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Gooiker GA, van Gijn W, Wouters MWJM, Post PN, van de Velde CJH, Tollenaar RAEM. Systematic review and meta-analysis of the volume-outcome relationship in pancreatic surgery. Br J Surg 2011; 98:485-94. [PMID: 21500187 DOI: 10.1002/bjs.7413] [Citation(s) in RCA: 262] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND Many studies have shown lower mortality and higher survival rates after pancreatic surgery with high-volume providers, suggesting that centralization of pancreatic surgery can improve outcomes. The methodological quality of these studies is open to question. This study involves a systematic review of the volume-outcome relationship for pancreatic surgery with a meta-analysis of studies considered to be of good quality. METHODS A systematic search of electronic databases up to February 2010 was performed to identify all primary studies examining the effects of hospital or surgeon volume on postoperative mortality and survival after pancreatic surgery. All articles were critically appraised with regard to methodological quality and risk of bias. After strict inclusion, meta-analysis assuming a random-effects model was done to estimate the effect of higher surgeon or hospital volume on patient outcome. RESULTS Fourteen studies were included in the meta-analysis. The results showed a significant association between hospital volume and postoperative mortality (odds ratio 0.32, 95 per cent confidence interval 0.16 to 0.64), and between hospital volume and survival (hazard ratio 0.79, 0.70 to 0.89).The effect of surgeon volume on postoperative mortality was not significant (odds ratio 0.46, 0.17 to 1.26). Significant heterogeneity was seen in the analysis of hospital volume and mortality. Sensitivity analysis showed no correlation with the extent of risk adjustment or study country; after removing one outlier study, the result was homogeneous. The data did not suggest publication bias. CONCLUSION There was a consistent association between high hospital volume and lower postoperative mortality rates with improved long-term survival.
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van Geel AN, Wouters MWJM, Lans TE, Schmitz PIM, Verhoef C. Chest wall resection for adult soft tissue sarcomas and chondrosarcomas: analysis of prognostic factors. World J Surg 2011; 35:63-9. [PMID: 20857106 PMCID: PMC3006644 DOI: 10.1007/s00268-010-0804-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Wide resection with tumor-free margins is necessary in soft-tissue sarcomas to minimize local recurrence and to contribute to long-term survival. Information about treatment outcome and prognostic factors of adult sarcoma requiring chest wall resection (CWR) is limited. Methods Sixty consecutive patients were retrospectively studied for overall survival (OS), local recurrence-free survival (LRFS), and disease-free survival (DFS). Twenty-one prognostic factors regarding survival were analyzed by univariate analysis using the Kaplan-Meier method and the log-rank test. Results With a median survival of 2.5 years, the OS was 46% (33%) at 5 (10) years. The LRFS was 64% at 5 and 10 years, and the DFS was 30% and 25% at 5 and 10 years. At the end of the study period, 26 patients (43%) were alive, of which 20 patients (33%) had no evidence of disease and 40 patients (67%) had no chest wall recurrence. In the group of 9 patients with a radiation-induced soft-tissue sarcoma, the median survival was 8 months. Favorable outcome in univariate analysis in OS and LRFS applied for the low-grade sarcoma, bone invasion, and sternal resection. For OS only, age below 60 years and no radiotherapy were significant factors contributing to an improved survival. CWR was considered radical (R0) at the pathological examination in 43 patients. There were 52 patients with an uneventful recovery. There was one postoperative death. Conclusions CWR for soft-tissue sarcoma is a safe surgical procedure with low morbidity and a mortality rate of less than 1%. With proper patient selection acceptable survival can be reached in a large group of patients. Care must be given to patients with radiation-induced soft-tissue sarcoma who have a significantly worse prognosis.
