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Peterson KJ, Drezdzon MK, Sparapani R, Calata JF, Ridolfi TJ, Ludwig KA, Peterson CY. Traveling Long Distances for Rectal Cancer Care: Institutional Outcomes and Patient Experiences. J Surg Res 2024; 302:916-924. [PMID: 39265279 DOI: 10.1016/j.jss.2024.07.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 07/18/2024] [Accepted: 07/24/2024] [Indexed: 09/14/2024]
Abstract
INTRODUCTION Mounting evidence supports traveling to high-volume centers for complex surgical procedures, such as a proctectomy, yet the burden of travel and outcomes of patients traveling long distances is not yet clear. Thus, we aimed to evaluate oncologic outcomes, quality of life, and travel burdens for patients treated for rectal cancer at a single tertiary-care institution. METHODS A retrospective study of patients treated with proctectomy for locally advanced rectal cancer was performed comparing long and short travel distance (STD) cohorts. Primary outcome measures included overall mortality, disease recurrence, and quality of life. Secondary outcomes included out-of-pocket expenses. The cohorts were compared using Wilcoxon rank-sum and Chi-square tests for continuous and categorical variables, respectively. Kaplan-Meier plots were created to evaluate overall and disease-free survival. RESULTS Among 102 patients, 51 (50%) were classified as long travel distance (LTD, mean 57.8 miles) and 51 (50%) were classified as STD (mean 12.8 miles). There was no statistical difference in 5-y mortality (4% LTD versus 4% STD, P = 1.000), disease recurrence (26% LTD versus 18% STD, P = 0.336), or quality of life (0.85 LTD versus 0.87 STD, P = 0.690). The LTD cohort did have significantly lower postresection compliance with surveillance (84% LTD versus 96% STD, P = 0.046). LTD cohort also had significantly more lodging ($77.1 LTD versus $0 STD, P = 0.025) and transportation expenses ($133.6 LTD versus $92.6 STD, P = 0.010). CONCLUSIONS As the surgical management of rectal cancer becomes increasingly centralized, this study found patients who traveled long-distances received comparable care with outcomes similar to those who lived locally. Higher travel costs and lower compliance with surveillance were identified as barriers to care in the long-distance population, but a number of solutions can be implemented to address these issues.
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Affiliation(s)
- Kent J Peterson
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Melissa K Drezdzon
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Rodney Sparapani
- Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jed F Calata
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Timothy J Ridolfi
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Kirk A Ludwig
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Carrie Y Peterson
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin.
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Murshed I, Dinger TL, de Gaay Fortman DPE, Traeger L, Bedrikovetski S, Hunter A, Kroon HM, Sammour T. Outcomes of rectal cancer treatment in rural Australia and New Zealand: analysis of the bowel cancer outcomes registry. ANZ J Surg 2024. [PMID: 39205431 DOI: 10.1111/ans.19194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 06/26/2024] [Accepted: 07/28/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The demographics and geography of Australia and New Zealand (ANZ), with few metropolitan centres and vast, sparsely populated rural areas, represent a challenge to providing equal care to all patients. This study aimed to compare rectal cancer care at rural and urban hospitals in ANZ. METHODS From the Bowel Cancer Outcomes Registry (BCOR, formerly known as the Bi-National Colorectal Cancer Audit; BCCA), rectal cancer patients treated between 2007 and 2020 were compared based on hospital location (urban versus rural). Propensity-score matching was performed to correct for differences in baseline characteristics between groups. RESULTS A total of 9385 rectal cancer patients were identified from the BCOR: 1329 (14.2%) were treated at rural hospitals and 8056 (85.8%) at urban hospitals. Propensity-score matching resulted in 889 patients in each group, matched for age, ASA score, hospital type (public/private), tumour height from the anal verge, and pre-treatment cT- and cAJCC-stage. Rural patients had fewer pre-treatment MRIs (67.9% versus 74.7%; P = 0.002), and underwent less neoadjuvant therapy (44.7% versus 50.9%; P = 0.01). Rural patients underwent fewer ULARs (39.4% versus 45.6%; P = 0.03), and fewer anastomoses were formed (67.9% versus 74.4%; P = 0.05). CRM rates and postoperative AJCC stages (P = 0.19) were similar between groups (P = 0.87). Fewer rural patients received adjuvant chemotherapy (37.8% versus 43.3%; P = 0.02). CONCLUSION There are significant differences in pre-treatment MRI rates, (neo)adjuvant treatment rates and surgical procedures performed between rectal cancer patients treated at rural and urban hospitals in ANZ, while CRM rates and postoperative AJCC stages are similar.
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Affiliation(s)
- Ishmam Murshed
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Tessa L Dinger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Department of Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - Duveke P E de Gaay Fortman
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Luke Traeger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew Hunter
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Schuld GJ, Schlager L, Monschein M, Riss S, Bergmann M, Razek P, Stift A, Unger LW. Does surgeon or hospital volume influence outcome in dedicated colorectal units?-A Viennese perspective. Wien Klin Wochenschr 2024:10.1007/s00508-024-02405-6. [PMID: 39093419 DOI: 10.1007/s00508-024-02405-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/30/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVE A clear relationship between higher surgeon volume and improved outcomes has not been convincingly established in rectal cancer surgery. The aim of this study was to evaluate the impact of individual surgeon's caseload and hospital volume on perioperative outcome. METHODS We retrospectively analyzed 336 consecutive patients undergoing oncological resection for rectal cancer at two Viennese hospitals between 1 January 2015 and 31 December 2020. The effect of baseline characteristics as well as surgeons' caseloads (low volume: 0-5 cases per year, high volume > 5 cases per year) on postoperative complication rates (Clavien-Dindo Classification groups of < 3 and ≥ 3) were evaluated. RESULTS No differences in baseline characteristics were found between centers in terms of sex, smoking status, or comorbidities of patients. Interestingly, only 14.7% of surgeons met the criteria to be classified as high-volume surgeons, while accounting for 66.3% of all operations. There was a significant difference in outcomes depending on the treating center in univariate and multivariate binary logistic regression analysis (odds ratio (OR) = 2.403, p = 0.008). Open surgery was associated with lower complication rates than minimally invasive approaches in univariate analysis (OR = 0.417, p = 0.003, 95%CI = 0.232-0.739) but not multivariate analysis. This indicated that the center's policy rather than surgeon volume or mode of surgery impact on postoperative outcomes. CONCLUSION Treating center standards impacted on outcome, while individual caseload of surgeons or mode of surgery did not independently affect complication rates in this analysis. The majority of rectal cancer resections are performed by a small number of surgeons in Viennese hospitals.
