Surgeon-related factors and outcome in rectal cancer

Preoperative management in octogenarian patients with rectal cancer

Background

In recent years, the rise in average lifespan has been linked to an increase in the occurrence of diseases associated with aging worldwide. Rectal tumors often occur in elderly patients.

Methods

Between January and August 2024, 6 experts in colorectal cancer met to develop an algorithm to organize the interdisciplinary and multimodal preoperative approaches in the octogenarian population with rectal cancer. To develop the algorithm, we conducted a straightforward search within the PubMed database and also reviewed the citations of the most pertinent articles we discovered. The quality of the methods used in the final selection of 76 sources was evaluated, every single source was scrutinized and analyzed, and a team of six experts created an algorithm.

Results

An algorithm for preoperative management of octogenarian patients with rectal cancer was created to encapsulate essential information and provide a contemporary resource for physicians, surgeons, physiotherapists, and nutritionists to utilize in optimal clinical practice.

Conclusions

Octogenarian patients with rectal cancer are special-character groups and require specific preoperative management to better the surgical outcome.

Does practice make perfect? Studying the relationship between surgeon experience and patient outcomes for paraesophageal hernia repairs

BACKGROUND

It has been reported that higher surgeon experience leads to better patient outcomes. In this study, we look at surgeon experience and its association with postoperative outcomes and variation among the practice of surgeons performing paraesophageal hernia repairs (PEH).

METHOD

This was a retrospective study of 1155 patients who underwent PEH repair at a single institution (2010-2023). Surgeon experience was defined as the number of surgeries performed per surgeon and was split using the median surgeries (n = 100), with surgeons performing at or above the median categorized as high-experience and below the median as low-experience surgeons. A multivariable logistic regression model was used to test correlation between surgeon experience and variables, including demographics and intra- and post-operative outcomes.

RESULTS

High-experience surgeons performed more elective cases (93.4% vs 85.5%), but low-experience surgeons operated more on emergent (2.7% vs 0.9%), semi-elective (2.3% vs 1.4%), and urgent cases (9.5% vs 4.3%). Low-experience surgeons operated more on patients who were older (67.5 vs 63.2 years, p < 0.001) and had an increased risk of CVD (72.9% vs 61.5%, p < 0.001). Intraoperative OR time was considerably less for high-experience surgeons (115.8 vs 172.9 min, p < 0.001). Low-experience surgeons had increased risk of intra-operative complications (4.5% vs 1.8%, p = 0.021) and post-op pneumonia within 30 days (1.8% vs 0.3%). However, long-term outcomes such as hernia recurrence (OR: 1.10, CI: 0.78-1.54) and redo-operations for hiatal hernia (OR: 1.10, CI: 0.65-1.75) were similar for both groups.

CONCLUSION

High-experience surgeons perform more complex revisional surgeries in less time with fewer complications. Low-experience surgeons operated more on patients with higher comorbidities but had significantly higher OR times. Long-term results of recurrence and redo-operations were comparable. These variations suggest that high-experience surgeons are more efficient while operating on more complex cases. These findings have pivotal implications to facilitate mentorship and education among less-experienced surgeons.

Surgeon and Hospital Factors Associated With Outcomes in the New York State Database

INTRODUCTION

We sought to explore the relationship between various surgeon-related and hospital-level characteristics and clinical outcomes among patients requiring cardiac surgery.

METHODS

We searched the New York State Cardiac Data Reporting System for all coronary artery bypass grafting (CABG) and valve cases between 2015 and 2017. The data were analyzed without dichotomization.

RESULTS

Among CABG/valve surgeons, case volume was positively correlated with years in practice (P = 0.002) and negatively correlated with risk-adjusted mortality ratio (P = 0.014). For CABG and CABG/valve surgeons, our results showed a negative association between teaching status and case volume (P = 0.002, P = 0.018). Among CABG surgeons, hospital teaching status and presence of cardiothoracic surgery residency were inversely associated with risk-adjusted mortality ratio (P = 0.006, P = 0.029).

CONCLUSIONS

There is a complex relationship between case volume, teaching status, and surgical outcomes suggesting that balance between academics and volume is needed.

Does practice make perfect? The impact of hospital and surgeon volume on complications after intra-abdominal procedures

BACKGROUND

There is increasing interest in the regionalization of surgical procedures. However, evidence on the volume-outcome relationship for emergency intra-abdominal surgery is not well-synthesized. This systematic review and meta-analysis summarize evidence regarding the impact of hospital and surgeon volume on complications.

METHODS

We identified cohort studies assessing the impact of hospital/surgeon volume on postoperative complications after emergency intra-abdominal procedures, with data collected after the year 2000 through a literature search without language restriction in the PubMed, Web of Science, and Cochrane databases. A weighted overall complication rate was calculated, and a random effect regression model was used for a summary odds ratio. A sensitivity analysis with the removal of studies contributing to heterogeneity was performed (PROSPERO: CRD42022358879).

RESULTS

The search yielded 2,153 articles, of which 9 cohort studies were included and determined to be good quality according to the Newcastle Ottawa Scale. These studies reported outcomes for the following procedures: cholecystectomy, colectomy, appendectomy, small bowel resection, peptic ulcer repair, adhesiolysis, laparotomy, and hernia repair. Eight studies (2,358,093 patients) with available data were included in the meta-analysis. Low hospital volume was not significantly associated with higher complications. In the sensitivity analysis, low hospital volume was significantly associated with higher complications when appropriate heterogeneity was achieved. Low surgeon volume was associated with higher complications, and these findings remained consistent in the sensitivity analysis.

CONCLUSION

We found that hospital and surgeon volume was significantly associated with higher complications in patients undergoing emergency intra-abdominal surgery when appropriate heterogeneity was achieved.

Meta-analysis of randomized clinical trials comparing robotic versus laparoscopic surgery for mid-low rectal cancers

INTRODUCTION

Robotic surgery (RS) is experiencing major development, particularly in the context of rectal cancer. The aim of this meta-analysis was to summarize data from the literature, focusing specifically on the safety and effectiveness of robotic surgery in mid-low rectal cancers, based on the hypothesis that that robotic surgery can find its most rational indication in this anatomical location.

METHOD

The meta-analysis was conducted according to the PRISMA 2000 recommendations, including all randomized trials that compared robotic surgery versus laparoscopic surgery (LS) that were found in the Medline-PICO, Cochrane Database, Scopus and Google databases. Data were extracted independently by two reviewers. The risk of bias was analyzed according to the Cochrane Handbook method and the certainty of the evidence according to the GRADE method. The analysis was carried out with R software Version 4.2-3 using the Package for Meta-Analysis "meta" version 6.5-0.

RESULTS

Eight randomized trials were included (with a total of 2342 patients), including four that focused specifically on mid-low rectal cancer (n=1,734 patients). No statistically significant difference was found for overall morbidity, intra-operative morbidity, anastomotic leakage, post-operative mortality, quality of mesorectal specimen, and resection margins. The main differences identified were a lower conversion rate for RS (RR=0.48 [0.24-0.95], p=0.04, I2=0%), and a longer operative time for RS (mean difference=39.11min [9.39-68.83], p<0.01, I2=96%). The other differences had no real clinical relevance, i.e., resumption of flatus passage (5hours earlier after RS), and lymph node dissection (one more lymph node for LS).

CONCLUSION

This meta-analysis does not confirm the initial hypothesis and does not show a statistically significant or clinically relevant benefit of RS compared to LS for mid-low rectal cancer.

Factors Associated With Racial and Ethnic Disparities in Locally Advanced Rectal Cancer Outcomes

Importance

Hispanic and non-Hispanic Black patients receiving neoadjuvant therapy and surgery for locally advanced rectal cancer (LARC) achieve less favorable clinical outcomes than non-Hispanic White patients, but the source of this disparity is incompletely understood.

Objective

To assess whether racial and ethnic disparities in treatment outcomes among patients with LARC could be accounted for by social determinants of health and demographic, clinical, and pathologic factors known to be associated with treatment response.

Design, Setting, and Participants

The National Cancer Database was interrogated to identify patients with T3 to T4 or N1 to N2 LARC treated with neoadjuvant therapy and surgery. Patients were diagnosed between January 1, 2004, and December 31, 2017. Data were culled from the National Cancer Database from July 1, 2022, through December 31, 2023.

Exposure

Neoadjuvant therapy for rectal cancer followed by surgical resection.

Main Outcomes and Measures

The primary outcome was the rate of pathologic complete response (pCR) following neoadjuvant therapy. Secondary outcomes were rate of tumor downstaging and achievement of pN0 status.

Results

A total of 34 500 patient records were reviewed; 21 679 of the patients (62.8%) were men and 12 821 (37.2%) were women. The mean (SD) age at diagnosis was 59.7 (12.0) years. In terms of race and ethnicity, 2217 patients (6.4%) were Hispanic, 2843 (8.2%) were non-Hispanic Black, and 29 440 (85.3%) were non-Hispanic White. Hispanic patients achieved tumor downstaging (48.9% vs 51.8%; P = .01) and pN0 status (66.8% vs 68.8%; P = .02) less often than non-Hispanic White patients. Non-Hispanic Black race, but not Hispanic ethnicity, was associated with less tumor downstaging (odds ratio [OR], 0.86 [95% CI, 0.78-0.94]), less frequent pN0 status (OR, 0.91 [95% CI, 0.83-0.99]), and less frequent pCR (OR, 0.81 [95% CI, 0.72-0.92]). Other factors associated with reduced rate of pCR included rural location (OR, 0.80 [95% CI, 0.69-0.93]), lack of or inadequate insurance (OR for Medicaid, 0.86 [95% CI, 0.76-0.98]; OR for no insurance, 0.65 [95% CI, 0.54-0.78]), and treatment in a low-volume center (OR for first quartile, 0.73 [95% CI, 0.62-0.87]; OR for second quartile, 0.79 [95% CI, 0.70-0.90]; OR for third quartile, 0.86 [95% CI, 0.78-0.94]). Clinical and pathologic variables associated with a decreased pCR included higher tumor grade (OR, 0.58 [95% CI, 0.49-0.70]), advanced tumor stage (OR for T3, 0.56 [95% CI, 0.42-0.76]; OR for T4, 0.30 [95% CI, 0.22-0.42]), and lymph node-positive disease (OR for N1, 0.83 [95% CI, 0.77-0.89]; OR for N2, 0.73 [95% CI, 0.65-0.82]).

