surgeries for the treatment of 9 disease conditions were studied. The meta-analysis shows a significantly lower absolute and risk-adjusted in-house mortality for surgery in hospitals with high treatment volumes compared to low volume hospitals. In the context of subgroup analysis, this effect is demonstrated especially for complex surgical procedures. The failure to rescue in patients suffering from sepsis is significantly lower in high volume centers compared to low volume centers. CONCLUSION This systematic review and meta-analysis shows on more than 2 million patients that there is a volume-outcome relationship for the surgical treatment of abdominal diseases in Germany across various organ systems, which is particularly true for complex interventions.
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Affiliation(s)
- Anne Hendricks
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Philip Baum
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany; Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126, Heidelberg, Germany
| | - Stephanie Weibel
- Clinic and Policlinic for Anesthesiology Surgery, University Hospital Würzburg, Germany
| | - Carolin Kastner
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Sophie Müller
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Johan Friso Lock
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Franziska Köhler
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Patrik Meybohm
- Clinic and Policlinic for Anesthesiology Surgery, University Hospital Würzburg, Germany
| | - Peter Kranke
- Clinic and Policlinic for Anesthesiology Surgery, University Hospital Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany; Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany; Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Germany; Department of Biochemistry and Molecular Biology University of Würzburg Würzburg, Germany.
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Anger F, Wellner U, Klinger C, Lichthardt S, Haubitz I, Löb S, Keck T, Germer CT, Buhr HJ, Wiegering A. The Effect of Day of the Week on Morbidity and Mortality From Colorectal and Pancreatic Surgery. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:521-527. [PMID: 33087240 DOI: 10.3238/arztebl.2020.0521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 10/31/2019] [Accepted: 05/07/2010] [Indexed: 12/29/2022]
Abstract
BACKGROUND A number of studies have revealed higher postoperative mortality after operations that were performed toward the end of the week. It is not yet known whether a day-of-the-week effect exists after visceral surgical procedures for cancer in Germany. METHODS Data on resections of carcinomas of the colon, rectum (2010-2017), and head of the pancreas (2014-2017) (n = 19 703) that had been prospectively acquired by the Study, Documentation, and Quality Center of the German Society for General and Visceral Surgery were analyzed in relation to the day of the week on which the operation was performed. The primary endpoint was postoperative 30-day mortality; the secondary endpoints were complications, length of hospital stay, and MTL30 (a combined outcome criterion that is positive if the patient has died, is still in the hospital, or has been transferred to another acute care hospital 30 days after the index procedure). RESULTS Resections of colon carcinomas that were performed on Mondays were associated with more advanced tumor stages (T4: 18.4% vs. 15.7%, p <0.001), higher 30-day mortality (3.5% vs. 2.3%, p = 0.004), and a more frequently positive MTL30 (10.5% vs. 8.5%, p = 0.004). Among patients who underwent pancreatic head resections, those whose procedures were on Tuesday had higher mortality (6.2% vs. 3.8%; p = 0.021). Among those who underwent surgery for rectal carcinoma, the day of the week on which the procedure was performed had no effect on postoperative morality. Multivariate analysis revealed that the independent risk factors for postoperative mortality were colonic resection on a Monday (odds ratio [OR]: 1.45; 95% confidence interval [1.11; 1.92], p = 0.008) and pancreatic head resection on a Tuesday (OR: 1.88 [1.18; 2.91], p = 0.006). CONCLUSION Elective surgery for carcinoma of the colon or pancreatic head is associated with slightly higher mortality if per - formed toward the beginning of the week. On the other hand, the day of the week has no effect on the outcome of surgery for rectal carcinoma.