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Affiliation(s)
- Gabor J Schuld
- Division of Visceral Surgery, Dept. of General Surgery, Medical University of Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Lukas Schlager
- Division of Visceral Surgery, Dept. of General Surgery, Medical University of Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Matthias Monschein
- Hospital Floridsdorf, Department of General Surgery, Brünner Straße 68, 1221, Vienna, Austria
| | - Stefan Riss
- Division of Visceral Surgery, Dept. of General Surgery, Medical University of Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Michael Bergmann
- Division of Visceral Surgery, Dept. of General Surgery, Medical University of Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Peter Razek
- Hospital Floridsdorf, Department of General Surgery, Brünner Straße 68, 1221, Vienna, Austria
| | - Anton Stift
- Division of Visceral Surgery, Dept. of General Surgery, Medical University of Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Lukas W Unger
- Division of Visceral Surgery, Dept. of General Surgery, Medical University of Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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Piozzi GN, Przedlacka A, Duhoky R, Ali O, Ghanem Y, Beable R, Higginson A, Khan JS. Robotic transanal minimally invasive surgery (r-TAMIS): perioperative and short-term outcomes for local excision of rectal cancers. Surg Endosc 2024; 38:3368-3377. [PMID: 38710889 PMCID: PMC11133047 DOI: 10.1007/s00464-024-10829-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/23/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Transanal minimally invasive surgery (TAMIS) is an advanced technique for excision of early rectal cancers. Robotic TAMIS (r-TAMIS) has been introduced as technical improvement and potential alternative to total mesorectal excision (TME) in early rectal cancers and in frail patients. This study reports the perioperative and short-term oncological outcomes of r-TAMIS for local excision of early-stage rectal cancers. METHODS Retrospective analysis of a prospectively collected r-TAMIS database (July 2021-July 2023). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated. RESULTS Twenty patients were included. Median age and body mass index were 69.5 (62.0-77.7) years and 31.0 (21.0-36.5) kg/m2. Male sex was prevalent (n = 12, 60.0%). ASA III accounted for 66.7%. Median distance from anal verge was 7.5 (5.0-11.7) cm. Median operation time was 90.0 (60.0-112.5) minutes. Blood loss was minimal. There were no conversions. Median postoperative stay was 2.0 (1.0-3.0) days. Minor and major complication rates were 25.0% and 0%, respectively. Seventeen (85.0%) patients had an adenocarcinoma whilst three patients had an adenoma. R0 rate was 90.0%. Most tumours were pT1 (55.0%), followed by pT2 (25.0%). One patient (5.0%) had a pT3 tumour. Specimen and tumour maximal median diameter were 51.0 (41.0-62.0) mm and 21.5 (17.2-42.0) mm, respectively. Median specimen area was 193.1 (134.3-323.3) cm2. Median follow-up was 15.5 (10.0-24.0) months. One patient developed local recurrence (5.0%). CONCLUSIONS r-TAMIS, with strict postoperative surveillance, is a safe and feasible approach for local excision of early rectal cancer and may have a role in surgically unfit and elderly patients who refuse or cannot undergo TME surgery. Future prospective multicentre large-scale studies are needed to report the long-term oncological outcomes.
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Affiliation(s)
| | - Ania Przedlacka
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Rauand Duhoky
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Oroog Ali
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
- Department of General Surgery, Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - Yasser Ghanem
- Department of General Surgery, Isle of Wight NHS Trust, Newport, UK
| | - Richard Beable
- Department of Radiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Antony Higginson
- Department of Radiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Jim S Khan
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK.
- University of Portsmouth, Portsmouth, UK.
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Bisset CN, Moug SJ, Oliphant R, Dames N, Parson S, Cleland J. Influencing factors in surgical decision-making: a qualitative analysis of colorectal surgeons' experiences of postoperative complications. Colorectal Dis 2024; 26:987-993. [PMID: 38485203 DOI: 10.1111/codi.16943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 01/25/2024] [Accepted: 02/21/2024] [Indexed: 05/26/2024]
Abstract
AIM When making anastomotic decisions in rectal cancer surgery, surgeons must consider the risk of anastomotic leakage, which bears implications for the patient's quality of life, cancer recurrence and, potentially, death. The aim of this study was to investigate the views of colorectal surgeons on how their individual attributes (e.g. experience, personality traits) may influence their decision-making and experience of complications. METHOD This qualitative study used individual interviews for data collection. Purposive sampling was used to invite certified UK-based colorectal surgeons to participate. Participants were recruited until ongoing data review indicated no new codes were generated, suggesting data sufficiency. Data were analysed thematically following Braun and Clarke's six-step framework. RESULTS Seventeen colorectal surgeons (eight female, nine male) participated. Two key themes with relevant subthemes were identified: (1) personal attributes influencing variation in decision-making (e.g. demographics, personality) and (2) the influence of complications on decision-making. Surgeons described variation in the management of complications based upon their personal attributes, which included factors such as gender, experience and subspeciality interests. Surgeons described the detrimental impact of anastomotic leakage on their mental and physical health. Experience of anastomotic leakage influences future decision-making and is associated with changes in practice even when a technical error is not identified. CONCLUSION Colorectal surgeons consider anastomotic leaks to be personal 'failures', which has a negative impact on surgeon welfare. Better understanding of how surgeons make difficult decisions, and how surgeons respond to and learn from complications, is necessary to identify 'personalized' methods of supporting surgeons at all career stages, which may improve patient outcomes.