Conclusions and Relevance

The findings of this cohort study suggest that disparate treatment outcomes for Hispanic and non-Hispanic Black patients are likely multifactorial in origin. Future investigation into additional social determinants of health and biological variables is warranted.

Specialty-Certified Colorectal Surgeons Demonstrate Favorable Short-term Surgical Outcomes for Laparoscopic Low Anterior Resection: Assessment of a Japanese Nationwide Database

BACKGROUND

There are few studies on the impact of a colorectal-specific technically certified surgeon on good surgical outcomes for laparoscopic low anterior resection in the real world.

OBJECTIVE

To evaluate the short-term outcomes of laparoscopic low anterior resection with the participation of a certified colorectal surgeon.

DESIGN

This was a retrospective cohort study using a Japanese nationwide database.

SETTING

This study was conducted as a project for the Japan Society of Endoscopic Surgery and the Japanese Society of Gastroenterological Surgery.

PATIENTS

This study included 41,741 patients listed in the National Clinical Database who underwent laparoscopic low anterior resection performed by certified, noncertified, and colorectal-specific certified surgeons, according to the Endoscopic Surgical Skill Qualification System, from 2016 to 2018.

MAIN OUTCOME MEASURES

Operative mortality rate and anastomotic leak rate were the primary outcome measures.

RESULTS

Overall 30-day mortality and operative mortality were 0.2% and 0.3%, respectively, without significant differences between all kinds of certified and noncertified surgeon groups. Overall anastomotic leak rate was 9.3%, with a significant difference between the 2 groups. Colorectal- and stomach-certified groups had lower 30-day mortality and operative mortality than the biliary-certified and noncertified groups. The anastomotic leak rate was the lowest in the colorectal-certified group. Based on a logistic regression analysis using the risk-adjusted model, operative mortality was significantly higher in the biliary-certified group than in the colorectal-certified group. Moreover, anastomotic leak rate was significantly lower in the colorectal-certified group than in the stomach-certified and noncertified groups.

LIMITATIONS

This study was a retrospective study, and there was a possibility of different definitions of anastomotic leak due to the use of a nationwide database.

CONCLUSIONS

The participation of a colorectal-specific certified surgeon may decrease the risk of operative mortality and anastomotic leak for laparoscopic low anterior resection.

CIRUJANO COLORRECTAL ALTAMENTE CALIFICADO PROVOCA RESULTADOS QUIRRGICOS FAVORABLES A CORTO PLAZO PARA LA RESECCIN ANTERIOR BAJA LAPAROSCPICA EVALUACIN DE LA BASE DE DATOS NACIONAL JAPONESA

ANTECEDENTES:Hay pocos estudios sobre el impacto de un cirujano certificado técnicamente especializado en cáncer colorrectal con un buen resultado quirúrgico para la resección anterior baja laparoscópica en el mundo real.OBJETIVO:Evaluar los resultados a corto plazo de la resección anterior baja laparoscópica con la participación de un cirujano colorrectal certificado.DISEÑO:Este fue un estudio de cohorte retrospectivo que utilizó una base de datos nacional japonesa.AJUSTE:Este estudio se realizó como un proyecto para la Sociedad Japonesa de Cirugía Endoscópica y la Sociedad Japonesa de Cirugía Gastroenterológica.PACIENTES:este estudio incluyó a 41 741 pacientes incluidos en la base de datos clínica nacional que se sometieron a una resección anterior baja laparoscópica realizada por cirujanos certificados, no certificados y certificados específicamente colorrectales, según el Sistema de calificación de habilidades quirúrgicas endoscópicas de 2016 a 2018.PRINCIPALES MEDIDAS DE RESULTADO:La tasa de mortalidad operatoria y la tasa de fuga anastomótica fueron los resultados primarios.RESULTADOS:La mortalidad general a los 30 días y la mortalidad operatoria fueron del 0,2 % y el 0,3 %, respectivamente, sin diferencias significativas entre los grupos de todos los tipos de cirujanos certificados y no certificados. La tasa global de fuga anastomótica fue del 9,3 %, con una diferencia significativa entre los dos grupos. Los grupos con certificación colorrectal y estomacal tuvieron una mortalidad a los 30 días y una mortalidad operatoria más bajas que los grupos con certificación biliar y sin certificación. La tasa de fuga anastomótica fue la más baja en el grupo certificado colorrectal. Con base en un análisis de regresión logística utilizando el modelo ajustado por riesgo, la mortalidad operatoria fue significativamente más alta en el grupo con certificación biliar que en el grupo con certificación colorrectal. Además, la tasa de fuga anastomótica fue significativamente más baja en el grupo con certificación colorrectal que en los grupos con certificación estomacal y sin certificación.LIMITACIONES:Este estudio fue retrospectivo y existía la posibilidad de diferentes definiciones de fuga anastomótica debido al uso de una base de datos nacional.CONCLUSIONES:La participación de un cirujano certificado en video específico colorrectal puede disminuir el riesgo de mortalidad operatoria y fuga anastomótica para la resección anterior baja laparoscópica. (Traducción-Dr. Mauricio Santamaria ).

Management and pharmacotherapy of pediatric colorectal carcinoma: a review

INTRODUCTION

Colorectal carcinoma (CRC) is one of the most common tumors in adult, but is extremely rare in children. In childhood, CRC often presents unfavorable aggressive histotypes, advanced clinical stage at onset and a worse prognosis. Pediatric CRC series are limited and include few patients, therefore information about treatment strategy and pharmacotherapy is scarce. For this reason, management of these patients represents a real challenge for pediatric oncologists.

AREAS COVERED

The authors provide an overview of the general features and management strategies of pediatric CRC with specific attention to systemic treatment. Literature data regarding pharmacotherapy in published pediatric series are summarized and analyzed in detail, according to adult treatment standards.

EXPERT OPINION

In the absence of specific recommendations for pediatric CRC, the general therapeutic strategy should follow the same principles as for adults and should be the result of a multidisciplinary discussion. Patient access to optimal treatment is difficult due to the lack of new drugs approved for the pediatric age group and non-availability of clinical trials. Collaboration between pediatric and adult oncologists is considered crucial in order to overcome these issues and find solutions to increase knowledge and improve the outcome of such a rare disease in children.

Evaluation of National Surgical Practice for Lateral Lymph Nodes in Rectal Cancer in an Untrained Setting

BACKGROUND

Involved lateral lymph nodes (LLNs) have been associated with increased local recurrence (LR) and ipsi-lateral LR (LLR) rates. However, consensus regarding the indication and type of surgical treatment for suspicious LLNs is lacking. This study evaluated the surgical treatment of LLNs in an untrained setting at a national level.

METHODS

Patients who underwent additional LLN surgery were selected from a national cross-sectional cohort study regarding patients undergoing rectal cancer surgery in 69 Dutch hospitals in 2016. LLN surgery consisted of either 'node-picking' (the removal of an individual LLN) or 'partial regional node dissection' (PRND; an incomplete resection of the LLN area). For all patients with primarily enlarged (≥7 mm) LLNs, those undergoing rectal surgery with an additional LLN procedure were compared to those  undergoing only rectal resection.

RESULTS

Out of 3057 patients, 64 underwent additional LLN surgery, with 4-year LR and LLR rates of 26% and 15%, respectively. Forty-eight patients (75%) had enlarged LLNs, with corresponding recurrence rates of 26% and 19%, respectively. Node-picking (n = 40) resulted in a 20% 4-year LLR, and a 14% LLR after PRND (n = 8; p = 0.677). Multivariable analysis of 158 patients with enlarged LLNs undergoing additional LLN surgery (n = 48) or rectal resection alone (n = 110) showed no significant association of LLN surgery with 4-year LR or LLR, but suggested higher recurrence risks after LLN surgery (LR: hazard ratio [HR] 1.5, 95% confidence interval [CI] 0.7-3.2, p = 0.264; LLR: HR 1.9, 95% CI 0.2-2.5, p = 0.874).

CONCLUSION

Evaluation of Dutch practice in 2016 revealed that approximately one-third of patients with primarily enlarged LLNs underwent surgical treatment, mostly consisting of node-picking. Recurrence rates were not significantly affected by LLN surgery, but did suggest worse outcomes. Outcomes of LLN surgery after adequate training requires further research.

Update on The National Accreditation Program for Rectal Cancer (NAPRC): the radiologist's role

The National Accreditation Program for Rectal Cancer (NAPRC) was established by the American College of Surgeons with the goal of standardizing care of rectal cancer patients in order to improve outcomes. NAPRC accreditation requires compliance with an established set of standards, many of which are directly related to radiology participation in multidisciplinary conference, rectal MR image acquisition, interpretation and reporting, and radiologist education. This paper outlines the pertinent standards/requirements for radiologists as part of the Rectal Cancer Multidisciplinary Team in the NAPRC guidelines, with proposed methods and tips for implementation of these standards from the perspective of the radiologist.

Measuring Quality at the Surgeon Level

Patients expect high-quality surgical care and increasingly are looking for ways to assess the quality of the surgeon they are seeing, but quality measurement is often more complicated than one might expect. Measurement of individual surgeon quality in a manner that allows for comparison among surgeons is particularly difficult. While the concept of measuring individual surgeon quality has a long history, technology now allows for new and innovative ways to measure and achieve surgical excellence. However, some recent efforts to make surgeon-level quality data publicly available have highlighted the challenges of this work. Through this chapter, the reader will be introduced to a brief history of surgical quality measurement, learn about the current state of quality measurement, and get a glimpse into what the future holds.

