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

Prognostic Impact of pT Stage and Peritoneal Invasion in Locally Advanced Colon Cancer

BACKGROUND

TNM stage has been identified as an independent variable for local recurrence and survival after colon cancer resection. It is still unclear whether peritoneal invasion (pT4a) is a risk factor for adverse oncologic outcome or whether these patients have better results compared with contiguous organs infiltration (pT4b), independent from nodal status (pN).

OBJECTIVE

The purpose of this study was to analyze whether peritoneal invasion is an independent risk factor for worse oncologic outcome after curative colon cancer resection.

DESIGN

This was a retrospective analysis with multivariate regression of a prospective database, according to Strengthening the Reporting of Observational Studies in Epidemiology Statement.

SETTINGS

The study was conducted in a specialized colorectal unit of a tertiary hospital.

PATIENTS

A consecutive series of pT3-pT4a-pT4b patients with colon cancer who underwent curative surgery (1993-2010) were included, and patients with metastasis were excluded.

MAIN OUTCOME MEASURES

A multivariate Cox regression analysis was performed to assess independent risk factors for 5-year local recurrence, peritoneal carcinomatosis-like recurrence, disease-free survival, and cancer-specific survival.

RESULTS

A total of 1010 patients were analyzed (79.3% pT3, 9.9% pT4a, and 10.8% pT4b). At diagnosis, 22.0% had obstructive symptoms, and 10.5% had bowel perforation. A total of 72.2% of the surgeries were elective, and in 15.6% en bloc resection of contiguous organs was performed. Median follow-up was 62 months (38-100 mo). For the whole group, 5-year actuarial rates were 8.8% for local recurrence, 2.5% for peritoneal carcinomatosis, 75.5% for disease-free survival, and 81.8% for cancer-specific survival. At multivariate analysis, pT4a stage was an independent risk factor for local recurrence (p = 0.002; HR = 3.1), peritoneal carcinomatosis (p = 0.02; HR = 4.9), worse disease-free survival (p = 0.002; HR = 1.9), and cancer-specific survival (p = 0.001; HR = 2.2). When considering only the 566 patients with ≥12 nodes identified, T stage was still associated with higher local recurrence (p = 0.04) and carcinomatosis rate (p = 0.04), as well as worse disease-free (p = 0.009) and cancer-specific survival (p = 0.014).

LIMITATIONS

This was a retrospective, single-center study.

CONCLUSIONS

pT4a stage is an independent risk factor for worse oncologic outcome after curative colon cancer resection compared with pT3 and pT4b stages. The current pT4a-pT4b classification should be reconsidered. Of note, even in pT4a patients, 5-year carcinomatosis rate does not exceed 6%. See Video Abstract at http://links.lww.com/DCR/A926.

Annual hospital volume of surgery for gastrointestinal cancer in relation to prognosis

BACKGROUND

Studies examining hospital volume for surgery for various gastrointestinal (GI) cancer types have shown conflicting results regarding the influence on long-term prognosis. The aim of this study was to examine annual hospital volume in relation to long-term survival after elective surgery for all GI cancers (esophagus, stomach, liver, pancreas, bile ducts, small bowel, colon, and rectum).

METHODS

Population-based cohort study including all 45,908 patients who underwent elective surgery for GI cancers in Sweden in 2005-2013. Follow-up was until 2016 for disease-specific 5-year mortality (main outcome) and 2018 for all-cause 5-year mortality (secondary outcome). Hospitals were divided into quartiles for each GI cancer according to a 4-year average annual volume of the year of surgery and three years earlier. Multivariable Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for relevant confounders.

RESULTS

Higher hospital volume was associated with a survival benefit in the large group of patients (n = 26,688) who underwent colon cancer resection, with HR 0.89 (95% CI 0.84-0.96) for disease-specific 5-year mortality comparing the highest with the lowest quartile. Higher hospital volume improved 5-year mortality in sub-groups of patients who underwent surgery for cancer of the esophagus, pancreas, and rectum. No such improvements were found for cancer of the stomach, liver, bile ducts, or small bowel.