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Affiliation(s)
- Friedrich Anger
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, Center for Operative Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Ulrich Wellner
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Carsten Klinger
- German Society for General and Visceral Surgery (DGAV), Berlin, Germany
| | - Sven Lichthardt
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, Center for Operative Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Imme Haubitz
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, Center for Operative Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Stefan Löb
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, Center for Operative Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Tobias Keck
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, Center for Operative Medicine, University Hospital of Würzburg, Würzburg, Germany; Comprehensive Cancer Center Mainfranken, University Hospital of Würzburg, Würzburg, Germany
| | | | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, Center for Operative Medicine, University Hospital of Würzburg, Würzburg, Germany; Comprehensive Cancer Center Mainfranken, University Hospital of Würzburg, Würzburg, Germany; Institute of Biochemistry and Molecular Biology I, University of Würzburg, Würzburg, Germany
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Impact of hospital volume on outcomes after emergency management of obstructive colon cancer: a nationwide study of 1957 patients. Int J Colorectal Dis 2020; 35:1865-1874. [PMID: 32504329 DOI: 10.1007/s00384-020-03602-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Volume-outcome relationship is well established in elective colorectal surgery for cancer, but little is known for patients managed for obstructive colon cancer (OCC). We aimed to compare the management and outcomes according to the hospital volume in this particular setting. METHODS Patients managed for OCC between 2005 and 2015 in centers of the French National Surgical Association were retrospectively analyzed. Hospital volume was dichotomized between low and high volume on the median number of patients included per center during the study period. RESULTS A total of 1957 patients with OCC were managed in 56 centers with a median number of 28 (1-123) patients per center: 298 (15%) were treated in low-volume hospitals (LVHs) and 1659 (85%) in high-volume hospitals (HVHs). Patients in LVH were significantly younger, and had fewer comorbidities and synchronous metastases. Proximal diverting stoma was the preferred surgical option in LVH (p < 0.0001), whereas tumor resection with primary anastomosis was more frequently performed in HVH (p < 0.0001). Cumulative morbidity (59 vs. 50%, p = 0.003), mortality (13 vs. 8%, p = 0.03), and length of hospital stay (22 ± 19 vs. 18 ± 14 days, p = 0.002) were significantly higher in LVH. At multivariate analysis, LVH was a predictor for cumulative morbidity (p < 0.0001) and mortality (p = 0.03). There was no difference between the two groups for tumor resection and stoma rates, and for oncological outcomes. CONCLUSIONS The hospital volume has no impact on outcomes after the first-stage surgery in OCC patients. When all surgical stages are considered, hospital volume influences cumulative postoperative morbidity and mortality but has no impact on oncological outcomes.
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Diers J, Baum P, Matthes H, Germer CT, Wiegering A. Mortality and complication management after surgery for colorectal cancer depending on the DKG minimum amounts for hospital volume. Eur J Surg Oncol 2020; 47:850-857. [PMID: 33020007 DOI: 10.1016/j.ejso.2020.09.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/16/2020] [Accepted: 09/21/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The German Cancer Society ("Deutsche Krebsgesellschaft"; DKG) certifies on a volunteer base colorectal cancer centers based on, among other things, minimum operative amounts (at least 30 oncological colon cancer resections and 20 oncological rectal cancer resections per year). In this work, nationwide hospital mortality and death after documented complications ('Failure to Rescue' = FtR) were evaluated depending on the fulfillment of the minimum amounts. METHODS This is a retrospective analysis of the nationwide hospital billing data (DRG data, 2012-2017). Categorization is based on the DKG minimum quantities (fully, partially or not fulfilled). RESULTS Of 287,227 patients analyzed, 56.5% were operated in centers that met the DKG minimum amounts. The overall hospital mortality rate was 5.0%. In centers which met the minimum quantities, it was significantly lower (4.3%) than in hospitals which partially (5.7%) or not (6.2%) met the minimum quantities. The risk-adjusted hospital mortality rate for patients in hospitals who meet the minimum amount was 20% lower (OR 0.80; 95% CI [0.74-0.87], p < 0.001). For complications, both surgical and non-surgical, there was an unadjusted and adjusted lower FtR in hospitals that met the minimum amounts (e.g. anastomotic leak: 11.2% vs. 15.6%, p < 0.001; pulmonary artery embolism 21.3% vs. 28.2%, p = 0.001). CONCLUSION There is a 1/3 lower mortality and FtR rate after surgery for a colon or rectal cancer in centers fulfilling the DKG minimum amounts. The presented data implicate that there is an urgent need for a nationwide centralization program.
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Affiliation(s)
- Johannes Diers
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 2, 97080, Wuerzburg, Germany; Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - Philip Baum
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 2, 97080, Wuerzburg, Germany; Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Harald Matthes
- Institute for Social Medicine, Epidemiology and Health Economics of the Charité - Universitätsmedizin Berlin, Germany; Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 2, 97080, Wuerzburg, Germany; Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Center, Josef-Schneiderstr. 6, 97080, Wuerzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 2, 97080, Wuerzburg, Germany; Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Center, Josef-Schneiderstr. 6, 97080, Wuerzburg, Germany; Department of Biochemistry and Molecular Biology, University of Wuerzburg, Germany.