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Gooiker GA, van der Geest LGM, Wouters MWJM, Vonk M, Karsten TM, Tollenaar RAEM, Bonsing BA. Quality improvement of pancreatic surgery by centralization in the western part of the Netherlands. Ann Surg Oncol 2011; 18:1821-9. [PMID: 21544657 PMCID: PMC3115061 DOI: 10.1245/s10434-010-1511-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Indexed: 02/06/2023]
Abstract
Background Centralization of pancreatic surgery in high-volume hospitals is under debate in many countries. In the western part of the Netherlands, the professional network of surgical oncologists agreed to centralize all pancreatic surgery from 2006 in two high-volume hospitals. Our aim is to evaluate whether centralization of pancreatic surgery has improved clinical outcomes and has changed referral patterns. Materials and Methods Data of the Comprehensive Cancer Centre West (CCCW) of all 249 patients who had a resection for suspected pancreatic cancer between 1996 and 2008 in the western part of the Netherlands were analyzed. Multivariable modeling was used to evaluate survival for 3 time periods; 1996–2000, 2001–2005 (introduction of quality standards), and 2006–2008 (after centralization). In addition, the differences in referral pattern were analyzed. Results From 2006, all pancreatic surgery was centralized in 2 hospitals. The 2-year survival rate increased after centralization from 39% to 55% (P = .09) for all patients who had a pancreatic resection for pancreatic cancer. After adjustment for age, tumor location, stage, histology, and adjuvant treatment, the latter period was significantly associated with improved survival (hazard ratio [HR] 0.50; 95% confidence interval [95% CI] 0.34–0.73). Conclusions Centralization of pancreatic surgery was successful and has resulted in improved clinical outcomes in the western part of the Netherlands, demonstrating the effectiveness of centralization.
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van Leersum NJ, Kolfschoten NE, Klinkenbijl JHG, Tollenaar RAEM, Wouters MWJM. ['Clinical auditing', a novel tool for quality assessment in surgical oncology]. NEDERLANDS TIJDSCHRIFT VOOR GENEESKUNDE 2011; 155:A4136. [PMID: 22085580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To determine whether systematic audit and feedback of information about the process and outcomes improve the quality of surgical care. DESIGN Systematic literature review. METHOD Embase, PubMed, and Web of Science databases were searched for publications on 'quality assessment' and 'surgery'. The references of the publications found were examined as well. Publications were included in the review if the effect of auditing on the quality of surgical care had been investigated. RESULTS In the databases 2415 publications were found. After selection, 28 publications describing the effect of auditing, whether or not combined with a quality improvement project, on guideline adherence or indications of outcomes of care were included. In 21 studies, a statistically significant positive effect of auditing was reported. In 5 studies a positive effect was found, but this was either not significant or statistical significance was not determined. In 2 studies no effect was observed. 5 studies compared the combination of auditing with a quality improvement project with auditing alone; 4 of these reported an additional effect of the quality improvement project. CONCLUSION Audit and feedback of quality information seem to have a positive effect on the quality of surgical care. The use of quality information from audits for the purpose of a quality improvement project can enhance the positive effect of the audit.
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van Steenbergen LN, van de Poll-Franse LV, Wouters MWJM, Jansen-Landheer MLEA, Coebergh JWW, Struikmans H, Tjan-Heijnen VCG, van de Velde CJH. Variation in management of early breast cancer in the Netherlands, 2003-2006. Eur J Surg Oncol 2010; 36 Suppl 1:S36-43. [PMID: 20620013 DOI: 10.1016/j.ejso.2010.06.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 06/08/2010] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To describe variation in staging and primary treatment by hospital characteristics including type and volume and region in patients with early breast cancer (BC) in the Netherlands, 2003-2006 after completion of national guidelines in 2002. METHODS All patients newly diagnosed with invasive BC in 2003-2006 and recorded in the Netherlands Cancer Registry were included (n = 51 354). Multivariable logistic regression analyses examined the influence of patient and hospital characteristics, also by region, on type of breast surgery, axillary lymph node dissection (ALND), sentinel node procedure (SNP), and adjuvant irradiation and/or systemic treatment. RESULTS Patients <40 years more often underwent breast conserving surgery (BCS) in general hospitals (OR 1.4 (95%CI 1.1-1.5)) than in teaching and academic hospitals, whereas patients of 40-69 years less often received BCS in an academic hospital (OR 0.9 (95%CI 0.8-1.0)) than in teaching hospitals. Patients with pT1-2N0 cancer more often underwent primary ALND in a general hospital than in a larger teaching or academic hospital. Type of hospital did not seem to affect utilization of adjuvant systemic therapy, but patient age and tumour size and grade did. Over time, patients more often received SNP, BCS, and adjuvant systemic therapy, primary ALND being on the decline, but with substantial regional variation between geographic regions. CONCLUSION With detailed evidence-based national guidelines since 2002 the considerable regional and hospital variation in staging procedures and primary treatment among newly diagnosed patients with early breast cancer in the Netherlands decreased markedly, suggesting the presence of late adaptors rather than specific hospital characteristics.