Analysis of Patterns of Compliance with Accreditation Standards of National Accreditation Program for Rectal Cancer

BACKGROUND

We identified commonly deficient standards across rectal cancer programs that underwent accreditation review by the National Accreditation Program for Rectal Cancer to evaluate for patterns of noncompliance.

STUDY DESIGN

With the use of the internal database of the American College of Surgeons, programs that underwent accreditation review from 2018 to 2020 were evaluated. The occurrence and frequency of noncompliance with the standards, using the 2017 standards manual, were evaluated. Programs were further stratified based on the year of review, annual rectal cancer volume, and Commission on Cancer classification.

RESULTS

A total of 25 programs with annual rectal cancer volume from 14 to more than 200 cases per year underwent accreditation review. Only 2 programs achieved 100% compliance with all standards. Compliance with standards ranged from 48% to 100%. The 2 standards with the lowest level of compliance included standard 2.5 and standard 2.11 that require all patients with rectal cancer to be discussed at a multidisciplinary team meeting before the initiation of definitive treatment and within 4 weeks after definitive surgical therapy, respectively. Patterns of noncompliance persisted when programs were stratified on the basis oof the year of survey, annual rectal cancer volume, and Commission on Cancer classification. The corrective action process allowed all programs to ultimately become successfully accredited.

CONCLUSION

During this initial phase of the National Accreditation Program for Rectal Cancer accreditation, the majority of programs undergoing review did not achieve 100% compliance and went through a corrective action process. Although the minimal multidisciplinary team meeting attendance requirements were simplified in the 2021 revised standards, noncompliance related to presentation of all patients at the multidisciplinary team meeting before and after definitive treatment highlights the need for programs seeking accreditation to implement optimized and standardized workflows to achieve compliance.

Multidisciplinary clinics for colorectal cancer may not provide more efficient coordination of care

BACKGROUND

This retrospective study compares a multidisciplinary clinic (MDC) to standard care for time to treatment of colorectal cancer.

METHODS

We queried our institutional ACS-NSQIP database for patients undergoing surgery for colorectal cancer from 2017 to 2020. Patients were stratified by initial clinic visit (MDC vs control). Primary endpoint was the time to start treatment (TST), either neoadjuvant therapy or surgery, from the date of diagnosis by colonoscopy.

RESULTS

A total of 405 patients were evaluated (115 MDC, 290 Control). TST from diagnosis was not significantly shorter for the MDC cohort (MDC 30 days, Control 37 days; p = 0.07) even when stratified by type of initial treatment of neoadjuvant therapy (MDC 30, Control 34 days; p = 0.28) or surgery (MDC 32.5 days, Control 38 days; p = 0.35).

CONCLUSION

Implementation of an MDC provides insignificant reduction in delay to start treatment for colorectal cancer patients as compared to standard care colorectal surgery clinics.

CLASSIFICATION

Colorectal.

Rural hospitals are not associated with worse postoperative outcomes for colon cancer surgery

PURPOSE

We sought to determine whether colorectal cancer surgery can be done safely at rural hospitals. The current study compared outcomes among rural patients who underwent colon resection at rural and nonrural hospitals.

METHODS

Medicare beneficiaries who underwent colon resection for cancer between 2013 and 2017 were identified using the Medicare Inpatient Standard Analytic Files. Patients and hospitals were designated as rural based on rural-urban continuum codes. Risk-adjusted postoperative outcomes and hospitalization spending were compared among patients undergoing resection at rural versus nonrural hospitals.

RESULTS

Among 3,937 patients who resided in a rural county and underwent colon resection for cancer, mean age was 76.3 (SD: 7.1) years and 1,432 (36.4%) patients underwent operative procedure at a rural hospital. On multivariable analyses, no differences in postoperative outcomes were noted among Medicare beneficiaries undergoing colon resection for cancer at nonrural versus rural hospitals. Specifically, the risk-adjusted probability of experiencing a postoperative complication at a nonrural hospital was 15.4% (95% CI: 14.1%-16.8%) versus 16.3% (95% CI: 14.2%-18.3%) at a rural hospital (OR 1.08, 95% CI: 0.85-1.38); 30-day mortality (nonrural: 2.9%, 95% CI: 2.2-3.6 vs rural: 3.5%, 95% CI: 2.4-4.5) was also comparable. In addition, price standardized, risk-adjusted expenditures were similar at nonrural ($18,610, 95% CI: $18,037-$19,183) and rural ($19,010, 95% CI: $18,630-$19,390) hospitals.

CONCLUSION

Among rural Medicare beneficiaries who underwent a colon resection for cancer, there were no differences in postoperative outcomes among nonrural versus rural hospitals. These findings serve to highlight the importance of policies and practice guidelines that secure safe, local surgical care, allowing rural clinicians to accommodate strong patient preferences while delivering high-quality surgical care.

Influence of the introduction of caseload requirements on indication for visceral cancer surgery in Switzerland

BACKGROUND

In 2013 Swiss health authorities implemented annual hospital caseload requirements (CR) for five areas of visceral surgery. We assess the impact of the implementation of CR on indication for surgery in esophageal, pancreatic and rectal cancer.

MATERIALS AND METHODS

Retrospective analysis of national registry data of all inpatient admissions between January 1st^, 2005 and December 31st^, 2015. Primary end-point was the age-adjusted resection rate for esophageal, pancreatic and rectal cancer among patients with at least one cancer-specific hospitalization per year. We calculated age-adjusted rate ratios for period effects before and after implementation of CR and odds ratios (OR) based on a generalized estimation equation. A relative increase of 5% in age-adjusted relative risk was set a priori as relevant from a health policy perspective.

RESULTS

Age-adjusted resection rates before and after the implementation of CR were 0.12 and 0.13 (Relative Risk [RR] 1.08; 95%-Confidence Interval [CI] 0.85-1.36) in esophageal cancer, 0.22 and 0.26 (RR 1.17; 95%-CI 0.85-1.58) in pancreatic cancer and 0.38 and 0.43 (RR 1.14; 95%-CI 0.99-1.30) in rectal cancer. In adjusted models OR for resection after the implementation of CR were 1.40 (95%-CI 1.24-1.58) in esophageal cancer, 1.05 (95%-CI 0.96-1.15) in pancreatic cancer and 0.92 (95%-CI 0.87-0.97) in rectal cancer.

CONCLUSION

Implementation of CR was associated with an increase of resection rates above the a priori set margins in all resections groups. In adjusted models, odds for resection were significantly higher for esophageal cancer, while they remained unchanged for pancreatic and decreased for rectal cancer.

Association between Functional Brain Network Metrics and Surgeon Performance and Distraction in the Operating Room

OBJECTIVE

The aim of this work was to examine (electroencephalogram) EEG features that represent dynamic changes in the functional brain network of a surgical trainee and whether these features can be used to evaluate a robot assisted surgeon's (RAS) performance and distraction level in the operating room.

MATERIALS AND METHODS

Electroencephalogram (EEG) data were collected from three robotic surgeons in an operating room (OR) via a 128-channel EEG headset with a frequency of 500 samples/second. Signal processing and network neuroscience algorithms were applied to the data to extract EEG features. The SURG-TLX and NASA-TLX metrics were subjectively evaluated by a surgeon and mentor at the end of each task. The scores given to performance and distraction metrics were used in the analyses here. Statistical test data were utilized to select EEG features that have a significant relationship with surgeon performance and distraction while carrying out a RAS surgical task in the OR.

RESULTS

RAS surgeon performance and distraction had a relationship with the surgeon's functional brain network metrics as recorded throughout OR surgery. We also found a significant negative Pearson correlation between performance and the distraction level (-0.37, p-value < 0.0001).

CONCLUSIONS

The method proposed in this study has potential for evaluating RAS surgeon performance and the level of distraction. This has possible applications in improving patient safety, surgical mentorship, and training.

Variables Affecting Basal Cell Carcinoma and Melanoma In Situ Excision Clearance: A Multi-institutional Retrospective Study

BACKGROUND

The primary endpoint for surgical excision of skin cancer is the positive margin status. Tumor characteristics may explain much of this risk, but other important factors can include physician specialty.

OBJECTIVE

To determine the variables affecting the success of a basal cell carcinoma (BCC) or melanoma in situ (MIS) excision.

METHODS/MATERIALS

An 8-year, multicenter, retrospective study of 5,800 BCC or MIS excisions performed at 13 different Kaiser Permanente medical centers. The margin status was determined by searching final pathology diagnosis texts for phrases associated with positive margins.

RESULTS

An incomplete excision rate was found in 23% of all specimens (BCC-22%, MIS-25%). Per specialty, the proportion of specimens with positive tumor margins was 24% for dermatology, 26% for plastic surgery, 28% for otolaryngology, and 12% for general surgery. General surgeons most often excised large tumors and tumors from truncal regions, 2 variables conferring lower odds of an incomplete excision. For non-Mohs procedures, dermatologists were no different than otolaryngologists or plastic surgeons in performing an incomplete BCC or MIS excision in all multivariate models (all p > .05).

CONCLUSION

Intrinsic tumor characteristics may influence the success of achieving tumor-free resection margins more than the specialty of the provider.

Navigating by Stars: Using CMS Star Ratings to Choose Hospitals for Complex Cancer Surgery

Background

The Centers for Medicare and Medicaid Services (CMS) developed risk-adjusted “Star Ratings,” which serve as a guide for patients to compare hospital quality (1 star = lowest, 5 stars = highest). Although star ratings are not based on surgical care, for many procedures, surgical outcomes are concordant with star ratings. In an effort to address variability in hospital mortality after complex cancer surgery, the use of CMS Star Ratings to identify the safest hospitals was evaluated.