CONCLUSION

Long-term survival was improved at higher volume hospitals for some GI cancers (colon, esophagus, pancreas, rectum), but not for others (stomach, liver, bile ducts, small bowel).

A Comparison of Pathologic Outcomes of Open, Laparoscopic, and Robotic Resections for Rectal Cancer Using the ACS-NSQIP Proctectomy-Targeted Database: a Propensity Score Analysis

BACKGROUND

There is ongoing debate regarding the benefits of minimally invasive techniques for rectal cancer surgery. The aim of this study was to compare pathologic outcomes of patients who underwent rectal cancer resection by open surgery, laparoscopy, and robotic surgery using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) proctectomy-targeted database.

METHODS

All patients from the 2016 ACS-NSQIP proctectomy-targeted database who underwent elective proctectomy for rectal cancer were identified. Patients were divided into three groups based on initial operative approach: open surgery, laparoscopy, and robotic surgery. Pathologic and 30-day clinical outcomes were then compared between the groups. A propensity score analysis was performed to control for confounders, and adjusted odds ratios for pathologic outcomes were reported.

RESULTS

A total of 578 patients were included-211 (36.5%) in the open group, 213 (36.9%) in the laparoscopic group, and 154 (26.6%) in the robotic group. Conversion to open surgery was more common among laparoscopic cases compared to robotic cases (15.0% vs. 6.5%, respectively; p = 0.011). Positive circumferential resection margin (CRM) was observed in 4.7%, 3.8%, and 5.2% (p = 0.79) of open, laparoscopic, and robotic resections, respectively. Propensity score adjusted odds ratios for positive CRM (open surgery as a reference group) were 0.70 (0.26-1.85, p = 0.47) for laparoscopy and 1.03 (0.39-2.70, p = 0.96) for robotic surgery.

CONCLUSIONS

The use of minimally invasive surgical techniques for rectal cancer surgery does not appear to confer worse pathologic outcomes.

Effect of hospital and surgeon volume on postoperative outcomes after distal gastrectomy for gastric cancer based on data from 145,523 Japanese patients collected from a nationwide web-based data entry system

BACKGROUND

Despite interest in surgeon and hospital volume effects on distal gastrectomy, clinical significance has not been confirmed in a large-scale population. We studied to clarify the effects of surgeon and hospital volume on postoperative mortality after distal gastrectomy for gastric cancer among Japanese patients in a nationwide web-based data entry system.

METHODS

We extracted data on distal gastrectomy for gastric cancer from the National Clinical Database between 2011 and 2015. The primary outcome was operative mortality. Hospital volume was divided into 3 tertiles: low (1-22 cases per year), medium (23-51) and high (52-404). Surgeon volume was divided into the 5 groups: 0-3, 4-10, 11-20, 21-50, 51 + cases per year. We calculated the 95% confidence interval (CI) for the mortality rate based on odds ratios (ORs) estimated from a hierarchical logistic regression model.

RESULTS

We analyzed 145,523 patients at 2182 institutions. Operative mortality was 1.9% in low-, 1.0% in medium- and 0.5% in high-volume hospitals. The operative mortality rate decreased definitively with surgeon volume, 1.6% in the 0-3 group and 0.3% in the 51 + group. After risk adjustment for surgeon and hospital volume and patient characteristics, hospital volume was significantly associated with operative morality (medium: OR 0.64, 95% CI 0.56-0.73, P < 0.001; high: OR 0.42, 95% CI 0.35-0.51, P < 0.001).

CONCLUSIONS

We demonstrate that hospital volume can have a crucial impact on postoperative mortality after distal gastrectomy compared with surgeon volume in a nationwide population study. These findings suggest that centralization may improve outcomes after distal gastrectomy.

Association Between Hospital and Surgeon Volume and Rectal Cancer Surgery Outcomes in Patients With Rectal Cancer Treated Since 2000: Systematic Literature Review and Meta-analysis

BACKGROUND

Previous reviews and meta-analyses, which predominantly focused on patients treated before 2000, have reported conflicting evidence about the association between hospital/surgeon volume and rectal cancer outcomes. Given advances in rectal cancer resection, such as total mesorectal excision, it is essential to determine whether volume plays a role in rectal cancer outcomes among patients treated since 2000.