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Affiliation(s)
- Carly N Bisset
- Department of General Surgery, Royal Alexandra Hospital, Paisley, UK
- University of Aberdeen, Aberdeen, UK
| | - Susan J Moug
- Department of General Surgery, Royal Alexandra Hospital, Paisley, UK
- Department of General Surgery, Golden Jubilee University National Hospital, Clydebank, UK
- University of Glasgow, Glasgow, UK
| | - Raymond Oliphant
- University of Aberdeen, Aberdeen, UK
- Department of Colorectal Surgery, Raigmore Hospital, Inverness, UK
| | - Nicola Dames
- Association of Coloproctology of Great Britain & Ireland Patient Liaison Group, Oxford, UK
| | | | - Jennifer Cleland
- Medical Education Research and Scholarship Unit, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Yeh CM, Lai TY, Hu YW, Teng CJ, Huang N, Liu CJ. The impact of surgical volume on outcomes in newly diagnosed colorectal cancer patients receiving definitive surgeries. Sci Rep 2024; 14:8227. [PMID: 38589462 PMCID: PMC11001606 DOI: 10.1038/s41598-024-55959-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 02/29/2024] [Indexed: 04/10/2024] Open
Abstract
Colorectal cancer (CRC) patients who receive cancer surgeries from higher-volume providers may have better outcomes. However, the definitions of surgical volume may affect the results. We aim to analyze the effects of different definitions of surgical volume on patient outcomes. We conducted a nationwide population-based study in Taiwan that enrolled all patients who underwent definitive surgery for newly diagnosed CRC. We used three common definitions of surgical volume: total volume means the total surgical number conducted by the same provider during the study period; cumulative volume was calculated as the number of operations the surgeon performed before the index procedure; annual volume was calculated as the number of times the surgeon had been responsible for surgery during the index year. In this study, we included 100,009 newly diagnosed CRC patients, including 55.8% males, of median age 66 years at diagnosis (range 20-105 years). After adjustment for the patient and provider characteristics, we found that CRC patients receiving definitive surgery by higher-volume providers had better outcomes, especially where surgeon volume may play a more important role than hospital volume. The cumulative volume could predict the 5-year mortality of the study cohort better than the total and annual volume.
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Affiliation(s)
- Chiu-Mei Yeh
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzu-Yu Lai
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Radiation Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Wen Hu
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Radiation Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Jen Teng
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Hematology and Oncology, Department of Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Nicole Huang
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, No. 155 Linong St., SeCc. 2, Beitou District, Taipei, 11217, Taiwan.
| | - Chia-Jen Liu
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.
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Zheng B, Wang B, Li Z, Qu Y, Qiu J. A modified method for precise anastomosis during laparoscopic low anterior resection for rectal cancer: the first clinical experience and application. BMC Surg 2024; 24:50. [PMID: 38336762 PMCID: PMC10858553 DOI: 10.1186/s12893-024-02335-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 01/28/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND There is no criterion to guide and evaluate the anastomosis of laparoscopic low anterior resection (LAR). We developed a new technique for precise anastomosis. This study endeavored to evaluate the effectiveness and safety of this new technology. METHODS Patients with mid-low rectal cancer who underwent laparoscopic LAR in our department were enrolled retrospectively between January 1, 2021 and July 1, 2023. During the LAR, the distance between the sacral promontory and the rectal stump was measured and used to determine the length of the sigmoid colon, which was preserved for anastomose. The demographic characteristics and short-term outcomes were analyzed. RESULTS Forty-nine patients (26 men, 23 women) with low and middle rectal cancer were retrospectively enrolled in the study. The distance of the tumor from the anal verge was 6.4 ± 2.7 cm. The operative time was 193 ± 42 min. All patients underwent precise anastomosis, among which 12 patients underwent freeing of the splenic flexure of the colon. According to our criteria, there was no redundant or tense state of the colon anterior to the sacrum after the anastomosis. Only one patient had a postoperative anastomotic leak (Grade B). All 15 patients receiving neoadjuvant chemoradiotherapy underwent terminal ileostomy. No postoperative death occurred within 30 days of the surgery. The median follow-up time in our study was 12 months. One patient developed a single metastasis in the right lobe of the liver in the eighth month after surgery and underwent microwave radiofrequency ablation, which did not recur in the four months of postoperative follow-up, and the rest of the patients survived disease-free without recurrence of metastasis. CONCLUSIONS Precise measurement of the proximal colon of the anastomosis can ensure accurate and convenient colorectal anastomosis and this may be a technique worthy of clinical application. However, its effectiveness needs to be further verified in a multicenter clinical trial.
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Affiliation(s)
- Bobo Zheng
- Department of General Surgery, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Ben Wang
- Department of General Surgery, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Zeyu Li
- Department of General Surgery, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Yaqi Qu
- Department of General Surgery, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Jian Qiu
- Department of General Surgery, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China.
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Protocol for a national audit of the watch-and-wait approach in patients with rectal cancer in Aotearoa New Zealand: The ACCORD study. Colorectal Dis 2024; 26:371-379. [PMID: 38124235 DOI: 10.1111/codi.16822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 09/12/2023] [Accepted: 09/12/2023] [Indexed: 12/23/2023]
Abstract
AIM The watch-and-wait approach is increasingly being used in the management of rectal cancer as many patients achieve a clinical complete response after neoadjuvant treatment This national, multicentre, retrospective cohort study aims to understand the use of the watch-and-wait approach in the management of rectal cancer in Aotearoa New Zealand and its associated outcomes. METHOD This retrospective cohort study will include patients aged 18 years and over with biopsy proven rectal adenocarcinoma diagnosed between January 2015 and December 2022 who have a clinical complete response following neoadjuvant treatment (including short-course radiotherapy, long-course chemoradiotherapy or total neoadjuvant treatment) and have been managed with a watch-and-wait approach. Data will be collected from centres that manage rectal cancer in Aotearoa New Zealand with the eligible population being identified using data linkage with the National Cancer Registry. CONCLUSION This multicentre, national cohort study will investigate the use of the watch-and-wait strategy for rectal cancer in Aotearoa New Zealand. Through novel data linkage approaches, these data and methods will lay the foundation for a future prospective registry and outcome-tracking initiative.