Methods

Patients older than 65 years of age who underwent complex cancer surgery (lobectomy, colectomy, gastrectomy, esophagectomy, pancreaticoduodenectomy) were evaluated in CMS Medicare Provider Analysis and Review files (2013-2016). The impact of reassignment was modeled by applying adjusted mortality rates of patients treated at 5-star hospitals to those at 1-star hospitals (Peters-Belson method).

Results

There were 105 823 patients who underwent surgery at 3146 hospitals. The 90-day mortality decreased with increasing star rating (1 star = 10.4%, 95% confidence interval [CI] = 9.8% to 11.1%; and 5 stars = 6.4%, 95% CI = 6.0% to 6.8%). Reassignment of patients from 1-star to 5-star hospitals (7.8% of patients) was predicted to save 84 Medicare beneficiaries each year. This impact varied by procedure (colectomy = 47 lives per year; gastrectomy = 5 lives per year). Overall, 2189 patients would have to change hospitals each year to improve outcomes (26 patients moved to save 1 life).

Conclusions

Mortality after complex cancer surgery is associated with CMS Star Rating. However, the use of CMS Star Ratings by patients to identify the safest hospitals for cancer surgery would be relatively inefficient and of only modest impact.

Provider caseload volume and short-term outcomes following colorectal surgeries in New Brunswick: a provincial-level cohort study

BACKGROUND

American studies have shown that higher provider and hospital volumes are associated with reduced risk of mortality following colorectal surgical interventions. Evidence from Canada is limited, and to our knowledge only a single study has considered outcomes other than death. We describe associations between provider surgical volume and all-cause mortality and postoperative complications following colorectal surgical interventions in New Brunswick.

METHODS

We used hospital discharge abstracts linked to vital statistics, the provincial cancer registry and patient registry data. We considered all admissions for colorectal surgeries from 2007 through 2013. We used logistic regression to identify odds of dying and odds of complications (from any of anastomosis leak, unplanned colostomy, intra-abdominal sepsis or pneumonia) within 30 days of discharge from hospital according to provider volume (i.e., total interventions performed over the preceding 2 years) adjusted for personal, contextual, provider and hospital characteristics.

RESULTS

Overall, 9170 interventions were performed by 125 providers across 18 hospitals. We found decreased odds of experiencing a complication following colorectal surgery per increment of 10 interventions performed per year (odds ratio 0.94, 95% confidence interval 0.91-0.96). We found no associations with mortality. Associations remained consistent across models restricted to cancer patients or to interventions performed by general surgeons and across models that also considered overall hospital volumes.

CONCLUSION

Our results suggest that increased caseloads are associated with reduced odds of complications, but not with all-cause mortality, following colorectal surgery in New Brunswick. We also found no evidence of volume having differential effects on outcomes from colon and rectal procedures.

The role of surgery for locally recurrent and second recurrent rectal cancer with metastatic disease

BACKGROUND

The role of surgery for locally recurrent rectal cancer (LRRC) with resectable distant metastases or second LRRC remains unclear. This study aimed to clarify the influence of synchronous distant metastases (SDMs), a history of distant metastasis resection (HDMR), and a second LRRC on the outcome.

METHODS

The long-term outcomes of 70 surgically treated patients with LRRC between 2006 and 2018 were compared by SDM (n = 10), HDMR (n = 17), and second LRRC (n = 7).

RESULTS

Among the 10 patients with SDM, 4 patients underwent simultaneous resection, whereas the other 6 underwent staged resection with distant first approach. Recurrence developed in 9 patients, of which 2 patients with liver re-resection achieved long-term survival without cancer. The patients with and without SDM had equivalent 5-year overall survival rate (40.5% vs. 53.3%, p = 0.519); however, patients with SDM had a worse 3-year recurrence-free survival rate than those without SDM (10.0% vs. 37.5%, p = 0.031). Multivariate analysis showed that primary non-sphincter-preserving surgery, second LRRC, and R1 resection were independent risk factors for overall survival. Similarly, primary non-sphincter-preserving surgery, second LRRC, SDM, and R1 resection were risk factors for recurrence-free survival.

CONCLUSIONS

Patients with SDM might still be suitable to undergo salvage surgery and achieve favourable overall survival. Distant metastasectomy should be performed first, followed by a sufficient interval to avoid unnecessary LRRC resection in uncurable patients. An HDMR should not be taken into consideration when making surgical plans. Surgical indication of second LRRC should be strict, especially in referred patients.

Differences in Travel Time to Cancer Surgery for Colon versus Rectal Cancer in a Rural State: A New Method for Analyzing Time-to-Place Data Using Survival Analysis

PURPOSE

Rectal cancer is rarer than colon cancer and is a technically more difficult tumor for surgeons to remove, thus rectal cancer patients may travel longer for specialized treatment compared to colon cancer patients. The purpose of this study was to evaluate whether travel time for surgery was different for colon versus rectal cancer patients.

METHODS

A secondary data analysis of colorectal cancer (CRC) incidence data from the Iowa Cancer Registry data was conducted. Travel times along a street network from all residential ZIP Codes to all cancer surgery facilities were calculated using a geographic information system. A new method for analyzing "time-to-place" data using the same type of survival analysis method commonly used to analyze "time-to-event" data is introduced. Cox proportional hazard model was used to analyze travel time differences for colon versus rectal cancer patients.

RESULTS

A total of 5,844 CRC patients met inclusion criteria. Median travel time to the nearest surgical facility was 9 minutes, median travel time to the actual cancer surgery facilities was 22 minutes, and the median number of facilities bypassed was 3. Although travel times to the nearest surgery facilities were not significantly different for colon versus rectal cancer patients, rectal cancer patients on average traveled 15 minutes longer to their actual surgery facility and bypassed 2 more facilities to obtain surgery.

DISCUSSION

In general, the survival analysis method used to analyze the time-to-place data as described here could be applied to a wide variety of health services and used to compare travel patterns among different groups.

Real-world impact of laparoscopic surgery for rectal cancer: a population-based analysis

Background

Randomized trials have demonstrated equivalent oncologic outcomes and decreased morbidity in patients with rectal cancer who undergo laparoscopic surgery (lapsx) compared with open surgery (opensx). The objective of the present study was to compare short-term outcomes after lapsx and opensx in a real-world setting.

Methods

A national discharge abstract database was used to identify all patients who underwent rectal cancer resection in Canada (excluding Quebec) from April 2004 through March 2015. Short-term outcomes examined included same-admission mortality and length of stay (los).

Results

Of 28,455 patients, 82.4% underwent opensx, and 17.6%, lapsx. The use of lapsx increased to 34% in 2014 from 5.9% in 2004 (p < 0.0001). Same-admission mortality was lower among patients undergoing lapsx than among those undergoing opensx (1.08% and 1.95% respectively, p < 0.0001). On multivariable analysis, the odds of same-admission mortality with lapsx was 36% lower than that with opensx (odds ratio: 0.64; p = 0.003). Median los was shorter after lapsx than after opensx (5 days and 8 days respectively, p = 0.0001). The strong association of lapsx with shorter los was maintained on multivariable analysis controlling for patient, surgeon, and hospital factors.

Conclusions

For patients with rectal cancer, shorter los and decreased same-admission mortality are associated with the use of lapsx compared with opensx.

Data Accuracy and Predictors of High Ratings of Colon and Rectal Surgeons on an Online Physician Rating Website

BACKGROUND

Online physician rating Web sites are used by over half of consumers to select doctors. No studies have examined physician rating Web sites for colon and rectal surgeons.

OBJECTIVE

The purpose of this study was to evaluate the accuracy and rating patterns of colon and rectal surgeons on the largest physician rating Web site.

DESIGN

Physician characteristics and ratings were collected from a randomly selected sample of 500 from 3043 Healthgrades "colon and rectal surgery specialists." Board certifications were verified with the American Board of Surgery and American Board of Colon and Rectal Surgery Web sites.

SETTINGS

Data acquisition was completed on July 18, 2018.

PATIENTS

Patients were not directly studied.

MAIN OUTCOME MEASURES

The primary outcome was to assess the accuracy of Healthgrades in reporting American Board of Surgery and American Board of Colon and Rectal Surgery certification. The secondary outcome was to identify factors associated with high star ratings.

RESULTS

A total of 48 (9.6%) of the 500 sampled were incorrectly identified as practicing US surgeons and excluded from subsequent analysis. Healthgrades showed 80.1% agreement with verified board certifications for American Board of Surgery and 85.4% for American Board of Colon and Rectal Surgery. The mean star rating was 4.2 of 5.0 (SD = 0.9), and 77 (21.6%) had 5-star ratings. In a multivariable logistic model (p < 0.001), 5-star rating was associated with 1 to 9 years (OR = 2.76; p = 0.04) or >40 years in practice (OR = 3.35; p = 0.04) and fewer reviews (OR = 0.88; p < 0.001). There were no significant associations with surgeon sex, age, geographic region, or board certification.

LIMITATIONS

Data were limited to a single physician rating Web site.

