Does the subspecialty of the surgeon performing primary colonic resection influence the outcome of patients with hepatic metastases referred for resection?

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.

Rural populations have equal surgical and survival outcomes in metastatic colorectal cancer

OBJECTIVE

Previous Australian studies have suggested poorer survival of patients with colorectal cancer in remote areas. To date no studies have assessed the geographic disparity in patients with metastatic disease. This retrospective cohort study looks at geographic differences in the surgical care and survival of patients with metastatic colorectal disease. The paper utilises data from the South Australian Clinical Registry for Metastatic Colorectal Cancer (SACRMCC).

DESIGN, PARTICIPANTS, INTERVENTIONS AND MAIN OUTCOME MEASURES

Data on patients' socio-economic status, primary and metastatic tumour characteristics, treatment and survival was extracted from the SACRMCC database. A binomial model analysis was used to identify geographical differences in the surgical treatment of patients and a Cox proportional hazards model was used to identify any geographic differences in survival.

RESULTS

The findings showed no differences in the diagnosis of liver metastases or provision of liver surgery between geographic areas, however there was a reduced likelihood of liver surgery with increasing age. The median overall survival rate, from the date of diagnosis of metastatic disease, was 20.0 months and the distribution by geographic remoteness was 19.1 months, 20.2 months, 22.0 months and 20.4 months in Major Cities, Inner Regional, Outer Regional and Remote areas respectively. This was not statistically significant.

CONCLUSION

Overall, there was no evidence of a geographical disparity in the diagnosis, surgical treatment or survival in metastatic colorectal cancer. This may be due to the shift toward centralising surgical care in South Australia. Nevertheless, there remains a need to improve the uptake of surgical care in the growing elderly population.

Surgeon specialization impacts the management but not outcomes of acute complicated diverticulitis

BACKGROUND

The management and outcomes of patients receiving nonelective surgical treatment of acute complicated diverticulitis by surgeon specialization have received little attention.

METHODS

A retrospective review was performed of consecutive patients with acute complicated diverticulitis who underwent surgery from 2006 to 2013. Patients were analyzed based on surgeon specialty: general surgery (GS) or colorectal surgery (CRS).

RESULTS

One hundred fifteen patients met criteria for study; 62 patients in the CRS and 53 in the GS group. GS were more likely to perform Hartmann's procedures or primary anastomosis and less likely to perform primary anastomosis with diverting ileostomy than CRS. There were no differences between groups for any outcome measures on univariate analysis. CRS patients had shorter operative time (P = .001) and length of stay (P ≤ .001) for stoma reversal procedures. Surgeon specialization was not associated with morbidity, readmission, or length of stay on multivariate analysis.

CONCLUSIONS

Although surgical management differed significantly between CRS and GS, comparable outcomes were observed at the index hospital admission.

Implementing chemoradiation treatment for patients with cervical cancer in a comprehensive cancer center community oncology practice

In 1999, the National Cancer Institute broadcast a clinical alert promoting the coadministration of radiation therapy and chemotherapy for women with advanced-stage cervical cancer. Since then, patterns of care studies suggest that implementation of these guidelines has been slow. We tested the hypothesis that women with advanced-stage cervical cancer were just as likely to receive coadministration of radiation therapy and chemotherapy at community oncology practices as at hospital-based cancer centers. Between January 2000 and December 2009, 198 women underwent radiation therapy for advanced-stage cervical cancer at treatment centers within a comprehensive cancer center community oncology practice. The majority, 140 (71%), received concurrent radiation therapy and cisplatin chemotherapy. Relative chemotherapy dose, relative time of chemotherapy administration, and relative dose intensity of chemotherapy were similar among the hospital-based comprehensive cancer center and the affiliated community oncology practices. This finding attests to the successful implementation of chemoradiotherapy for cervical cancer in a large networked oncology practice.