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Matthes N, Diers J, Schlegel N, Hankir M, Haubitz I, Germer CT, Wiegering A. Validation of MTL30 as a quality indicator for colorectal surgery. PLoS One 2020; 15:e0238473. [PMID: 32857807 PMCID: PMC7454590 DOI: 10.1371/journal.pone.0238473] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/16/2020] [Indexed: 01/01/2023] Open
Abstract
Background Valid indicators are required to measure surgical quality. These ideally should be sensitive and selective while being easy to understand and adjust. We propose here the MTL30 quality indicator which takes into account 30-day mortality, transfer within 30 days, and a length of stay of 30 days as composite markers of an uneventful operative/postoperative course. Methods Patients documented in the StuDoQ|Colon and StuDoQ|Rectal carcinoma register of the German Society for General and Visceral Surgery (DGAV) were analyzed with regard to the effects of patient and tumor-related risk factors as well as postoperative complications on the MTL30. Results In univariate analysis, the MTL30 correlated significantly with patient and tumor-related risk factors such as ASA score (p<0.001), age (p<0.001), or UICC stage (p<0.001). There was a high sensitivity for the postoperative occurrence of complications such as re-operations (p<0.001) or subsequent bleeding (p<0.001), as well as a significant correlation with the CDC classification (p<0.001). In multivariate analysis, patient-related risk factors and postoperative complications significantly increased the odds ratio for a positive MTL30. A negative MTL30 showed a high specify for an uneventful operative and postoperative course. Conclusion The MTL30 is a valid indicator of colorectal surgical quality.
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Affiliation(s)
- Niels Matthes
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Johannes Diers
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Nicolas Schlegel
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Mohammed Hankir
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Imme Haubitz
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
- Comprehensive Cancer Center Mainfranken, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
- Comprehensive Cancer Center Mainfranken, University Hospital Wuerzburg, Wuerzburg, Germany
- Department of Biochemistry and Molecular Biology, Theodor Boveri Institute, University of Wuerzburg, Wuerzburg, Germany
- * E-mail:
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The Post COVID-19 Surgical Backlog: Now is the Time to Implement Enhanced Recovery After Surgery (ERAS). World J Surg 2020; 44:3197-3198. [PMID: 32803298 PMCID: PMC7427753 DOI: 10.1007/s00268-020-05734-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2020] [Indexed: 12/21/2022]
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Baum P, Diers J, Lichthardt S, Kastner C, Schlegel N, Germer CT, Wiegering A. Mortality and Complications Following Visceral Surgery: A Nationwide Analysis Based on the Diagnostic Categories Used in German Hospital Invoicing Data. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:739-746. [PMID: 31774053 DOI: 10.3238/arztebl.2019.0739] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 06/24/2019] [Accepted: 08/29/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND The in-hospital mortality after visceral surgery in Germany is unknown. METHODS In this retrospective, descriptive analysis, nationwide hospital billing data based on diagnosis-related groups (DRG) over the period 2009-2015 were studied to determine the in-hospital mortality, complications and their management, and deaths after documented severe complications (failure to rescue, FTR) after visceral surgery in Germany. Organ-system subgroups were defined and subdivided into frequent operations (inguinal hernia repair, appendectomy, thyroid operations, cholecystec- tomy), colorectal operations, and complex operations (surgery of the esophagus, pancreas, liver, and stomach). RESULTS 3 287 199 patients from 1392 hospitals were included in the analysis. The in-hospital mortality after visceral surgery was 1.9%. The lowest mortality was after the frequently performed operations (0.04-0.4%), the highest after complex surgery of the esophagus (8.6%) and stomach (11.7%). Severe complications were most commonly seen after complex surgery of the pan- creas (27.7%), liver (24.3%), esophagus (37.8%), and stomach (36.7%). 90.6% of deaths occurred after colorectal or complex operations, which together accounted for 23% of all operations. The FTR rate was 8.4% after appendectomy and cholecystec- tomy (95% confidence interval [8.34; 8.46]) and 20.3% after esophageal surgery ([19.8; 20.8]). CONCLUSION In Germany, in-hospital mortality after visceral surgery is not uncommon, with a frequency of nearly 2%. Improved complication management after complex operations appears necessary. A limitation of this study is the identification of compli- cations from anonymized billing data.