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Rottoli M, Spinelli A, Pellino G, Gori A, Calini G, Flacco ME, Manzoli L, Poggioli G. Effect of centre volume on pathological outcomes and postoperative complications after surgery for colorectal cancer: results of a multicentre national study. Br J Surg 2024; 111:znad373. [PMID: 37963162 PMCID: PMC10771132 DOI: 10.1093/bjs/znad373] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/29/2023] [Accepted: 10/22/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND The association between volume, complications and pathological outcomes is still under debate regarding colorectal cancer surgery. The aim of the study was to assess the association between centre volume and severe complications, mortality, less-than-radical oncologic surgery, and indications for neoadjuvant therapy. METHODS Retrospective analysis of 16,883 colorectal cancer cases from 80 centres (2018-2021). Outcomes: 30-day mortality; Clavien-Dindo grade >2 complications; removal of ≥ 12 lymph nodes; non-radical resection; neoadjuvant therapy. Quartiles of hospital volumes were classified as LOW, MEDIUM, HIGH, and VERY HIGH. Independent predictors, both overall and for rectal cancer, were evaluated using logistic regression including age, gender, AJCC stage and cancer site. RESULTS LOW-volume centres reported a higher rate of severe postoperative complications (OR 1.50, 95% c.i. 1.15-1.096, P = 0.003). The rate of ≥ 12 lymph nodes removed in LOW-volume (OR 0.68, 95% c.i. 0.56-0.85, P < 0.001) and MEDIUM-volume (OR 0.72, 95% c.i. 0.62-0.83, P < 0.001) centres was lower than in VERY HIGH-volume centres. Of the 4676 rectal cancer patients, the rate of ≥ 12 lymph nodes removed was lower in LOW-volume than in VERY HIGH-volume centres (OR 0.57, 95% c.i. 0.41-0.80, P = 0.001). A lower rate of neoadjuvant chemoradiation was associated with HIGH (OR 0.66, 95% c.i. 0.56-0.77, P < 0.001), MEDIUM (OR 0.75, 95% c.i. 0.60-0.92, P = 0.006), and LOW (OR 0.70, 95% c.i. 0.52-0.94, P = 0.019) volume centres (vs. VERY HIGH). CONCLUSION Colorectal cancer surgery in low-volume centres is at higher risk of suboptimal management, poor postoperative outcomes, and less-than-adequate oncologic resections. Centralisation of rectal cancer cases should be taken into consideration to optimise the outcomes.
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Affiliation(s)
- Matteo Rottoli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Colorectal Surgery, RCCS Humanitas Research Hospital, Milan, Italy
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy
- Colorectal Surgery, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Alice Gori
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giacomo Calini
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Maria E Flacco
- Department of Environmental and Preventive Sciences, University of Ferrara, Ferrara, Italy
| | - Lamberto Manzoli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
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Dundon NA, Al Ghazwi AH, Davey MG, Joyce WP. Rectal cancer surgery: does low volume imply worse outcome-a single surgeon experience. Ir J Med Sci 2023; 192:2673-2679. [PMID: 37154997 PMCID: PMC10165279 DOI: 10.1007/s11845-023-03372-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/11/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND The centralisation of rectal cancer management to high-volume oncology centres has translated to improved oncological and survival outcomes. We hypothesise that individual surgeon caseload, specialisation, and experience may be as significant in determining oncologic and postoperative outcomes in rectal cancer surgery. METHODS A prospectively maintained colorectal surgery database was reviewed for patients undergoing rectal cancer surgery between January 2004 and June 2020. Data studied included demographics, Dukes' and TNM staging, neoadjuvant treatment, preoperative risk assessment scores, postoperative complications, 30-day readmission rates, length of stay (LOS), and long-term survival. Primary outcome measures were 30-day mortality and long-term survival compared to national and international standards and best practice guidelines. RESULTS In total, 87 patients were included (mean age: 66 years [range: 36-88]). The mean length of stay (LOS) was 16.5 days (SD 6.0). The median ICU LOS was 3 days (range 2-17). Overall, 30-day readmission rate was 16.4%. Twenty-four patients (26.4%) experienced ≥ 1 postoperative complication. The 30-day operative mortality rate was 3.45%. Overall 5-year survival rate was 66.6%. A significant correlation was observed between P-POSSUM scores and postoperative complications (p = 0.041), and all four variants of POSSUM, CR-POSSUM, and P-POSSUM scores and 30-day mortality. CONCLUSION Despite improved outcomes seen with centralisation of rectal cancer services at an institutional level, surgeon caseload, experience, and specialisation is of similar importance in obtaining optimal outcomes within institutions.