Development of Spontaneous Bacterial Peritonitis after Extended Hepatic Resection in a Patient without Evidence of Liver Cirrhosis

Hilar cholangiocarcinomas are often treated with liver resections. Hepatic dysfunction and infection are common postoperative complications. Although secondary bacterial peritonitis due to abdominal abscess or perforation is common, we report herein the first case of spontaneous bacterial peritonitis after hepatic resection. A 61-year-old male patient without underlying liver disease was diagnosed as having a Klatskin tumor, and a right trisectionectomy with caudate lobectomy was performed. From postoperative days 18-28, the patient gained 4.1 kg as ascites developed, and showed evidence of hepatic insufficiency with prolonged prothrombin time and jaundice. Computed tomography, performed at postoperative day 28 when fever had developed, showed only ascites without bowel perforation or abscess. When paracentesis was performed, the serum-ascites albumin gradient was 2.3 g/dL, indicating portal hypertension, and the ascites' polymorphonuclear cell count was 1,156/mm(3). Since the clinical, laboratory, and image findings were compatible with spontaneous bacterial peritonitis, we started empirical antibiotics without additional intervention. Follow-up analysis of the ascites after 48 hours revealed that the polymorphonuclear cell count had decreased markedly to 108/mm(3); the fever and leukocytosis had also improved. After 2 weeks of antibiotic treatment, the patient recovered well, and was discharged without any problem.

Staged or simultaneous resection of synchronous liver metastases from colorectal cancer--a systematic review

OBJECTIVE

A systematic review of the literature was undertaken to estimate the differences in length of hospital stay, morbidity, mortality and long-term survival between staged and simultaneous resection of synchronous liver metastases from colorectal cancer to determine the level of evidence for recommendations of a treatment strategy.

METHOD

A Pub-med search was undertaken for studies comparing patients with synchronous liver metastases, who either had a combined or staged resection of metastases. Twenty-six were considered and 16 were included based on Newcastle Ottawa Quality Assessment Scale. All studies were retrospective and had a general bias, because the staged procedure was significantly more often undertaken in patients with left-sided primary tumours and larger, more numerous and bi-lobar metastases. Analyses of primary outcomes were performed using the random effects model.

RESULTS

For the reason of the heterogeneity of the observational studies, no odds ratios were calculated. In 11 studies, there was a tendency towards a shorter hospital stay in the synchronous resection group. Fourteen studies compared total perioperative morbidity and lower morbidity was observed in favour of a combined resection. Fifteen studies compared perioperative mortality, which seemed to be lower with the staged approach. Eleven studies compared 5-year survival, which seemed to be similar in the two groups.

CONCLUSION

No randomized controlled trials were identified, and hence a meta-analysis was not performed. The evidence level is II to III with grade C recommendations. Synchronous resections can be undertaken in selected patients, provided that surgeons specialized in colorectal and hepatobiliary surgery are available.

Surgeon specialty and operative mortality with lung resection

OBJECTIVE

We sought to examine the effect of subspecialty training on operative mortality following lung resection.

SUMMARY BACKGROUND DATA

While several different surgical subspecialists perform lung resection for cancer, many believe that this procedure is best performed by board-certified thoracic surgeons.

METHODS

Using the national Medicare database 1998 to 1999, we identified patients undergoing lung resection (lobectomy or pneumonectomy) for lung cancer. Operating surgeons were identified by unique physician identifier codes contained in the discharge abstract. We used the American Board of Thoracic Surgery database, as well as physician practice patterns, to designate surgeons as general surgeons, cardiothoracic surgeons, or noncardiac thoracic surgeons. Using logistic regression models, we compared operative mortality across surgeon subspecialties, adjusting for patient, surgeon, and hospital characteristics.

RESULTS

Overall, 25,545 Medicare patients underwent lung resection, 36% by general surgeons, 39% by cardiothoracic surgeons, and 25% by noncardiac thoracic surgeons. Patient characteristics did not differ substantially by surgeon specialty. Adjusted operative mortality rates were lowest for cardiothoracic and noncardiac thoracic surgeons (7.6% general surgeons, 5.6% cardiothoracic surgeons, 5.8% noncardiac thoracic surgeons, P = 0.001). In analyses restricted to high-volume surgeons (>20 lung resections/y), mortality rates were lowest for noncardiac thoracic surgeons (5.1% noncardiac thoracic, 5.2% cardiothoracic, and 6.1% general surgeons) (P < 0.01 for difference between general surgeons and thoracic surgeons). In analyses restricted to high-volume hospitals (>45 lung resections/y), mortality rates were again lowest for noncardiac thoracic surgeons (5.0% noncardiac thoracic, 5.3% cardiothoracic, and 6.1% general surgeons) (P < 0.01 for differences between all 3 groups).