OBJECTIVE

The purpose of this study was to determine whether there is an association between hospital/surgeon volume and rectal cancer surgery outcomes among patients treated since 2000.

DATA SOURCES

We searched PubMed and EMBASE for articles published between January 2000 and December 29, 2017.

STUDY SELECTION

Articles that analyzed the association between hospital/surgeon volume and rectal cancer outcomes were selected.

INTERVENTION

Rectal cancer resection was the study intervention.

MAIN OUTCOME MEASURES

The outcome measures of this study were surgical morbidity, postoperative mortality, surgical margin positivity, permanent colostomy rates, recurrence, and overall survival.

RESULTS

Although 2845 articles were retrieved and assessed by the search strategy, 21 met the inclusion and exclusion criteria. There was a significant protective association between higher hospital volume and surgical morbidity (OR = 0.80 (95% CI, 0.70-0.93); I = 35%), permanent colostomy (OR = 0.51 (95% CI, 0.29-0.92); I = 34%), and postoperative mortality (OR = 0.62 (95% CI, 0.43-0.88); I = 34%), and overall survival (OR = 0.99 (95% CI, 0.98-1.00); I = 3%). Stratified analysis showed that the magnitude of association between hospital volume and rectal cancer surgery outcomes was stronger in the United States compared with other countries. Surgeon volume was not significantly associated with overall survival. The articles included in this analysis were high quality according to the Newcastle-Ottawa scale. Funnel plots suggested that the potential for publication bias was low.

LIMITATIONS

Some articles included rectosigmoid cancers.

CONCLUSIONS

Among patients diagnosed since 2000, higher hospital volume has had a significant protective effect on rectal cancer surgery outcomes.

Relationship between surgeon volume and outcomes in spine surgery: a dose-response meta-analysis

Background

The relationship between surgeon volume and outcomes in spine surgery is unclear and published studies report inconsistent results. Therefore, a dose-response meta-analysis was conducted to clarify the influence of surgeon volume on outcomes in spine surgery.

Methods

PubMed, Embase, and The Cochrane Library were systematically searched without language limitation for observational studies which investigated the relationship between surgeon volume and outcomes in spine surgery. The primary outcome was postoperative morbidity and the secondary outcomes consisted of mortality, length of hospital stay, readmission, and hospital costs. For binary variable and continuous variable, odds ratios (ORs) with 95% CIs and weighted mean differences (WMDs) with 95% CIs were pooled respectively. Additionally, a dose-response meta-analysis was performed for the primary outcome.

Results

Eleven studies with 1,986,545 patients were included in the current meta-analysis. Pooled estimate indicated that a higher surgeon volume was associated with lower postoperative morbidity (OR, 0.62; 95% CI: 0.52-0.75; I²=93.9%), lower mortality (OR, 0.76; 95% CI: 0.66-0.87; I²=0), shorter length of hospital stay (WMD, -7.07; 95% CI: -7.08 to -7.06; I²=100%), less readmission (OR, 0.78; 95% CI: 0.72-0.85; I²=93.1%), and lower hospital costs (WMD, -25,497.47; 95% CI: -25,528.43 to -25,466.51; I²=100%). Dose-response analysis suggested a nonlinear relationship between surgeon volume and postoperative morbidity (P for nonlinearity less than 0.00001).

Conclusions

The current evidence indicate that higher surgeon volume is associated with lower morbidity and mortality, shorter length of hospital stay, less readmission, and lower hospital costs in spine surgery.