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Elferink MAG, Krijnen P, Wouters MWJM, Lemmens VEPP, Jansen-Landheer MLEA, van de Velde CJH, Langendijk JA, Marijnen CAM, Siesling S, Tollenaar RAEM. Variation in treatment and outcome of patients with rectal cancer by region, hospital type and volume in the Netherlands. Eur J Surg Oncol 2010; 36 Suppl 1:S74-82. [PMID: 20598844 DOI: 10.1016/j.ejso.2010.06.028] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Accepted: 06/10/2010] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Aim of this study was to describe treatment patterns and outcome according to region and hospital type and volume among patients with rectal cancer in the Netherlands. METHODS All patients with rectal carcinoma diagnosed in the period 2001-2006 were selected from the Netherlands Cancer Registry. Logistic regression analyses were performed to examine the influence of relevant factors on the odds of receiving preoperative radiotherapy and on the odds of postoperative mortality. Relative survival analysis was used to estimate relative excess risk of dying according to hospital type and volume. RESULTS In total, 16 039 patients were selected. Patients diagnosed in a teaching or university hospital had a lower odds (OR 0.85; 95% CI 0.73-0.99 and OR 0.70; 95% CI 0.52-0.92) and patients diagnosed in a hospital performing >50 resections per year had a higher odds (OR 1.95; 95% CI 1.09-1.76) of receiving preoperative radiotherapy. A large variation between individual hospitals in rates of preoperative radiotherapy and between Comprehensive Cancer Centre-regions in the administration of preoperative chemoradiation was revealed. Postoperative mortality was not correlated to hospital type or volume. Patients with T1-M0 tumours diagnosed in a hospital with >50 resections per year had a better survival compared to patients diagnosed in a hospital with <25 resections per year (RER 0.11; 95% CI 0.02-0.78). CONCLUSION This study demonstrated variation in treatment and outcome of patients with rectal cancer in the Netherlands, with differences related to hospital volume and hospitals teaching or academic status. However, variation in treatment patterns between individual hospitals proved to be much larger than could be explained by the investigated characteristics. Future studies should focus on the reasons behind these differences, which could lead to a higher proportion of patients receiving optimal treatment for their stage of the disease.
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Wouters MWJM, Siesling S, Jansen-Landheer ML, Elferink MAG, Belderbos J, Coebergh JW, Schramel FMNH. Variation in treatment and outcome in patients with non-small cell lung cancer by region, hospital type and volume in the Netherlands. Eur J Surg Oncol 2010; 36 Suppl 1:S83-92. [PMID: 20598845 DOI: 10.1016/j.ejso.2010.06.020] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Accepted: 06/08/2010] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Care processes for patients with NSCLC can vary by provider, which may lead to unwanted variation in outcomes. Therefore, in modern health care an increased focus on guideline development and implementation is seen. It is expected that more guideline adherence leads to a higher number of patients receiving optimal treatment for their cancer which could improve overall survival. OBJECTIVE The aim of this study was to evaluate variations in treatment patterns and outcomes of patients with NSCLC treated in different (types of) hospitals and regions in the Netherlands. Especially, variation in the percentage of patients receiving the optimal treatment for the stage of their disease, according to the Dutch national guideline of 2004, was analyzed. METHODS All patients with a histological confirmed primary NSCLC diagnosed in the period 2001-2006 in all Dutch hospitals (N = 97) were selected from the population-based Netherlands Cancer Registry. Hospitals were divided in groups based on their region (N = 9), annual volume of NSCLC patients, teaching status and presence of radiotherapy facilities. Stage-specific differences in optimal treatment rates between (groups of) hospitals and regions were evaluated. RESULTS In the study period 43 544 patients were diagnosed with NSCLC. The resection rates for stage I/II NSCLC patients increased during the study period, but resection rates varied by region and were higher in teaching hospitals for thoracic surgeons (OR 1.5; 95%CI 1.2-1.9, p = 0.001) and in hospitals with a diagnostic volume of more than 50/year (OR 1.3; 95%CI 1.1-1.5, p = 0.001). Also the use of chemoradiation in stage III patients increased, though marked differences between hospitals in the use of chemoradiation for stage III patients were revealed. Differences in optimal treatment rates between hospitals led to differences in survival. CONCLUSION Treatment patterns and outcome of NSCLC patients in the Netherlands varied by region and the hospital their cancer was diagnosed in. Though resection rates were higher in hospitals training thoracic surgeons, variation between individual hospitals was much more distinct. Hospital characteristics like a high diagnostic volume, teaching status or availability of radiotherapy facilities proved no guarantee for optimal treatment rates.