CONCLUSIONS

In the modern age of healthcare consumerism, physician rating Web sites should be used with caution given inaccuracies. More accurate online resources are needed to inform patient decisions in the selection of specialized colon and rectal surgical care. See Video Abstract at http://links.lww.com/DCR/B91. PRECISIÓN DE DATOS Y PREDICTORES DE ALTAS CALIFICACIONES DE CIRUJANOS DE COLON Y RECTO EN UN SITIO WEB DE CALIFICACIÓN MÉDICA EN LÍNEA: Más de la mitad de los consumidores utilizan los sitios web de calificación de médicos en línea para seleccionar médicos. Ningún estudio ha examinado los sitios web de calificación de médicos para cirujanos de colon y recto.Evaluar la precisión y los patrones de calificación de los cirujanos de colon y recto en el sitio web más grande de calificación de médicos.Las características y calificaciones de los médicos se obtuvieron de una muestra seleccionada al azar de 500 de 3,043 "especialistas en cirugía de colon y recto" de Healthgrades. Las certificaciones del Consejo se verificaron en los sitios web del Consejo Americano de Cirugía y del Consejo Americano de Cirugía de Colon y Recto.La adquisición de datos se completó el 18 de julio de 2018.Los pacientes no fueron estudiados directamente.El resultado primario fue evaluar la precisión de Healthgrades al informar la certificación por el Consejo Americano de Cirugía y por el Consejo Americano de Cirugía de Colon y Recto. El resultado secundario fue identificar factores asociados con altas calificaciones en estrellas.Un total de 48 (9.6%) de la muestra de 500 fueron identificados incorrectamente como cirujanos practicantes de EE. UU. y excluidos del análisis subsecuente. Healthgrades mostró un 80.1% de concordancia con las certificaciones verificadas del Consejo Americano de Cirugía y el 85.4% con el Consejo Americano de Cirugía de Colon y Recto. La calificación promedio de estrellas fue 4.2 / 5 (SD 0.9), y 77 (21.6%) tuvieron calificaciones de 5 estrellas. En un modelo logístico multivariable (p <0.001), la calificación de 5 estrellas se asoció con 1-9 años (OR 2.76, p = 0.04) o más de 40 años en la práctica (OR 3.35, p = 0.04) y menos evaluaciones (OR 0.88, p <0.001). No hubo asociaciones significativas con el género, edad, región geográfica o certificación por los Consejos del cirujano.Los datos se limitaron a un solo sitio web de calificación de médicos.En la era moderna del consumismo en atención médica, los sitios web de calificación de los médicos deben usarse con precaución debido a imprecisiones. Se necesitan recursos en línea más precisos para que las decisiones de los pacientes sean informadas en la selección de atención quirúrgica especializada de colon y recto. Consulte Video Resumen en http://links.lww.com/DCR/B91. (Traducción-Dr. Jorge Silva-Velazco).

Compliance With Preoperative Elements of the American Society of Colon and Rectal Surgeons Rectal Cancer Surgery Checklist Improves Pathologic and Postoperative Outcomes

BACKGROUND

In 2016, the American Society of Colon and Rectal Surgeons published a rectal cancer surgery checklist composed of the essential elements of preoperative, intraoperative, and postoperative care for patients undergoing rectal cancer surgery.

OBJECTIVE

The purpose of this study was to assess whether compliance with preoperative checklist elements was associated with improved pathologic and 30-day postoperative outcomes after rectal cancer surgery.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study involved North American hospitals contributing to the American College of Surgeons National Surgical Quality Improvement Program.

PATIENTS

Adult patients who underwent elective rectal cancer surgery from 2016 to 2017 were included.

INTERVENTION

The study encompassed checklist compliance with 6 preoperative elements from the checklist.

MAIN OUTCOME MEASURES

Pathologic outcomes (circumferential resection margin status, distal resection margin status, and adequate lymph node harvest ≥12), 30-day surgical morbidity, and length of stay were measured.

RESULTS

In total, 2217 patients were included in the analysis. Individual compliance with the 6 available preoperative checklist items was variable, including 91.3% for pretreatment documentation of tumor location within the rectum, 86.8% for complete colonoscopy, 84.0% for appropriate preoperative stoma marking, 79.8% for appropriate use of neoadjuvant radiotherapy, 76.6% for locoregional staging, and 70.8% for distant staging. Only 836 patients (37.7%) had all 6 checklist elements complete, whereas 1381 (62.3%) did not. Compared with patients without checklist compliance, patients with checklist compliance were younger (60.0 vs 63.0 y; p < 0.001) but otherwise had similar demographic characteristics. On multivariate regression, checklist compliance was associated with lower odds of circumferential resection margin positivity (OR = 0.47 (95% CI, 0.31-0.71); p < 0.001), higher odds of an adequate lymph node harvest ≥12 (OR = 1.60 (95% CI, 1.29-2.00); p < 0.001), reduced surgical morbidity (OR = 0.78 (95% CI, 0.65-0.95); p = 0.01), and shorter length of stay (β = -0.87 (95% CI, -1.51 to -0.24); p = 0.007). The association between checklist compliance and reduced odds of circumferential resection margin positivity remained on sensitivity analysis (OR = 0.61 (95% CI, 0.42-0.88); p = 0.009) when adjusting for neoadjuvant radiation.

LIMITATIONS

This study was limited by its absence of long-term oncologic data and missing variables.

CONCLUSIONS

Compliance with 6 preoperative elements of the American Society of Colon and Rectal Surgeons rectal cancer surgery checklist was associated with significantly improved pathologic outcomes and reduced postoperative morbidity. See Video Abstract at http://links.lww.com/DCR/B80. EL CUMPLIMIENTO CON LOS ELEMENTOS PREOPERATORIOS DE LA LISTA DE VERIFICACIÓN DE CIRUGÍA PARA CÁNCER RECTAL DE LA SOCIEDAD AMERICANA DE CIRUJANOS DE COLON Y RECTO MEJORA LOS RESULTADOS HISTOPATOLÓGICOS Y POSTOPERATORIOS: En 2016, la Sociedad Americana de Cirujanos de Colon y Recto publicó una lista de verificación de cirugía de cáncer de recto que comprende los elementos esenciales de la atención pre, intra y postoperatoria para pacientes sometidos a cirugía de cáncer de recto.Evaluar si el cumplimiento con los elementos preoperatorios de la lista de verificación se asoció con mejores resultados histopatológicos y postoperatorios a 30 días después de la cirugía de cáncer rectal.Estudio de cohorte retrospectiva.Hospitales norteamericanos que contribuyen al Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Americano de Cirujanos.Pacientes adultos que se sometieron a cirugía electiva de cáncer rectal entre 2016 y 2017.Cumplimiento de la lista de verificación con seis elementos preoperatorios de la lista de verificación.Resultados histopatológicos (estado del margen de resección circunferencial, estado del margen de resección distal, cosecha adecuada de ganglios linfáticos ≥12), morbilidad quirúrgica a 30 días y duración de la estadía.En total, 2,217 pacientes fueron incluidos en el análisis. El cumplimiento individual de los seis ítems disponibles de la lista de verificación preoperatoria fue variable: 91.3% para la documentación previa al tratamiento de la localización del tumor dentro del recto, 86.8% para colonoscopía completa, 84.0% para el marcado preoperatorio apropiado del sitio de estoma, 79.8% para el uso apropiado de radioterapia neoadyuvante, 76.6 % para estadificación locorregional y 70.8% para estadificación distante. Solo 836 (37.7%) pacientes tenían los seis elementos de la lista de verificación completos, mientras que 1,381 (62.3%) no. En comparación con los pacientes sin cumplimiento de la lista de verificación, los pacientes con cumplimiento de la lista de verificación eran más jóvenes (60.0 vs. 63.0 años, p <0.001), pero por lo demás tenían características demográficas similares. En la regresión multivariada, el cumplimiento de la lista de verificación se asoció con menores probabilidades de positividad en el margen de resección circunferencial (OR = 0.47; IC del 95%: 0.31-0.71, p <0.001), mayores probabilidades de una cosecha adecuada de ganglios linfáticos ≥12 (OR = 1.60, IC 95% 1.29-2.00, p <0.001), menor morbilidad quirúrgica (OR = 0.78, IC 95% 0.65-0.95, p = 0.01) y menor duración de estadía (β = -0.87, IC 95% -1.51 - - 0.24, p = 0.007). La asociación entre el cumplimiento de la lista de verificación y las probabilidades reducidas de positividad del margen de resección circunferencial se mantuvo en el análisis de sensibilidad (OR = 0.61; IC del 95%: 0.42-0.88, p = 0.009) al ser ajustado con radiación neoadyuvante.Ausencia de datos oncológicos a largo plazo y variables faltantes.El cumplimiento de seis elementos preoperatorios de la lista de verificación de cirugía de cáncer rectal de la Sociedad Americana de Cirujanos de Colon y Recto se asoció con resultados histopatológicos significativamente mejores y una menor morbilidad postoperatoria. Vea el resumen en video en http://links.lww.com/DCR/B80.

State-wide outcomes in elective rectal cancer resection: is there a case for centralization in Victoria?

BACKGROUND

The role of service centralization in rectal cancer surgery is controversial. Recent studies suggest centralization to high-volume centres may improve postoperative mortality. We used a state-wide administrative data set to determine the inpatient mortality for patients undergoing elective rectal cancer surgery and to compare individual hospital volumes.

METHODS

The Victorian Admitted Episodes Dataset was explored using the Dr Foster Quality Investigator tool. The inpatient mortality rate, 30-day readmission rate and the proportion of patients with increased length of stay were measured for all elective admissions for rectal cancer resections between 2012 and 2016. A peer group of 14 hospitals were studied using funnel plots to determine inter-hospital variation in mortality. Procedure types were compared between the groups.

RESULTS

There were 2241 elective resections performed for rectal cancer in Victoria over 4 years. The crude inpatient mortality rate was 1.1%. There were no significant differences in mortality among 14 hospitals within the peer group. The number of elective resections over 4 years ranged from 14 to 136 (median 65) within these institutions. Ultralow anterior resection was the commonest procedure performed.

CONCLUSION

Inpatient mortality after elective rectal cancer surgery in Victoria is rare and compares favourably internationally. Based on inpatient mortality alone, there is no compelling evidence to further centralize elective rectal cancer surgery in Victoria. More work is needed to develop data sets with oncological information capable of providing accurate complete state-wide data which will be essential for future service planning, training and innovation.

Disparity of Colon Cancer Outcomes in Rural America: Making the Case to Travel the Extra Mile

OBJECTIVES

Rural patients experience disparities in cancer care compared to urban patients. We hypothesized that rural patients with colon cancer who traveled to high-volume centers for treatment have similar survival compared to urban patients who also traveled to high-volume centers to seek treatment for colon cancer.