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Affiliation(s)
- Philip Baum
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery University Hospital of Würzburg; Comprehensive Cancer Center Mainfranken, University Hospital of Würzburg; Biochemistry and Molecular Biology, University of Würzburg
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Diers J, Wagner J, Baum P, Lichthardt S, Kastner C, Matthes N, Matthes H, Germer CT, Löb S, Wiegering A. Nationwide in-hospital mortality rate following rectal resection for rectal cancer according to annual hospital volume in Germany. BJS Open 2020; 4:310-319. [PMID: 32207577 PMCID: PMC7093786 DOI: 10.1002/bjs5.50254] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/15/2019] [Indexed: 12/11/2022] Open
Abstract
Background The impact of hospital volume after rectal cancer surgery is seldom investigated. This study aimed to analyse the impact of annual rectal cancer surgery cases per hospital on postoperative mortality and failure to rescue. Methods All patients diagnosed with rectal cancer and who had a rectal resection procedure code from 2012 to 2015 were identified from nationwide administrative hospital data. Hospitals were grouped into five quintiles according to caseload. The absolute number of patients, postoperative deaths and failure to rescue (defined as in‐hospital mortality after a documented postoperative complication) for severe postoperative complications were determined. Results Some 64 349 patients were identified. The overall in‐house mortality rate was 3·9 per cent. The crude in‐hospital mortality rate ranged from 5·3 per cent in very low‐volume hospitals to 2·6 per cent in very high‐volume centres, with a distinct trend between volume categories (P < 0·001). In multivariable logistic regression analysis using hospital volume as random effect, very high‐volume hospitals (53 interventions/year) had a risk‐adjusted odds ratio of 0·58 (95 per cent c.i. 0·47 to 0·73), compared with the baseline in‐house mortality rate in very low‐volume hospitals (6 interventions per year) (P < 0·001). The overall postoperative complication rate was comparable between different volume quintiles, but failure to rescue decreased significantly with increasing caseload (15·6 per cent after pulmonary embolism in the highest volume quintile versus 38 per cent in the lowest quintile; P = 0·010). Conclusion Patients who had rectal cancer surgery in high‐volume hospitals showed better outcomes and reduced failure to rescue rates for severe complications than those treated in low‐volume hospitals.
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Affiliation(s)
- J Diers
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany.,Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - J Wagner
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - P Baum
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - S Lichthardt
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - C Kastner
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - N Matthes
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany.,Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany
| | - H Matthes
- Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - C-T Germer
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany.,Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany
| | - S Löb
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - A Wiegering
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany.,Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany.,Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany
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Klupp F, Schuler S, Kahlert C, Halama N, Franz C, Mayer P, Schmidt T, Ulrich A. Evaluation of the inflammatory markers CCL8, CXCL5, and LIF in patients with anastomotic leakage after colorectal cancer surgery. Int J Colorectal Dis 2020; 35:1221-1230. [PMID: 32307587 PMCID: PMC7320065 DOI: 10.1007/s00384-020-03582-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leakage constitutes a dreaded complication after colorectal surgery, leading to increased morbidity and mortality as well as prolonged hospitalization. Most leakages become clinically apparent about 8 days after surgery; however, early detection is quintessential to reduce complications and to improve patients' outcome. We therefore investigated the significance of specific protein expression profiles as putative biomarkers, indicating anastomotic leakage. METHODS In this single-center prospective cohort study serum and peritoneal fluid samples-from routinely intraoperatively inserted drainages-of colorectal cancer patients were collected 3 days after colorectal resection. Twenty patients without anastomotic leakage and 18 patients with an anastomotic leakage and without other complications were included. Protein expression of seven inflammatory markers in serum and peritoneal fluid was assessed by multiplex ELISA and correlated with patients' clinical data. RESULTS Monocyte chemoattractant protein 2 (CCL8/MCP-2), leukemia-inhibiting factor (LIF), and epithelial-derived neutrophil-activating protein (CXCL5/ENA-78) were significantly elevated in peritoneal fluid but not in serum samples from patients subsequently developing anastomotic leakage after colorectal surgery. No expressional differences could be found between grade B and grade C anastomotic leakages. CONCLUSION Measurement 3 days after surgery revealed altered protein expression patterns of the inflammatory markers CCL8/MCP2, LIF, and CXCL5/ENA-78 in peritoneal fluid from patients developing anastomotic leakage after colorectal surgery. Further studies with a larger patient cohort with inclusion of different variables are needed to evaluate their potential as predictive biomarkers for anastomotic leakage.
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Affiliation(s)
- F. Klupp
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - S. Schuler
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - C. Kahlert
- grid.4488.00000 0001 2111 7257Department of Visceral, Thoracic and Vascular Surgery, University of Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - N. Halama
- grid.7700.00000 0001 2190 4373National Center for Tumor Diseases, Medical Oncology and Internal Medicine VI, Tissue Imaging and Analysis Center, Bioquant, University of Heidelberg, Im Neuenheimer Feld 267, 69120 Heidelberg, Germany
| | - C. Franz
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - P. Mayer
- grid.5253.10000 0001 0328 4908Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - T. Schmidt
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - A. Ulrich
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany ,grid.416164.0Department of General and Visceral Surgery, Lukas Hospital Neuss, Preußenstr. 84, 41464 Neuss, Germany
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