CONCLUSIONS

Operative mortality with lung resection varies by surgeon specialty. Some, but not all, of this variation in operative mortality is attributable to hospital and surgeon volume.

The value of residual liver volume as a predictor of hepatic dysfunction and infection after major liver resection

BACKGROUND AND AIMS

Major liver resection incurs a risk of postoperative liver dysfunction and infection and there is a lack of objective evidence relating residual liver volume to these complications.

PATIENTS AND METHODS

Liver volumetry was performed on computer models derived from computed tomography (CT) angioportograms of 104 patients with normal synthetic liver function scheduled for liver resection. Relative residual liver volume (%RLV) was calculated as the relation of residual to total functional liver volume and related to postoperative hepatic dysfunction and infection. Receiver operator characteristic curve analysis was undertaken to determine the critical %RLV predicting severe hepatic dysfunction and infection. Univariate analysis and multivariate logistic regression analysis were performed to delineate perioperative predictors of severe hepatic dysfunction and infection.

RESULTS

The incidence of severe hepatic dysfunction and infection following liver resection increased significantly with smaller %RLV. A critical %RLV of 26.6% was identified as associated with severe hepatic dysfunction (p<0.0001). Additionally, body mass index (BMI), operating time, and intraoperative blood loss were significant prognostic indicators for severe hepatic dysfunction. It was not possible to predict the individual risk of postoperative infection precisely by %RLV. However, in patients undergoing major liver resection, infection was significantly more common in those who developed postoperative severe hepatic dysfunction compared with those who did not (p=0.030).

CONCLUSIONS

The likelihood of severe hepatic dysfunction following liver resection can be predicted by a small %RLV and a high BMI whereas postoperative infection is more related to liver dysfunction than precise residual liver volume. Understanding the relationship between liver volume and synthetic and immune function is the key to improving the safety of major liver resection.

Early Stress Protein Gene Expression in a Human Model of Ischemic Preconditioning

Intermittent clamping of the porta hepatis (PHC) is commonly performed during liver surgery to reduce blood loss and has been reported to precondition livers resulting in improved outcome after liver surgery (humans) and transplantation (animals). This study investigated the early expression of cytoprotective stress proteins during ischemia-reperfusion induced by PHC. Liver samples were taken before and after each event in a two-cycle ischemia-reperfusion protocol using 15 minutes of PHC followed by 5 minutes of reperfusion. Liver tissue was analyzed by real-time polymerase chain reaction for heme oxygenase (HO)-1 and heat shock protein (HSP)-70 mRNA expression. Extracted protein was analyzed by Western blot for HO-1, and HSP-70 and nuclear extracts were analyzed by DNA mobility shift assay for hypoxia inducible factor (HIF)-1alpha and heat shock factor (HSF)-1. Within minutes of PHC, significant increases in HO-1 mRNA expression were detected, and these were maintained throughout the protocol (P < 0.01). Protein expression of HO-1 (P < 0.03) and HO-1 activity (P < 0.05) were similarly increased between the start and end of ischemia- reperfusion (40 minutes). Binding of active HIF-1alpha to its consensus sequence was increased within 15 minutes of the start of the ischemia-reperfusion cycle. Although evidence of the transcriptionally active form of HSF-1 was detected at the same time point, this was not reflected in measurable changes in HSP-70 mRNA or protein. In conclusion, expression of the cytoprotective protein HO-1 is significantly up-regulated in the liver within minutes of PHC. It is likely that HO-1 contributes to the early protective effects of ischemic preconditioning.