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Affiliation(s)
| | | | | | - William P Joyce
- Department of Surgery, Galway Clinic, Galway, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
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11
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Boyle JM, van der Meulen J, Kuryba A, Cowling TE, Braun MS, Aggarwal A, Walker K, Fearnhead NS. What is the impact of hospital and surgeon volumes on outcomes in rectal cancer surgery? Colorectal Dis 2023; 25:1981-1993. [PMID: 37705203 PMCID: PMC10946964 DOI: 10.1111/codi.16745] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/24/2023] [Accepted: 05/30/2023] [Indexed: 09/15/2023]
Abstract
AIM Evidence for a positive volume-outcome relationship for rectal cancer surgery is unclear. This study aims to evaluate the volume-outcome relationship for rectal cancer surgery at hospital and surgeon level in the English National Health Service (NHS). METHOD All patients undergoing a rectal cancer resection in the English NHS between 2015 and 2019 were included. Multilevel multivariable logistic regression was used to model relationships between outcomes and mean annual hospital and surgeon volumes (using a linear plus a quadratic term for volume) with adjustment for patient characteristics. RESULTS A total of 13 858 patients treated in 166 hospitals were included. Six hospitals (3.6%) performed fewer than 10 rectal cancer resections per year, and 381 surgeons (45.0%) performed fewer than five such resections per year. Patients treated by high-volume surgeons had a reduced length of stay (p = 0.016). No statistically significant volume-outcome relationships were demonstrated for 90-day mortality, 30-day unplanned readmission, unplanned return to theatre, stoma at 18 months following anterior resection, positive circumferential resection margin and 2-year all-cause mortality at either hospital or surgeon level (p values > 0.05). CONCLUSION Almost half of colorectal surgeons in England do not meet national guidelines for rectal cancer surgeons to perform a minimum of five major resections annually. However, our results suggest that centralizing rectal cancer surgery with the main focus of increasing operative volume may have limited impact on NHS surgical outcomes. Therefore, quality improvement initiatives should address a wider range of evidence-based process measures, across the multidisciplinary care pathway, to enhance outcomes for patients with rectal cancer.
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Affiliation(s)
- Jemma M. Boyle
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Jan van der Meulen
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Angela Kuryba
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Thomas E. Cowling
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Michael S. Braun
- Department of OncologyThe Christie NHS Foundation TrustManchesterUK
- School of Medical SciencesUniversity of ManchesterManchesterUK
| | - Ajay Aggarwal
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Department of OncologyGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Kate Walker
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
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12
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LeLeannec IC, Madoff RD, Jensen CC. Specialization Reduces Costs Associated With Colon Cancer Care: A Cost Analysis. Dis Colon Rectum 2023; 66:1185-1193. [PMID: 35522784 DOI: 10.1097/dcr.0000000000002370] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Colorectal surgeons have been reported to have superior outcomes to general surgeons in the management of colon cancer, but it is unclear whether this leads to a difference in costs associated with cancer care. OBJECTIVE This study aimed to investigate whether colorectal surgeons versus general surgeons performing elective colectomies for colon cancer resulted in cost savings. DESIGN A decision analysis model was built to evaluate the cost of care. One-way and Monte Carlo sensitivity analyses were performed to test the assumptions of the model. SETTING Data for the model were taken from previously published studies. PATIENTS This study included a simulated cohort of patients undergoing elective colectomy for colon cancer. MAIN OUTCOME MEASURES Total cost of care from the societal and health care system perspectives. RESULTS In the base case scenario, from the societal perspective, colectomy performed by a colorectal surgeon costs $38,798 during the 5-year window versus $46,571 when performed by a general surgeon (net savings, $7773). From the health care system perspective, surgery performed by a colorectal surgeon costs $25,125 versus surgery performed by a general surgeon, which costs $29,790 (net savings, $4665). In probabilistic sensitivity analyses, surgeries performed by colorectal surgeons were cost saving or equivalent to those performed by general surgeons in 997 of 1000 simulations in the societal perspective and 989 of 1000 simulations in the health care system perspective. Overall, this finding was primarily driven by differences in reported overall recurrence rates and patient loss of productivity. LIMITATIONS The limitation of this study was reliance on published data, some of which included rectal cancer cases. CONCLUSIONS In our decision analysis model, elective colectomies for colon cancer had lower associated costs when performed by colorectal versus general surgeons. See Video Abstract at http://links.lww.com/DCR/B974 . LA ESPECIALIZACIN REDUCE LOS COSTOS ASOCIADOS CON LA ATENCIN DEL CNCER DE COLON UN ANLISIS DE COSTOS ANTECEDENTES: Se ha informado que los cirujanos colorrectales obtienen mejores resultados que los cirujanos generales en el tratamiento del cáncer de colon, pero no está claro si esto conduce a una diferencia en los costos asociados con la atención del cáncer.OBJETIVO: Investigar si los cirujanos colorrectales que realizan colectomías electivas para el cáncer de colon generaron ahorros de costos en comparación con los cirujanos generales.DISEÑO: Se construyó un modelo de análisis de decisiones para evaluar el costo de la atención. Se realizaron análisis de sensibilidad unidireccional y de Monte Carlo para probar los supuestos del modelo.AJUSTE: Los datos para el modelo se tomaron de estudios publicados previamente.PACIENTES: Una cohorte simulada de pacientes sometidos a colectomía electiva por cáncer de colon.PRINCIPALES MEDIDAS DE RESULTADO: Costo total de la atención y desde la perspectiva de la sociedad y del sistema de salud.RESULTADOS: El escenario del caso base incluyó suposiciones sobre las diferencias en los resultados, incluida la recurrencia general y local, el porcentaje de recurrencia operable, la mortalidad a los 30 días, la duración de la estadía, el porcentaje de cirugía mínimamente invasiva, las complicaciones y los costos asociados. En el escenario de caso base, desde la perspectiva social, la colectomía con un cirujano colorrectal costó $38 798 durante la ventana de cinco años, frente a $46 571 con un cirujano general (ahorros netos, $7 773). Desde la perspectiva del sistema de atención médica, la cirugía realizada por un cirujano colorrectal fue de $25 125 frente a $29 790 con la cirugía realizada por un cirujano general (ahorro neto, $4665). En los análisis de sensibilidad de probabilidad, los cirujanos colorrectales ahorraron costos o fueron equivalentes a los cirujanos generales en 997 de 1000 simulaciones en la perspectiva social y 989 de 1000 simulaciones en la perspectiva del sistema de salud. En general, este hallazgo se debió principalmente a las diferencias en las tasas de recurrencia generales informadas y la pérdida de productividad de los pacientes.LIMITACIONES: Dependencia de los datos publicados, algunos de los cuales incluyeron casos de cáncer de rectoCONCLUSIONES: En nuestro modelo de análisis de decisiones, las colectomías electivas por cáncer de colon tuvieron menores costos asociados cuando las realizaron cirujanos colorrectales versus generales. Consulte Video Resumen en http://links.lww.com/DCR/B974 . (Traducción-Dr Yolanda Colorado).