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Goossens-Laan CA, Visser O, Wouters MWJM, Jansen-Landheer MLEA, Coebergh JWW, van de Velde CJH, Hulshof MCCM, Kil PJM. Variations in treatment policies and outcome for bladder cancer in the Netherlands. Eur J Surg Oncol 2010; 36 Suppl 1:S100-7. [PMID: 20598491 DOI: 10.1016/j.ejso.2010.06.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 06/01/2010] [Indexed: 01/04/2023] Open
Abstract
AIM To describe the population-based variation in treatment policies and outcome for bladder cancer in the Netherlands. METHODS All newly diagnosed patients with primary bladder cancers during 2001-2006 were selected from the Netherlands Cancer Registry (n = 29,206). Type of primary treatment was analysed according to Comprehensive Cancer Centre region, hospital type (academic, non-academic teaching or other hospitals) and volume (< or =5, 6-10 or >10 cystectomies yearly). For stage II-III patients undergoing cystectomy we analyzed the proportion of lymph node dissections and 30-days mortality. RESULTS 44% of patients with stage II-III bladder cancer underwent cystectomy, while 26% were not treated with curative intent. Cystectomy was the preferred option in three of nine regions, radiotherapy in two, and two regions waived curative treatment more often. Between 2001 and 2006 the number of cystectomies increased with 20% (n = 108). Twenty-one percent (n = 663) of these procedures were performed in 44 low-volume hospitals. In 79% of the cystectomies lymph node dissections were performed, more often in high and medium-volume centers (82% and 81% respectively) than in low-volume hospitals (71%, the odds ratio being 1.5). The overall 30-days post-operative mortality rate was 3.4% and increased with older age. It was significantly lower in high-volume centers (1.2%). CONCLUSION Treatment policies for muscle-invasive bladder cancer in the Netherlands showed regional preferences and a gradual increase of cystectomy. Cystectomy albeit considered as golden standard, was performed in a minority of the muscle-invasive cases. In high-volume institutions, lymph node dissection rates were higher and post-operative mortality rates were lower.
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Aukema TS, Valdés Olmos RA, Wouters MWJM, Klop WMC, Kroon BBR, Vogel WV, Nieweg OE. Utility of Preoperative 18F-FDG PET/CT and Brain MRI in Melanoma Patients with Palpable Lymph Node Metastases. Ann Surg Oncol 2010; 17:2773-8. [DOI: 10.1245/s10434-010-1088-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Indexed: 11/18/2022]
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Aukema TS, Olmos RAV, Korse CM, Kroon BBR, Wouters MWJM, Vogel WV, Bonfrer JMG, Nieweg OE. Utility of FDG PET/CT and Brain MRI in Melanoma Patients with Increased Serum S-100B Level During Follow-up. Ann Surg Oncol 2010; 17:1657-61. [DOI: 10.1245/s10434-010-0963-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Indexed: 11/18/2022]
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Gooiker GA, Veerbeek L, van der Geest LGM, Stijnen T, Dekker JWT, Nortier JWRH, Marinelli AWKS, Struikmans H, Wouters MWJM, Tollenaar RAEM. [The quality indicator 'tumour positive surgical margin following breast-conserving surgery' does not provide transparent insight into care]. NEDERLANDS TIJDSCHRIFT VOOR GENEESKUNDE 2010; 154:A1142. [PMID: 20482902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To determine whether the quality indicator 'tumour positive surgical margin following breast-conserving surgery, consistently measured the quality of breast-cancer surgery independently of the different definitions used and differences in case mix, taking statistical random variation into account. DESIGN Descriptive study. METHODS Data was collected from 762 patients who underwent breast-conserving surgery for invasive or in situ carcinoma of the breast, in the period 1 July 2007 - 30 June 2008 in 1 of the 9 hospitals in the region of the Comprehensive Cancer Centre West in the Netherlands. We compared 3 definitions for 'tumour positive surgical margin': the one used by the Health Care Inspectorate, the one used by the organisation 'Zichtbare Zorg' ('transparent care') and the percentage of re-resection. For case mix correction we identified risk factors for tumour margin positivity with logistic regression. The results were presented in a funnel plot, using 95% confidence interval (CI) around the national standard of 20%. RESULTS Depending on the definition used, the tumour positive surgical margin rate of