METHODS

The National Cancer Database was interrogated for patients treated for stage I-III colon cancer (2004-2015). Travel distance to treatment centers and annual hospital volume were divided into quartiles. Two groups of patients were identified and compared: (1) rural patients who traveled to high-volume hospitals and (2) urban patients who also traveled to high-volume centers. The primary outcome was overall survival (OS).

RESULTS

Of 647,949 patients, 634, 447 were urban and 13,502 were rural. Rural patients were more likely to be Caucasian, with lower income, more comorbidities, and be treated at non-academic centers. In multivariable analysis, rural patients had worse OS compared to urban patients (hazard ratio [HR] 1.08; 95% confidence interval [CI] 1.04-1.12; p = < 0.001). There were 46,781 (7%) urban patients and 1276 (9%) rural patients who traveled a long distance (median 40 and 108 miles, respectively) to high-volume centers. There was no difference in adjusted OS between urban and rural patients who traveled to high-volume centers for treatment (HR 1.06; 95%CI 0.94-1.20; p = 0.36).

CONCLUSIONS

This nationwide analysis suggests that rural patients with colon cancer experience worse survival than urban patients, but that this disparity might be mitigated by rural patients traveling to high-volume centers for treatment.

Disparity of Colon Cancer Outcomes in Rural America: Making the Case to Travel the Extra Mile

OBJECTIVES

Rural patients experience disparities in cancer care compared to urban patients. We hypothesized that rural patients with colon cancer who traveled to high-volume centers for treatment have similar survival compared to urban patients who also traveled to high-volume centers to seek treatment for colon cancer.

METHODS

The National Cancer Database was interrogated for patients treated for stage I-III colon cancer (2004-2015). Travel distance to treatment centers and annual hospital volume were divided into quartiles. Two groups of patients were identified and compared: (1) rural patients who traveled to high-volume hospitals and (2) urban patients who also traveled to high-volume centers. The primary outcome was overall survival (OS).

RESULTS

Of 647,949 patients, 634, 447 were urban and 13,502 were rural. Rural patients were more likely to be Caucasian, with lower income, more comorbidities, and be treated at non-academic centers. In multivariable analysis, rural patients had worse OS compared to urban patients (hazard ratio [HR] 1.08; 95% confidence interval [CI] 1.04-1.12; p = < 0.001). There were 46,781 (7%) urban patients and 1276 (9%) rural patients who traveled a long distance (median 40 and 108 miles, respectively) to high-volume centers. There was no difference in adjusted OS between urban and rural patients who traveled to high-volume centers for treatment (HR 1.06; 95%CI 0.94-1.20; p = 0.36).

CONCLUSIONS

This nationwide analysis suggests that rural patients with colon cancer experience worse survival than urban patients, but that this disparity might be mitigated by rural patients traveling to high-volume centers for treatment.

Does Hospital Volume Affect Outcomes in Patients Undergoing Vestibular Schwannoma Surgery?

OBJECTIVE

To determine the effect of hospital surgical case volume on the outcomes of vestibular schwannoma surgery.

STUDY DESIGN

Retrospective case review.

SETTING

University HealthSystem Consortium member hospitals (includes nearly every US academic medical center).

PATIENTS

Three thousand six hundred ninety-seven patients who underwent vestibular schwannoma resection over a 3-year timespan (2012-2015) grouped by race, age, comorbidities, payer, and sex.

INTERVENTION

Surgical resection of vestibular schwannoma.

MAIN OUTCOME MEASURES

Morbidity and mortality following vestibular schwannoma excision are compared by hospital volume (low, medium, and high) including deciles.

RESULTS

There was significantly longer length of stay (p ≤ 0.005) among groups with low-volume hospitals followed by medium-volume hospitals and high-volume hospitals. Low-volume hospitals had a significantly higher rate of complications including stroke, aspiration, and respiratory failure (p ≤ 0.0175). Patient characteristics of age, sex, sex, and baseline comorbidities were similar between hospital groups. However, patients at high-volume hospitals were more likely to be Caucasian (83.1%, p = 0.0001) and have private insurance (76.7%, p < 0.0001). There was a strong negative correlation between complication rates and hospital volume (r = -0.8164, p = 0.0040).

CONCLUSION

The volume of vestibular schwannoma surgeries performed at a hospital impacts length of stay and rates of postoperative complications. Demographics among hospital groups were similar though high-volume hospitals had significantly more patients who were privately insured and Caucasian.

Clinicopathologic and Prognostic Differences between Three Different Age Groups (Child/Adolescent, Young Adults, and Adults) of Colorectal Cancer Patients: A Multicentre Study

BACKGROUND

Colorectal cancer (CRC) is a rare disease amongst children and adolescents. Previous studies have reported a number of differences between children/adolescents, young adults, and adult patients with CRC. However, none of these studies compared these age groups according to their clinicopathologic and prognostic characteristics. In the current study, we compare these three age groups.

METHODS

A total of 173 (1.1% of 15,654 patients) young CRC patients (≤25 years) were included in the study. As a control group, 237 adult CRC patients (>25 years) were also included. Patients were divided into three age groups: child/adolescent (10-19 years), young adult (20-25 years), and adult (>25 years).

RESULTS

Statistical differences amongst the three groups in terms of gender (p = 0.446), family history (p = 0.578), symptoms of presentation (p = 0.306), and interval between initiation of symptoms and diagnosis (p = 0.710) could not be demonstrated. Whilst abdominal pain (p < 0.001) and vomiting (p = 0.002) were less common in young adults than in other groups, rectal bleeding and changes in bowel habits were relatively less common in adolescents than in other groups. Rectal localisation (p = 0.035), mucinous adenocarcinoma (p < 0.001), and a poorly differentiated histologic subtype (p < 0.001) were less common in the adult group than in other groups. The percentage of patients with metastasis and sites of metastasis (e.g., peritoneum and lung) differed between groups. The median overall survival was 32.6 months in the adolescent group, 57.8 months in the young adult group and was not reached in the adult group (p = 0.022). The median event-free survival of the adolescent, young adult, and adult groups was 29.0, 29.9, and 61.6 months, respectively (p = 0.003).

CONCLUSIONS

CRC patients of different age groups present different clinicopathologic and prognostic characteristics. Clinicians should be aware of and manage the disease according to these differences.

Trends in Routine and Complex Hepatobiliary Surgery Among General and Pediatric Surgical Residents: What is the Next Generation Learning and is it Enough?

OBJECTIVE

Previous studies reveal a correlation between surgical volume and outcomes; thus, a similar relationship likely exists between trainee operative volume and technical competence. While routine hepatobiliary surgery is commonplace, trainee exposure to the more advanced procedures may be lacking. We hypothesize that experience in complex hepatobiliary procedures may be deficient both during general surgery residency and pediatric surgery fellowship training.

DESIGN

Case log data from the ACGME were queried for general surgery residents (2000-2017) and pediatric surgery fellows (2004-2017). Laparoscopic cholecystectomy was considered a routine hepatobiliary procedure for both specialties. For general surgery, hepatic lobectomy/segmentectomy and choledochoenteric anastomosis were considered complex and for pediatric surgery, hepatic lobectomy, biliary atresia and choledochal cyst procedures were considered complex.

SETTING

Publicly available case log data from the ACGME.

PARTICIPANTS

General surgery residents and pediatric surgery fellows at ACGME-accredited training programs.

RESULTS

The number of trainees increased over the study period for both groups. Mean case volumes for laparoscopic cholecystectomy increased by 36% in surgery graduates and by 114% in pediatric surgery graduates. In surgery, the mean volumes for choledochoenteric anastomosis procedures decreased by 53% from 3.0 to 1.4 procedures/year with increasing variability in trainee experience. Volumes for hepatic lobectomy/segmentectomy increased by 68% from 3.4 to 5.7 procedures/year with decreasing variability. In pediatric surgery, case volumes for complex procedures were low (mean <4/year), highly variable among trainees, and appear unchanged between 2004 and 2017. In every year analyzed, at least 1 pediatric surgery trainee reported doing 0 cases in one of these complex categories.

CONCLUSIONS

Case logs suggest that the volume of complex hepatobiliary surgery remains low and highly variable in both disciplines with some trainees obtaining minimal or no exposure to certain cases. The relationship between these trends and the development of competency is worthy of further study.

Examining the transferability of colon and rectal operative experience on outcomes following laparoscopic rectal surgery

BACKGROUND

Laparoscopic rectal surgery is technically challenging and often low volume. Alternatively, colon resections utilize similar advanced laparoscopic skills and are more common but it is unknown whether this experience affects laparoscopic rectal surgery outcomes. The purpose of this paper is to determine the volume-outcome relationship between several colorectal procedures and laparoscopic rectal surgery outcomes.

METHODS

This was a population-based retrospective cohort of all colorectal surgeries with primary anastomoses performed across Canada (excluding Quebec) between April 2008 and March 2015. Patient characteristics, comorbidities, procedures, and discharge details were collected from the Canadian Institute for Health Information. Volumes for common colorectal procedures were calculated for individual surgeons. All-cause morbidity, defined as complications arising during the index admission and contributing to an increased length of stay by more than 24 h, was the primary outcome examined.

RESULTS

A total of 5323 laparoscopic rectal surgery cases and 108,034 colorectal cases, between 180 hospitals and 620 surgeons, were identified. Data analysis demonstrated that high-volume laparoscopic rectal surgeons (OR 0.77, CI 0.61-0.96, p = 0.020) and high-volume open rectal surgeons (OR 0.76, CI 0.61-0.93, p = 0.009) significantly reduced all-cause morbidity. Conversely, surgeon volumes for laparoscopic and open colon cases had no effect on laparoscopic rectal outcomes.