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Affiliation(s)
- Isabelle C LeLeannec
- Division of Colon and Rectal Surgery, Department of Surgery, NYU Grossman School of Medicine, New York, New York
| | - Robert D Madoff
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Christine C Jensen
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
- Colon and Rectal Surgery Associates, Minneapolis, Minnesota
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Kawai K, Hirakawa S, Tachimori H, Oshikiri T, Miyata H, Kakeji Y, Kitagawa Y. Updating the Predictive Models for Mortality and Morbidity after Low Anterior Resection Based on the National Clinical Database. Dig Surg 2023; 40:130-142. [PMID: 37311436 DOI: 10.1159/000531370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/25/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION We previously developed risk models for mortality and morbidity after low anterior resection using a nationwide Japanese database. However, the milieu of low anterior resection in Japan has undergone drastic changes since then. This study aimed to construct risk models for 6 short-term postoperative outcomes after low anterior resection, i.e., in-hospital mortality, 30-day mortality, anastomotic leakage, surgical site infection except for anastomotic leakage, overall postoperative complication rate, and 30-day reoperation rate. METHODS This study enrolled 120,912 patients registered with the National Clinical Database, who underwent low anterior resection between 2014 and 2019. Multiple logistic regression analyses were performed to generate predictive models of mortality and morbidity using preoperative information, including the TNM stage. RESULTS We developed new risk prediction models for the overall postoperative complication and 30-day reoperation rates for low anterior resection, which were absent from the previous version. The concordance indices for each endpoint were 0.82 for in-hospital mortality, 0.79 for 30-day mortality, 0.64 for anastomotic leakage, 0.62 for surgical site infection besides anastomotic leakage, 0.63 for complications, and 0.62 for reoperation. The concordance indices of all four models included in the previous version showed improvement. CONCLUSION This study successfully updated the risk calculators for predicting mortality and morbidity after low anterior resection using a model based on vast nationwide Japanese data.
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Affiliation(s)
- Kazushige Kawai
- Department of Colorectal Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
- Database Committee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Shinya Hirakawa
- Endowed Course for Health system Innovation, Keio University School of Medicine, Tokyo, Japan
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hisateru Tachimori
- Endowed Course for Health system Innovation, Keio University School of Medicine, Tokyo, Japan
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taro Oshikiri
- Database Committee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Health Policy and Management, Keio University School of Medicine, Tokyo, Japan
| | - Yoshihiro Kakeji
- Database Committee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Yuko Kitagawa
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
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Chen YT, Su ECY, Hung FM, Hiramatsu T, Hung TJ, Kuo CY. Constructing a Learning Curve to Discuss the Medical Treatments and the Effect of Vaccination of COVID-19. Healthcare (Basel) 2023; 11:1591. [PMID: 37297731 PMCID: PMC10252948 DOI: 10.3390/healthcare11111591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/23/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Acknowledging the extreme risk COVID-19 poses to humans, this paper attempted to analyze and compare case fatality rates, identify the existence of learning curves for COVID-19 medical treatments, and examine the impact of vaccination on fatality rate reduction. Confirmed cases and deaths were extracted from the "Daily Situation Report" provided by the World Health Organization. The results showed that low registration and low viral test rates resulted in low fatality rates, and the learning curve was significant for all countries except China. Treatment for COVID-19 can be improved through repeated experience. Vaccinations in the U.K. and U.S.A. are highly effective in reducing fatality rates, but not in other countries. The positive impact of vaccines may be attributed to higher vaccination rates. In addition to China, this study identified the existence of learning curves for the medical treatment of COVID-19 that can explain the effect of vaccination rates on fatalities.
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Affiliation(s)
- Yi-Tui Chen
- Smart Healthcare Interdisciplinary College, National Taipei University of Nursing and Health Sciences, Taipei 112, Taiwan
- Department of Health Care Management, College of Health Technology, National Taipei University of Nursing and Health Sciences, Taipei 112, Taiwan
- Department of Education and Research, Taipei City Hospital, Taipei 103, Taiwan
| | - Emily Chia-Yu Su
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, New Taipei City 235, Taiwan
- Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei 110, Taiwan
| | - Fang Ming Hung
- Department of Surgical Intensive Care Unit, Far Eastern Memorial Hospital, New Taipei City 220, Taiwan
| | - Tomoru Hiramatsu
- School of Policy Studies, Kwansei Gakuin University, Gakuen Uegahara 1, Sanda 669-1330, Japan
| | - Tzu-Jen Hung
- Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Chao-Yang Kuo
- Smart Healthcare Interdisciplinary College, National Taipei University of Nursing and Health Sciences, Taipei 112, Taiwan
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Kabha K, Zager Y, Anteby R, Ram E, Khaikin M, Gutman M, Nachmany I, Horesh N. Risk Factors for Readmission and Mortality Following Colonic Surgery: A Consecutive Retrospective Series of More Than 2500 Cases. J Laparoendosc Adv Surg Tech A 2023. [PMID: 37036789 DOI: 10.1089/lap.2023.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023] Open
Abstract
Introduction: The optimal strategy to reduce short-term readmission rates following colectomy remains unclear. Identifying possible risk factors can minimize the burden associated with surgical complications leading to readmissions. Materials and Methods: A retrospective review of all adult patients who underwent colectomies between January 2008 and December 2020 in a large tertiary medical center was conducted. Data were collected from patient's medical charts and analyzed. Results: Overall, 2547 patients were included in the study (53% females; mean age 68.3 years). The majority of patients (83%, n = 2112) were operated in an elective setting, whereas 435 patients (17%) underwent emergency colonic resection. Overall, the 30-day readmission rate was 8.3% (n = 218) with an overall 30-day mortality rate of 1.65% (n = 42). Multivariable analysis of possible risk factors for 30-day readmission demonstrated that patient age (odds ratio [OR] 0.98; P = .002), length of stay before surgery (OR 1.01; P = .003), and blood transfusion rate during hospitalization (OR 2.09; P < .001) were all independently associated with an increased risk. Laparoscopic colectomy (OR 0.53; P = .001) was associated with a reduced risk for readmission. Multivariable analysis of risk factors for mortality showed that age (OR 1.10; P < .001), cognitive decline (OR 12.35; P < .001), diabetes (OR 1.00; P = .004), and primary ostomy formation (OR 2.80; P = .006) were all associated with higher mortality. Conclusion: Patient age, history of cognitive decline, and blood transfusion along with a longer hospital stay were all correlated with an increased risk for 30-day patient readmission following colectomy.