the total group varied from 11 to 21%. Individual hospital rates varied by up to 19%. In situ carcinoma was associated with higher tumour positive surgical margin rates. Results differed significantly between hospitals for all 3 definitions. However, the funnel plot showed that results for most hospitals fell within the 95% CI of the standard. Whether a hospital fell within the 95% CI of the standard depended upon on the definition used and case mix correction. CONCLUSION The lack of a single definition for the quality indicator 'tumour positive surgical margin following breast-conserving surgery' and the lack of case-mix correction undermine the validity of the indicator. Standardisation of definitions, uniform registration and the use of funnel plots can provide a more transparent insight into the quality of care.
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Veenstra HJ, van der Ploeg IMC, Wouters MWJM, Kroon BBR, Nieweg OE. Reevaluation of the Locoregional Recurrence Rate in Melanoma Patients With a Positive Sentinel Node Compared to Patients With Palpable Nodal Involvement. Ann Surg Oncol 2009; 17:521-6. [DOI: 10.1245/s10434-009-0776-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Indexed: 11/18/2022]
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van Gijn W, Wouters MWJM, Peeters KCMJ, van de Velde CJH. Nationwide outcome registrations to improve quality of care in rectal surgery. An initiative of the European Society of Surgical Oncology. J Surg Oncol 2009; 99:491-6. [PMID: 19031492 DOI: 10.1002/jso.21203] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
In recent years there have been significant improvements in rectal cancer treatment. New surgical techniques as well as effective neoadjuvant treatment regimens have contributed to these improvements. Key is to spread these advances towards every rectal cancer patient and to ensure that not only patients who are treated within the framework of clinical trials may benefit from these advancements. Throughout Europe there have been interesting quality programmes that have proved to facilitate the spread of up to date knowledge and skills among medical professionals resulting in improved treatment outcome. Despite these laudable efforts there is still a wide variation in treatment outcome between countries, regions and institutions, which calls for a European audit on cancer treatment outcome.
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Wouters MWJM, Karim-Kos HE, le Cessie S, Wijnhoven BPL, Stassen LPS, Steup WH, Tilanus HW, Tollenaar RAEM. Centralization of esophageal cancer surgery: does it improve clinical outcome? Ann Surg Oncol 2009; 16:1789-98. [PMID: 19370377 PMCID: PMC2695873 DOI: 10.1245/s10434-009-0458-9] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2007] [Revised: 01/27/2009] [Accepted: 01/27/2009] [Indexed: 12/22/2022]
Abstract
Background The volume–outcome relationship for complex surgical procedures has been extensively studied. Most studies are based on administrative data and use in-hospital mortality as the sole outcome measure. It is still unknown if concentration of these procedures leads to improvement of clinical outcome. The aim of our study was to audit the process and effect of centralizing oesophageal resections for cancer by using detailed clinical data. Methods From January 1990 until December 2004, 555 esophagectomies for cancer were performed in 11 hospitals in the region of the Comprehensive Cancer Center West (CCCW); 342 patients were operated on before and 213 patients after the introduction of a centralization project. In this project patients were referred to the hospitals which showed superior outcomes in a regional audit. In this audit patient, tumor, and operative details as well as clinical outcome were compared between hospitals. The outcome of both cohorts, patients operated on before and after the start of the project, were evaluated. Results Despite the more severe comorbidity of the patient group, outcome improved after centralizing esophageal resections. Along with a reduction in postoperative morbidity and length of stay, mortality fell from 12% to 4% and survival improved significantly (P = 0.001). The hospitals with the highest procedural volume showed the biggest improvement in outcome. Conclusion Volume is an important determinant of quality of care in esophageal cancer surgery. Referral of patients with esophageal cancer to surgical units with adequate experience and superior outcomes (outcome-based referral) improves quality of care.