Tertiary Care Multidisciplinary Teams Associated with Improved Survival in Rectal Cancer Patients: A Comparative Study

For stage II/III rectal cancer patients, comprehensive multidisciplinary care (MDC) affects outcomes. Randomized trials have shown the effectiveness of adjuvant and neoadjuvant therapy in treatment of these patients. However, the effectiveness of collaboration within MDC is undetermined. It is possible that regional variation in survival outcomes may be tied to treatment facility. We retrospectively reviewed a prospectively collected database of patients with stage II/III rectal cancer who received MDC at any location and underwent oncologic colorectal resection at a tertiary care center (TCC) between 2005 and 2011. Of the 571 rectal cancer patients, 391 had a stage II/III rectal cancer and received surgery at a TCC. After exclusion criteria, we observed that 120 patients received neoadjuvant therapy and 119 patients received adjuvant therapy. For neoadjuvant patients, no difference in overall survival was observed between treatment received at a TCC versus an outside facility. However, a significant improvement in survival was observed in patients who received adjuvant therapy at a TCC ( P = 0.01). Thus, the location of postoperative adjuvant therapy shows improvement in 10-year survival at a TCC versus elsewhere. Thus, standardization of care can impact outcomes for invasive rectal cancer patients. The limitations of this study are its retrospective nature and relatively small sample size.

Time to rethink surgeon-specific outcome data for colorectal surgeons in England: Cross-sectional data of 73,842 resections for colorectal cancer

Since 2013, individual surgeon and NHS Trusts outcomes following elective colorectal cancer surgery have been in the public domain in England. The 90-day operative mortality rates following colorectal resections are available for the public to view online.

AIM

The aim of this study is to evaluate the quality of the published data. It also aims to find whether this data will show the expected pattern of inverse correlation between case volume and the postoperative 90-day mortality rate.

METHODOLOGY

The postoperative 90-day mortality data was taken from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) website. Surgeons and Trusts were categorized according to case volume. Completeness of data at Trust and surgeon levels was analysed. All statistical analyses were performed in Statistical Package for Social Science (SPSS, version 23, IBM, Armonk, NY).

RESULTS

788 colorectal surgeons performed 73,842 resections for colorectal cancer in 143 hospitals over a 5-year period (1st April 2010 and 31st March 2015). The mean national 90-day mortality after colorectal resections was 2.6%. No significant effect was identified when mortality rates were correlated with the surgeon or Trust volume. There was a missing data of 3874 patients in the individual surgeon level analysis when compared to the number of procedures included in Trust analysis (73,842 vs 69,968 cases). About one-third of hospitals (n = 43) had a case ascertainment of less than 90%. Out of the 788 surgeons, there were only two outliers whose mortality rates were outside the "funnel limit".

CONCULSION

The expected relationship between case volume and mortality rates could not be established. The completeness of data and low numbers of procedures per surgeon are major concerns. Additional outcome metrics should be utilized to assess performance quality. Failure to Rescue approach should be explored and utilized. It is crucial to have more rigorous and streamlined methods for data collection and case ascertainment to present to the public reliable, complete and relevant data.

CCR-CARESS score for predicting operative mortality in patients with colorectal cancer

BACKGROUND

The aim of this study was to assess factors associated with outcomes after surgery for colorectal cancer and to design and internally validate a simple score for predicting perioperative mortality.

METHODS

Patients undergoing surgery for primary invasive colorectal cancer in 22 centres in Spain between June 2010 and December 2012 were included. Clinical variables up to 30 days were collected prospectively. Multiple logistic regression techniques were applied and a risk score was developed. The Hosmer-Lemeshow test was applied and the area under the receiver operating characteristic (ROC) curve (AUC, with 95 per cent c.i.) was estimated.

RESULTS

A total of 2749 patients with a median age of 68·5 (range 24-97) years were included; the male : female ratio was approximately 2 : 1. Stage III tumours were diagnosed in 32·6 per cent and stage IV in 9·5 per cent. Open surgery was used in 39·3 per cent, and 3·6 per cent of interventions were urgent. Complications were most commonly infectious or surgical, and 25·5 per cent of patients had a transfusion during the hospital stay. The 30-day postoperative mortality rate was 1·9 (95 per cent c.i. 1·4 to 2·4) per cent. Predictive factors independently associated with mortality were: age 80 years or above (odds ratio (OR) 2·76), chronic obstructive pulmonary disease (COPD) (OR 3·62) and palliative surgery (OR 10·46). According to the categorical risk score, a patient aged 80 years or more, with COPD, and who underwent palliative surgery would have a 23·5 per cent risk of death within 30 days of the intervention.