CONCLUSION

High-volume surgeon status in laparoscopic and open rectal surgery are important predictors of all-cause morbidity after laparoscopic rectal surgery, while laparoscopic colon surgery volumes did not impact outcomes. This may reflect more dissimilarity between colon and rectal cases and less transferability of advanced laparoscopic skills than previously thought.

Structured-mentorship Program for Periacetabular Osteotomy Resulted in Few Complications for a Low-volume Pelvic Surgeon

BACKGROUND

The Bernese periacetabular osteotomy (PAO) is a complex surgical procedure with a substantial learning curve. Although larger hospital and surgeon procedure volumes have recently been associated with a lower risk of complications, in geographically isolated regions, some complex operations such as PAO will inevitably be performed in low volume. A continuous structured program of distant mentoring may offer benefits when low numbers of PAOs are undertaken, but this has not been tested. We sought to examine a structured, distant-mentorship program of a low-volume surgeon in a geographically remote setting.

QUESTIONS/PURPOSES

The purposes of this study were (1) to identify the clinical results of PAO performed in a remote-mentorship program, as determined by patient-reported outcome measures and complications of the surgery; (2) to determine radiographic results, specifically postoperative angular corrections, hip congruity, and progression of osteoarthritis; and (3) to determine worst-case analysis of PAO survivorship, defined as nonconversion to THA, in a regionally isolated cohort of patients with a high rate of followup.

METHODS

Between August 1992 and August 2016, 85 PAOs were undertaken in 72 patients under a structured, distant-mentorship program. The patients were followed for a median of 5 years (range, 2-25 years). There were 18 males (21 hips) and 54 females (64 hips). The median age of the patients at the time of surgery was 26 years (range, 14-45 years). One patient was lost to followup (two PAOs) and one patient died as a result of an unrelated event. Patient-reported outcome measures and complications were collected through completion of patient and doctor questionnaires and clinical examination. Radiographic assessment of angular correction, joint congruity, and osteoarthritis was undertaken using standard radiology software. PAO survivorship was defined as nonconversion to THA and is presented using worst-case analysis. The loss-to-followup quotient-number of patients lost to followup divided by the number of a patients converted to THA-was calculated to determine quality of followup and reliability of survivorship data.

RESULTS

The median preoperative Harris hip scores of 58 (range, 20-96) improved postoperatively to 78 (range, 33-100), 86 (range, 44-100), 87 (range, 55-97), and 80 (range, 41-97) at 1, 5, 10, and 14 years, respectively. Sink Grade III complications at 12 months included four relating to the PAO and one relating to the concomitant femoral procedure. The median lateral center-edge angle correction achieved was 22° (range, 3°-50°) and the median correction of acetabular index was 19° (range, 3°-37°). Osteoarthritis progressed from a preoperative mean Tönnis grade of 0.6 (median, 1; range, 0-2) to a postoperative mean of 0.9 (median, 1; range, 0-3). Six hips underwent conversion to THA: five for progression of osteoarthritis and one for impingement. At 12-year followup, survivorship of PAO was 94% (95% confidence interval [CI], 85%-98%) and survivorship with worst-case analysis was 90% (95% CI, 79%-96%). The loss-to-followup quotient for this study was low, calculated to be 0.3.

CONCLUSIONS

When PAO is performed using a structured process of mentoring under the guidance of an expert, one low-volume surgeon in a geographically isolated region achieved good patient-reported outcomes, a low incidence of complications at 12 months, satisfactory radiographic outcomes, and high survivorship. A structured distant-mentorship program may be a suitable method for initially learning and continuing to perform low-volume complex surgery in a geographically isolated region.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Comparable perioperative outcomes, long-term outcomes, and quality of life in a retrospective analysis of ulcerative colitis patients following 2-stage versus 3-stage proctocolectomy with ileal pouch-anal anastomosis

PURPOSE

Many surgeons assume 3-stage ileal pouch-anal anastomosis (IPAA) is safer than 2-stage IPAA in patients with active ulcerative colitis (UC), although recent data suggest outcomes are comparable. This study aimed to compare perioperative complications, late complications, and functional outcomes after 2- versus 3-stage IPAA in patients with active UC.

METHODS

A retrospective review was conducted of patients who underwent 2- or 3-stage IPAA for active UC from 2000 to 2015 in a high-volume institution. Patients completed quality-of-life surveys 6 months following ileostomy reversal. Perioperative and late complications were recorded. Outcomes were compared with the Fisher exact test, and multivariable logistic regression was used to adjust for potential confounders.

RESULTS

We identified 212 patients who underwent 2- or 3-stage IPAA for active UC, of whom 157 patients (74.1%) underwent 2-stage procedures and 55 (25.9%) underwent 3-stage procedures. More patients undergoing 2-stage procedures were taking immunomodulators preoperatively (46.3% vs. 23.1%, p = 0.01), but there was no difference in use of steroids (p = 0.09) or biologic agents (p = 0.85). Three-stage procedures were more likely to be urgent (78.6% vs. 30.2%, p < 0.001). There were no differences in perioperative complications (p = 0.50), anastomotic leak (p = 0.94), pouchitis (p = 0.45), pouch failure (p = 0.46), perceived quality of life (p = 0.68), number of bowel movements per day (p = 0.27), or sexual satisfaction (p = 0.21) between the 2- and 3-stage groups.

CONCLUSIONS

Patients undergoing 2-stage compared to 3-stage IPAA for active ulcerative colitis have comparable outcomes and quality of life following ileostomy reversal. Two-stage IPAA appears to be safe and appropriate, even in high-risk patients.

Hospital and surgeon variation in positive circumferential resection margin among rectal cancer patients

BACKGROUND

The objective of this study was to evaluate variation in positive CRM at the surgeon and hospital levels and assess impact on disease-specific survival.

METHODS

Patients with stage I-III rectal cancer were identified in New York State. Bayesian hierarchical regressions estimated observed-to-expected (O/E) ratios for each surgeon/hospital. Competing-risks analyses estimated disease-specific survival among patients who were treated by surgeons/hospitals with O/E > 1 compared to those with O/E ratio ≤ 1.

RESULTS

Among 1,251 patients, 208 (17%) had a positive CRM. Of the 345 surgeons and 118 hospitals in the study, 99 (29%) and 48 (40%) treated a higher number of patients with CRM than expected, respectively. Patients treated by surgeons with O/E > 1 (HR = 1.38, 95% CI = 1.16, 1.67) and those treated at hospitals with O/E > 1 (HR = 1.44, 95% CI = 1.11, 1.85) had worse disease-specific survival.

DISCUSSION

Surgeon and hospital performance in positive CRM is associated with worse prognosis suggesting opportunities to enhance referral patterns and standardize care.

Trends and outcomes of sphincter-preserving surgery for rectal cancer: a national cancer database study

PURPOSE

Previous studies have shown that sphincter-preserving surgery is associated with better quality of life in postsurgical rectal cancer patients. However, the factors predicting the likelihood of undergoing sphincter-preserving surgery have not been well-described. The aim of this study was to report the factors that determined the likelihood of undergoing sphincter-preserving surgery.

METHODS

Characteristics of 24,018 rectal cancer patients undergoing sphincter-preserving surgery and abdominoperineal resection diagnosed from 2008 to 2012 from the National Cancer Database were investigated retrospectively for rate, pattern, and differences in mortality. Cox proportional hazards models were used to calculate hazard ratios for assessing mortality. Odds ratios were calculated using logistic regressions models for outcome sphincter-preserving surgery.

RESULTS

Eighteen thousand four hundred fifty-two (77%) patients had sphincter-preserving surgery. Majority of sphincter-preserving surgery patients were aged < 70 (74%), had private insurance (52%), and got treatment at a comprehensive community cancer program (54%). Multivariable analysis showed that patients with age ≥ 70 (OR 0.87, 95% CI 0.80-0.95), male gender (OR 0.90, 95% CI 0.84-0.96), having Medicare (OR 0.83, 95% CI 0.76-0.90), Medicaid (OR 0.72, 95% CI 0.63-0.81), and poorly differentiated grade (OR 0.78, 95% CI 0.71-0.85) were less likely to undergo sphincter-preserving surgery. Multivariable analysis showed that patients having abdominoperineal resection have higher likelihood of mortality than sphincter-preserving surgery (HR 1.26, 95% CI 1.16-1.36).

CONCLUSIONS

We were able to identify several patient and tumor-related factors impacting the likelihood of undergoing sphincter-preserving surgery. Patients undergoing non-sphincter sparing surgery had a higher mortality that sphincter preservation.

Hand Surgeons Performing More Open Carpal Tunnel Releases Do Not Show Better Patient Outcomes

BACKGROUND

Although previous studies have shown that more experienced surgeons have better patient outcomes following a variety of procedures, in hand surgery and carpal tunnel release in particular, this relation remains unproven. The authors assessed whether there is an association between surgeon volume and patient outcomes following open carpal tunnel release.

METHODS

Patients who underwent carpal tunnel release between 2011 and 2015 at outpatient hand surgery clinics in The Netherlands were included. Surgeon annual volume was defined as the average number of carpal tunnel releases performed per year per participating surgeon over the study period. Primary outcome measures were the Symptom Severity Scale and Functional Status Scale of the Boston Carpal Tunnel Questionnaire 6 months postoperatively. Multilevel random intercept linear regression analyses were performed to assess whether there was an association between surgeon annual volume and outcome measures, with adjustment for patient characteristics, concomitant procedures, and intake score on the Boston Carpal Tunnel Questionnaire.

RESULTS

A total of 1345 patients were included, operated on by 17 surgeons. Median annual surgeon volume was 75 (interquartile range, 50 to 149). Only 0.5 to 0.6 percent of the total variance in patient outcome on the Boston Carpal Tunnel Questionnaire could be explained by random differences between surgeons. The authors did not find an association between annual surgeon volume and outcome measures 6 months postoperatively (Symptom Severity Scale: β = 0.000; 95 percent CI, -0.001 to 0.001; and Functional Status Scale: β = 0.000; 95 percent CI, -0.001 to 0.001).