Patient outcomes for segmental colon resection according to surgeon's training, certification, and experience

Background. We examined patient outcomes for colon resection to determine if they varied according to surgeon-specific factors including: (1) American Board of Surgery (ABS) certification, (2) colorectal surgery subspecialty certification, (3) site of residency training (university-based vs nonuniversity-based), and (4) years of experience since ABS certification. Methods. We performed a retrospective study of 15,427 admissions of northern Illinois residents who underwent segmental colon resection as their primary operation from 1994 to 1997 at 76 nonfederal Illinois hospitals. There were 514 surgeons. Main outcome measures were inpatient mortality, complications, and hospital length of stay. Regression analyses with mixed effects were used to assess the significance of surgeon-specific variables as a predictor of outcomes after risk adjustment for patient age, gender, emergency admission, surgeon volume, hospital site, colon pathology, and comorbid illnesses. Results. ABS-certification was associated with reduced mortality and morbidity. Increasing years of experience was associated with reduced mortality. Colorectal surgery certification and site of residency training did not significantly affect outcomes. Conclusion. We were able to link patient outcomes with surgeon's training. Certification was an important determinant of patient outcomes for colon resection. Increasing surgeon experience also had a favorable effect on outcomes, suggesting a continued learning curve subsequent to residency. (Surgery 2002;132:663-72).

The value of specialization--is there an outcome difference in the management of fistulas complicating diverticulitis

PURPOSE

The value of specialization has frequently been challenged by many health care institutions and providers. This review was conducted to determine whether there were any outcome differences in the management of fistulas complicating diverticulitis.

METHODS

We conducted an historical cohort study using hospital charts of all cases of fistulas complicating diverticulitis that were operated on in four university-affiliated hospitals between 1975 and 1995. There were 122 patients, with 37 under the care of fully trained colorectal surgeons and 85 under the care of general surgeons.

RESULTS

There were no significant differences in patient demographics, preoperative comorbidities, or the number of preoperative diagnostic investigations between the two groups. The colorectal surgeons performed more intraoperative ureteral stenting (Colorectal Surgery 55.5 percent vs. General Surgery 24.4 percent, P = 0.001). The general surgeons performed more initial diverting Hartmann's and colostomy procedures (Colorectal Surgery 5.4 percent vs. General Surgery 27 percent, P = 0.013). The patients in the General Surgery group had longer preoperative lengths of stay (median Colorectal Surgery 3 (range, 1-28) days vs. General Surgery 8 (range, 0-29) days; P < 0.001), longer postoperative lengths of stay (median Colorectal Surgery 11 (range, 5-40) days vs. General Surgery 14 (range, 2-80) days; P = 0.001), and longer total lengths of stay (median Colorectal Surgery 14 (range, 6-62) days vs. General Surgery 24 (range, 6-100) days; P < 0.001). The patients in the General Surgery group experienced a higher rate of wound infections (Colorectal Surgery 5.4 percent vs. General Surgery 12.9 percent), and a larger proportion of them experienced complications (Colorectal Surgery 27 percent vs. General Surgery 41.2 percent).

CONCLUSIONS

We conclude that specialization in colon and rectal surgery contributed to an improved outcome, with a lower rate of diverting procedures, a shorter hospital stay, and a lower rate of complications.

Virtual hepatic resection using three-dimensional reconstruction of helical computed tomography angioportograms

OBJECTIVE

To establish the accuracy of virtual hepatic resection using three-dimensional (3D) models constructed from computed tomography angioportography (CTAP) images in determining the liver volume (LV) resected during resectional liver surgery.

SUMMARY BACKGROUND DATA

The ability to measure LV before surgery could be useful in determining the extent and nature of hepatic resection. Accurate assessment of LV and an estimate of liver function may also allow prediction of postoperative liver failure in patients undergoing resection, assist in volume-enhancing embolization procedures, help with the planning of staged hepatic resection for bilobar disease, and aid in selection of living-related liver donors.

METHODS

A retrospective study was conducted involving 27 patients scheduled for liver resection. Using mapping technology, 3D models were constructed from helical CTAP images. From these 3D models, tumor volume, total LV, and functional LV were calculated and were compared with body weight. The 3D liver models were subjected to a virtual hepatectomy along established anatomical planes, and the resected LV was calculated. The resected volume predicted by radiologists (unaware of the actual weight) was compared with the specimen weight measured after actual surgical resection.

RESULTS

A significant correlation was found between body weight and functional LV but not total LV. The computer prediction of resected LV after virtual hepatectomy of 3D models compared well with resected liver weight.

CONCLUSION

Virtual hepatectomy of 3D CTAP reconstructed images provides an accurate prediction of liver mass removed during subsequent hepatic resection. The authors intend to combine this technology with an assessment of liver function to attempt to predict patients at risk for liver failure after hepatic resection.