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Affiliation(s)
- Kamal Kabha
- Department of General Surgery and Transplantations, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yaniv Zager
- Department of General Surgery and Transplantations, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roi Anteby
- Department of General Surgery and Transplantations, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Edward Ram
- Department of General Surgery and Transplantations, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Marat Khaikin
- Department of General Surgery and Transplantations, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Mordechai Gutman
- Department of General Surgery and Transplantations, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ido Nachmany
- Department of General Surgery and Transplantations, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nir Horesh
- Department of General Surgery and Transplantations, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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Marano L, Verre L, Carbone L, Poto GE, Fusario D, Venezia DF, Calomino N, Kaźmierczak-Siedlecka K, Polom K, Marrelli D, Roviello F, Kok JHH, Vashist Y. Current Trends in Volume and Surgical Outcomes in Gastric Cancer. J Clin Med 2023; 12:jcm12072708. [PMID: 37048791 PMCID: PMC10094776 DOI: 10.3390/jcm12072708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023] Open
Abstract
Gastric cancer is ranked as the fifth most frequently diagnosed type of cancer. Complete resection with adequate lymphadenectomy represents the goal of treatment with curative intent. Quality assurance is a crucial factor in the evaluation of oncological surgical care, and centralization of healthcare in referral hospitals has been proposed in several countries. However, an international agreement about the setting of “high-volume hospitals” as well as “minimum volume standards” has not yet been clearly established. Despite the clear postoperative mortality benefits that have been described for gastric cancer surgery conducted by high-volume surgeons in high-volume hospitals, many authors have highlighted the limitations of a non-composite variable to define the ideal postoperative period. The textbook outcome represents a multidimensional measure assessing the quality of care for cancer patients. Transparent and easily available hospital data will increase patients’ awareness, providing suitable elements for a more informed hospital choice.
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Affiliation(s)
- Luigi Marano
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Luigi Verre
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Ludovico Carbone
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Gianmario Edoardo Poto
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Daniele Fusario
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | | | - Natale Calomino
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Karolina Kaźmierczak-Siedlecka
- Department of Medical Laboratory Diagnostics-Fahrenheit Biobank BBMRI.pl, Medical University of Gdansk, 80-308 Gdańsk, Poland
| | - Karol Polom
- Department of Surgical Oncology, Medical University of Gdansk, 80-308 Gdańsk, Poland
| | - Daniele Marrelli
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Franco Roviello
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Johnn Henry Herrera Kok
- Department of General and Digestive Surgery, Complejo Asistencial Universitario de León, 24071 León, Spain
| | - Yogesh Vashist
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia
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17
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Blohm M, Sandblom G, Enochsson L, Hedberg M, Andersson MF, Österberg J. Relationship between surgical volume and outcomes in elective and acute cholecystectomy: nationwide, observational study. Br J Surg 2023; 110:353-361. [PMID: 36422988 PMCID: PMC10364541 DOI: 10.1093/bjs/znac415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 08/02/2022] [Accepted: 11/07/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND High surgical volumes are attributed to improved quality of care, especially for extensive procedures. However, it remains unknown whether high-volume surgeons and hospitals have better results in gallstone surgery. The aim of this study was to investigate whether operative volume affects outcomes in cholecystectomies. METHODS A registry-based cohort study was performed, based on the Swedish Registry of Gallstone Surgery. Cholecystectomies from 2006 to 2019 were included. Annual volumes for the surgeon and hospital were retrieved. All procedures were categorized into volume-based quartiles, with the highest group as reference. Low volume was defined as fewer than 20 operations per surgeon per year and fewer than 211 cholecystectomies per hospital per year. Differences in outcomes were analysed separately for elective and acute procedures. RESULTS The analysis included 154 934 cholecystectomies. Of these, 101 221 (65.3 per cent) were elective and 53 713 (34.7 per cent) were acute procedures. Surgeons with low volumes had longer operating times (P < 0.001) and higher conversion rates in elective (OR 1.35; P = 0.023) and acute (OR 2.41; P < 0.001) operations. Low-volume surgeons also caused more bile duct injuries (OR 1.41; P = 0.033) and surgical complications (OR 1.15; P = 0.033) in elective surgery, but the results were not statistically significant for acute procedures. Low-volume hospitals had more bile duct injuries in both elective (OR 1.75; P = 0.002) and acute (OR 1.96; P = 0.003) operations, and a higher mortality rate after acute surgery (OR 2.53; P = 0.007). CONCLUSION This study has demonstrated that operative volumes influence outcomes in cholecystectomy. The results indicate that gallstone surgery should be performed by procedure-dedicated surgeons at hospitals with high volumes of this type of benign surgery.