CONCLUSION

In the authors' sample of highly specialized hand surgeons operating in high-volume centers, they found no differences in outcome between high- and low-volume surgeons.

Laparoscopic intersphincteric resection with intraoperative radiotherapy using low-energy X-rays for locally advanced ultra-low rectal cancer

Background

In order to overcome the shortcomings of laparoscopic intersphincteric resection (Lap ISR), an alternative method of delivering intraoperative radiotherapy by Intrabeam X-rays radiotherapy system (XRS) is proposed in this paper. Intrabeam XRS is a device that uses low-energy X-rays source generated by a mobile controller unit, which is featured in accurate irradiation, reduced complications, and less exposure. The purpose of this study is to discuss the feasibility of Lap ISR with intra-operative radiotherapy using low-energy X-rays for locally advanced ultra-low rectal cancer in Asian woman. This novel proposed method will greatly increase the anus preserving probability and improved the quality of life.

Methods

A 53-year-old woman diagnosed with rectal adenocarcinoma had a strong desire to preserve the anal function and presented at the Jilin University Second Hospital, Jilin, China. The tumor’s size was 4 cm × 3 cm. It was located 2 cm from the anus merge and invaded the levator ani muscle. Preoperative clinical staging was T4N1M0 and could be reached R0 resection. After the consent form was signed by the patient, Lap ISR combined with the applicator put through the anus (natural orifice) to the tumor bed was performed and prophylactic ileostomy synchronized the anastomosis. Patient only received 1-cycle chemotherapy regimen of oxaliplatin with capecitabine postoperatively due to personal reasons. Pre- or postoperative radiotherapy was not given.

Results

After clinical follow-up, until now, there is not any sign of local recurrence. Anus function and short-term complications are acceptable. The short-term effect is satisfying and we look forward to further assess the long-term effect.

Conclusion

Laparoscopic intersphincteric resection with IORT using low-energy X-rays for the patients with late-stage ultra-low rectal cancer could provide an opportunity of preserving the anus function, and it is feasible for the selected patients.

Trial registration

Retrospectively registered; Trial registration: NCT03393234; Registered time: 05 January 2017.

Reliability and validity assessment of administrative databases in measuring the quality of rectal cancer management

PURPOSE

Measurement and monitoring of the quality of care using a core set of quality measures are increasing in health service research. Although administrative databases include limited clinical data, they offer an attractive source for quality measurement. The purpose of this study, therefore, was to evaluate the completeness of different administrative data sources compared to a clinical survey in evaluating rectal cancer cases.

METHODS

Between May 2012 and November 2014, a clinical survey was done on 498 Lombardy patients who had rectal cancer and underwent surgical resection. These collected data were compared with the information extracted from administrative sources including Hospital Discharge Dataset, drug database, daycare activity data, fee-exemption database, and regional screening program database. The agreement evaluation was performed using a set of 12 quality indicators.

RESULTS

Patient complexity was a difficult indicator to measure for lack of clinical data. Preoperative staging was another suboptimal indicator due to the frequent missing administrative registration of tests performed. The agreement between the 2 data sources regarding chemoradiotherapy treatments was high. Screening detection, minimally invasive techniques, length of stay, and unpreventable readmissions were detected as reliable quality indicators. Postoperative morbidity could be a useful indicator but its agreement was lower, as expected.

CONCLUSIONS

Healthcare administrative databases are large and real-time collected repositories of data useful in measuring quality in a healthcare system. Our investigation reveals that the reliability of indicators varies between them. Ideally, a combination of data from both sources could be used in order to improve usefulness of less reliable indicators.

Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve

BACKGROUND

Transanal total mesorectal excision (TaTME) provides an excellent view of the resection margins for rectal cancer from below, but is challenging due to few anatomical landmarks. During implementation of this technique, patient safety and optimal outcomes need to be ensured. The aim of this study was to evaluate the learning curve of TaTME in patients with rectal cancer in order to optimize future training programs.

METHODS

All consecutive patients after TaTME for rectal cancer between February 2012 and January 2017 were included in a single-center database. Influence of surgical experience on major postoperative complications, leakage rate and operating time was evaluated using cumulative sum charts and the splitting model. Correction for potential case-mix differences was performed.

RESULTS

Over a period of 60 months, a total of 138 patients were included in this study. Adjusted for case-mix, improvement in postoperative outcomes was clearly seen after the first 40 patients, showing a decrease in major postoperative complications from 47.5 to 17.5% and leakage rate from 27.5 to 5%. Mean operating time (42 min) and conversion rate (from 10% to zero) was lower after transition to a two-team approach, but neither endpoint decreased with experience. Readmission and reoperation rates were not influenced by surgical experience.

CONCLUSIONS

The learning curve of TaTME affected major (surgical) postoperative complications for the first 40 patients. A two-team approach decreased operative time and conversion rate. When implementing this new technique, a thorough teaching and supervisory program is recommended to shorten the learning curve and improve the clinical outcomes of the first patients.

Population-level surgical outcomes for infantile hypertrophic pyloric stenosis

OBJECTIVES

Determine national outcomes for pyloromyotomy; how these are affected by: (i) surgical approach (open/laparoscopic), or (ii) centre type/volume and establish potential benchmarks of quality.

METHODS

Hospital Episode Statistics data were analysed for admissions 2002-2011. Data presented as median (IQR).

RESULTS

9686 infants underwent pyloromyotomy (83% male). Surgery was performed in 22 specialist (SpCen) and 39 nonspecialist centres (NonSpCen). The proportion treated in SpCen increased linearly by 0.4%/year (r=0.76, p=0.01). Annual case volume in SpCen vs. NonSpCen was 40 (24-53) vs. 1 (0-3). Time to surgery was shorter in SpCen (1day [1, 2] vs. 2 [1-3]), but total stay equal (4days [3-6]). 137 (1.4%) had complications requiring reoperation (wound problem 0.6%; repeat pyloromyotomy 0.5% and perforation, bleeding or obstruction 0.2%): pooled rates were similar between SpCen and NonSpCen (1.4% vs. 1.6%, p=0.52). Three NonSpCen had >5% reoperations (within 99.8% C.I. as small denominators). There was no relationship between reoperation and centre volume. Laparoscopic pyloromyotomy had increased risk of repeat pyloromyotomy (OR 2.28 [1.14-4.57], p=0.029).

CONCLUSIONS

Pyloric stenosis surgery shifted from centres local to patients, but outcomes were unaffected by centre type/volume. Modest reported benefits of laparoscopy appear offset by increased reoperations. Quality benchmarks could be set for reoperation <4%.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

Level III.

[Effect of Thoracic Surgeons on Lung Cancer Patients' Survival]

BACKGROUND

Surgeons are the direct decision-makers and performers in the surgical treatment of patients with lung cancer. Whether the differences among doctors affect the survival of patients is unclear. This study analyzed the five-year survival rates of different thoracic surgeries in patients undergoing surgery to assess the physician's impact and impact.

METHODS

A retrospective analysis of five years between 2002-2007 in the Department of Thoracic Surgery, Cancer Hospital, Chinese Academy of Medical Sciences, for surgical treatment of lung cancer patients. According to different surgeons grouping doctors to compare the basic information of patients, surgical methods, short-term results and long-term survival differences.

RESULTS

A total of 712 patients treated by 11 experienced thoracic surgeons were included in this study. The patients have nosignificant difference with gender, age, smoking, pathological type between groups. There were significant differences in clinical staging, surgery type, operation time, blood transfusion rate, number of lymph node dissection, palliative resection rate, postoperative complications and perioperative mortality. There was a significant difference in five-year survival rates among patients treated by different doctors. This difference can be seen in all clinical stage analyzes with consistency. In the multivariate analysis, it was suggested that surgeon was an independent factor influencing the prognosis of patients.

CONCLUSIONS

Thoracic surgeon has a significant effect on the therapeutic effect of lung cancer patients.

Systematic review and a meta-analysis of hospital and surgeon volume/outcome relationships in colorectal cancer surgery

BACKGROUND

Numerous hospitals worldwide are considering setting minimum volume standards for colorectal surgery. This study aims to examine the association between hospital and surgeon volume on outcomes for colorectal surgery.

METHODS

Two investigators independently reviewed six databases from inception to May 2016 for articles that reported outcomes according to hospital and/or surgeon volume. Eligible studies included those in which assessed the association hospital or surgeon volume with outcomes for the surgical treatment of colon and/or rectal cancer. Random effects models were used to pool the hazard ratios (HRs) for the association between hospital/surgeon volume with outcomes.

RESULTS

There were 47 articles pooled (1,122,303 patients, 9,877 hospitals and 9,649 surgeons). The meta-analysis demonstrated that there is a volume-outcome relationship that favours high volume facilities and high volume surgeons. Higher hospital and surgeon volume resulted in reduced 30-day mortality (HR: 0.83; 95% CI: 0.78-0.87, P<0.001 & HR: 0.84; 95% CI: 0.80-0.89, P<0.001 respectively) and intra-operative mortality (HR: 0.82; 95% CI: 0.76-0.86, P<0.001 & HR: 0.50; 95% CI: 0.40-0.62, P<0.001 respectively). Post-operative complication rates depended on hospital volume (HR: 0.89; 95% CI: 0.81-0.98, P<0.05), but not surgeon volume except with respect to anastomotic leak (HR: 0.59; 95% CI: 0.37-0.94, P<0.01). High volume surgeons are associated with greater 5-year survival and greater lymph node retrieval, whilst reducing recurrence rates, operative time, length of stay and cost. The best outcomes occur in high volume hospitals with high volume surgeons, followed by low volume hospitals with high volume surgeons.

CONCLUSIONS

High volume by surgeon and high volume by hospital are associated with better outcomes for colorectal cancer surgery. However, this relationship is non-linear with no clear threshold of effect being identified and an apparent ceiling of effect.