CONCLUSION

Elderly patients with co-morbidity and palliative intention of surgery have an unacceptably high risk of death.

Education and the pediatric surgeon

There have been many changes in the domain of clinical surgery over the last 2 decades, but probably none more so than in education. The British Association of Pediatric Surgeons recognizes the importance of this topic and has commissioned a special session on this subject jointly with the International Pediatric Endosurgery Group. Free papers presented on a number of educational subjects and specific topics of recruitment and simulation were covered in invited lectures. The session was completed with a keynote lecture from the renowned educationalist Professor Roger Kneebone.

LEVEL OF EVIDENCE

5 (Expert Opinion).

Minimally invasive hysterectomy surgery rates for endometrial cancer performed at National Comprehensive Cancer Network (NCCN) Centers

OBJECTIVES

Minimally invasive surgery (MIS) is a quality measure for endometrial cancer (EC) established by the Society of Gynecologic Oncology and the American College of Surgeons. Our study objective was to assess the proportion of EC cases performed by MIS at National Comprehensive Cancer Network (NCCN) centers and evaluate perioperative outcomes.

METHODS

A retrospective cohort study of women who underwent surgical treatment for EC from 2013 to 2014 was conducted at four NCCN centers. Multivariable mixed logistic regression models analyzed factors associated with failure to perform MIS and perioperative complications.

RESULTS

In total 1621 patients were evaluated; 86.5% underwent MIS (robotic-assisted 72.5%, laparoscopic 20.9%, vaginal 6.6%). On multivariable analysis, factors associated with failure to undergo MIS were uterine size >12cm (Odds Ratio [OR]: 0.17, 95% CI 0.03-0.9), stage III (OR: 0.16, 95% CI 0.05-0.49) and IV disease (OR: 0.07, 95% CI 0.02-0.22). For stage I/II disease, complications occurred in 5.1% of MIS and 21.7% of laparotomy cases (p<0.01). Laparotomy was associated with increases in any complication (OR: 6.0, 95% CI 3.3-10.8), gastrointestinal (OR: 7.2, 95% CI 2.6-19.5), wound (OR: 3.7, 95% CI 1.5-9.2), respiratory (OR 37.5, 95% CI 3.9-358.0), VTE (OR 10.5, 95% CI 1.3-82.8) and 30-day readmission (OR: 2.6, 95% CI 1.4-4.9) compared to MIS.

CONCLUSIONS

At NCCN-designated centers, the MIS hysterectomy rate in EC is higher than the published national average, with low perioperative complications. Previously identified disparities of age, race, and BMI were not observed. A proposed MIS hysterectomy benchmark of >80% in EC care is feasible when performed at high volume centers.

Management of stage II and III rectal cancer in British Columbia: Is there a rural-urban difference?

BACKGROUND

This study assessed management of patients with locally advanced rectal cancer from rural, small and large local health authorities (LHA) in British Columbia (BC), Canada.

METHODS

We analyzed patients from 2004-2009 using a prospective database. Patients were defined as living in rural, small or large LHA using Statistics Canada definitions. Differences in treatments and outcomes were analyzed using chi-squared and log-rank tests, respectively.

RESULTS

Among 1964 patients, 13% lived in rural, 22% in small, and 66% in large LHAs. There were no differences in rates of abdominoperineal resections in rural (33%), small (39%) and large (35%) areas (p = 0.30). The proportion of patients who received radiotherapy (86-88%, p = 0.80) and adjuvant chemotherapy (56-57%, p = 0.89) were similar. There was no difference in 5-year disease-free survival (84-86%, p = 0.98) or overall survival (57-59%, p = 0.99).

CONCLUSIONS

The management and outcome of locally advanced rectal cancer patients seems to be comparable for rural and non-rural BC.