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Wouters MWJM, van Geel AN, Menke-Pluijmers M, de Kanter AY, de Bruin HG, Verhoog L, Eggermont AMM. Should internal mammary chain (IMC) sentinel node biopsy be performed? Breast 2008; 17:152-8. [PMID: 17890088 DOI: 10.1016/j.breast.2007.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2007] [Revised: 07/09/2007] [Accepted: 08/06/2007] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Although the status of the regional lymph nodes is an important determinant of prognosis in breast cancer, harvesting sentinel nodes (SN) detected in the internal mammary chain (IMC) is still controversial. AIMS To determine in how many patients a positive IMC-SN might change the systemic or locoregional adjuvant therapy, with a possible benefit in outcome. PATIENTS AND METHODS During 6 1/2 years data of T1-2 breast cancer patients, having an SN procedure, were prospectively collected. Our policy was not to explore the IMC even if it was the only localization of an SN. RESULTS In 86 of 571 patients lymphoscintigraphy showed an IMC-SN. In 64 of these, the axillary SN was negative and only 25 of these patients did not have an indication for adjuvant systemic treatment based on their tumor characteristics. In the literature, IMC metastases are found in 0-10% of axillary negative patients. Routine IMC-SN biopsies would have resulted in an indication for adjuvant systemic therapy in 2-3 of our patients. Four parasternal recurrences were found during a median follow-up of 51 months. CONCLUSIONS Harvesting IMC-SNs is a procedure of which only a limited number of patients have therapeutical benefit. Even with a thorough selection of patients, the extra morbidity of the procedure should be weighed against the potential benefit for the patient.
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Hennink S, Wouters MWJM, Klomp HM, Baas P. Necrotizing pneumonitis caused by postoperative pulmonary torsion. Interact Cardiovasc Thorac Surg 2007; 7:144-5. [PMID: 18042566 DOI: 10.1510/icvts.2007.158378] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pulmonary torsion is an adverse event with a reported incidence of 0.089-0.4%. It may occur spontaneously, after trauma but most often as a rare complication after pulmonary surgery. We describe a case of lobar torsion of the left upper lobe after lobectomy of the left lower lobe, which resulted in a necrotizing pneumonitis with fever, hemoptysis and weight loss. A completion pneumonectomy was performed after which the patient recovered well. A review of the literature shows that a delay in diagnosis and treatment of this rare complication can have catastrophic consequences. Surgery is the treatment of choice since sparing of the lobe is hardly ever possible due to the irreversible ischemic changes. Detorsion, instead of resection, may lead to fatal complications. Although infrequent, one should be aware of lobar torsion and the necessity for immediate re-intervention.
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de Kanter AY, Menke-Pluymers MM, Wouters MWJM, Burgmans I, van Geel AN, Eggermont AMM. 5-Year follow-up of sentinel node negative breast cancer patients. Eur J Surg Oncol 2006; 32:282-6. [PMID: 16439094 DOI: 10.1016/j.ejso.2005.11.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2005] [Accepted: 11/28/2005] [Indexed: 02/06/2023] Open
Abstract
AIM To report the long-term results of sentinel node negative breast cancer patients treated without axillary lymph node dissection and the 5-year follow-up results of 149 patients. METHODS The incidence of axillary-and local recurrences and second ipsilateral primary tumours was evaluated. The added value of annual ultrasound of the treated axilla, being part of the standard follow-up, was also evaluated. RESULTS After a mean follow-up of 65 months (50-79) axillary recurrences were observed in four patients, local recurrences or ipsilateral second primary tumours were diagnosed in another seven patients. All axillary recurrences were diagnosed because of a palpable axillary mass; ultrasound in combination with fine needle aspiration cytology did not have an added value. CONCLUSION It can be concluded that the incidence of axillary recurrences after negative SN is much lower than expected. There is no added value of US and FNAC of the axilla in the routine follow-up of SN negative patients.
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