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Affiliation(s)
- My Blohm
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Mora Hospital, Mora, Sweden.,Center for Clinical Research, Uppsala University, Falun, Sweden
| | - Gabriel Sandblom
- Department of Clinical Science and Education, South General Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Lars Enochsson
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Department of Surgery, Sunderby Hospital, Luleå, Sweden
| | - Mats Hedberg
- Department of Surgery, Mora Hospital, Mora, Sweden
| | - Mikael Franko Andersson
- Department of Clinical Science and Education, South General Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Johanna Österberg
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Mora Hospital, Mora, Sweden.,Center for Clinical Research, Uppsala University, Falun, Sweden
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Postoperative outcomes of right hemicolectomy for cancer in 11 countries of Latin America: A multicentre retrospective study. Colorectal Dis 2023; 25:923-931. [PMID: 36748272 DOI: 10.1111/codi.16505] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/02/2023] [Accepted: 01/23/2023] [Indexed: 02/08/2023]
Abstract
AIM There is scant evidence regarding surgical outcomes of patients with colon cancer in Latin America. The aim of this work was to compare perioperative (30 day) outcomes of patients undergoing surgery for right colon cancer in Latin America based on centre volume. METHOD This is a multi-institutional retrospective cohort study. Individuals operated on for right colon cancer with curative intent in an urgent or elective setting between 2016 and 2021 were eligible for inclusion in the study. Patients were divided into two groups according to whether they were operated on in low-volume or high-volume centres (defined as more than 30 cases/year). RESULTS A total of 2676 patients from 46 hospitals in 11 countries of Latin America were included, with 389 (14.5%) in the low-volume group. The median age was 67.37 years. The high-volume group presented higher rates of laparoscopic procedures (56.8 vs. 35.7%, p < 0.001, OR 2.36), with lower conversion rates, fewer intraoperative complications and a shorter operating time. The high-volume group had a shorter length of hospital stay. The overall complication rate for the whole group was 15.9%, with a lower incidence of these events in the high-volume group (13.7 vs. 28.7%, p < 0.001, OR 0.40). Overall, anastomotic leakage, reoperation and mortality rates were 5.6%, 9.2% and 6.1%, respectively, with differences favouring high-volume centres. On multivariate analysis, low-volume group, history of cardiac disease, emergency surgery, operation performed by a general surgeon, open approach and intraoperative complications were independent predictors of major postoperative complications. CONCLUSION This is the first study in Latin America to show better postoperative outcomes at a regional scale when surgery for right colon cancer is performed in high-volume centres. Further studies are needed to validate these data and to identify which of the factors can explain the present results.
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19
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Rosander E, Holm T, Sjövall A, Hjern F, Weibull CE, Nordenvall C. The impact of hospital volume on survival in patients with locally advanced colonic cancer. BJS Open 2022; 6:6843377. [PMID: 36417311 PMCID: PMC9683387 DOI: 10.1093/bjsopen/zrac140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/22/2022] [Accepted: 10/04/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND High hospital volume has been shown associated with improved survival in patients with several cancers. The aim of this nationwide cohort study was to investigate whether hospital volume affects survival in patients with locally advanced colonic cancer. METHODS All patients with non-metastatic locally advanced colonic cancer diagnosed between 2007 and 2017 in Sweden were included. Tertiles of annual hospital volume of locally advanced colonic cancer were analysed and 5-year overall and colonic cancer-specific survival were calculated with the Kaplan-Meier method. HRs comparing all-cause and colonic cancer-specific mortality rates were estimated using Cox models adjusted for potential confounders (age, sex, year of diagnosis, co-morbidity, elective/emergency resection, and university hospital) and mediators (preoperative multidisciplinary team assessment, neoadjuvant chemotherapy, radical resection, and surgical experience). RESULTS A total of 5241 patients were included with a mean follow-up of 2.7-2.8 years for low- and high-volume hospitals. The number of patients older than 79 years were 569 (32.3 per cent), 495 (29.9 per cent), and 482 (26.4 per cent) for low-, medium- and high-volume hospitals respectively. The 3-year overall survival was 68 per cent, 60 per cent and 58 per cent for high-, medium- and low-volume hospitals, respectively (P < 0.001 from log rank test). High volume hospitals were associated with reduced all-cause and colon cancer-specific mortality after adjustments for potential confounders (HR 0.76, 95 per cent CI 0.62 to 0.93 and HR 0.73, 95 per cent CI 0.59 to 0.91, respectively). The effect remained after inclusion of potential mediators. CONCLUSIONS High hospital volume is associated with reduced mortality in patients with locally advanced colonic cancer.
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Affiliation(s)
- Emma Rosander
- Correspondence to: Emma Rosander, Department of Surgery and Urology, Danderyd Hospital, 182 88 Stockholm, Sweden (e-mail: )
| | - Torbjörn Holm
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Annika Sjövall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden,Department of Pelvic Cancer, Gastrointestinal (GI) Oncology and Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Hjern
- Department of Surgery and Urology, Danderyd Hospital, Stockholm, Sweden,Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - Caroline E Weibull
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Caroline Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden,Department of Pelvic Cancer, Gastrointestinal (GI) Oncology and Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden
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20
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Asoglu O, Bulut A, Aliyev V, Piozzi GN, Guven K, Bakır B, Goksel S. Chemoradiation and consolidation chemotherapy for rectal cancer provides a high rate of organ preservation with a very good long-term oncological outcome: a single-center cohort series. World J Surg Oncol 2022; 20:358. [PMCID: PMC9646475 DOI: 10.1186/s12957-022-02816-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Aim
To report long-term oncological outcomes and organ preservation rate with a chemoradiotherapy-consolidation chemotherapy (CRT-CNCT) treatment for locally advanced rectal cancer (LARC).
Method
Retrospective analysis of prospectively maintained database was performed. Oncological outcomes of mid-low LARC patients (n=60) were analyzed after a follow-up of 63 (50–83) months. Patients with clinical complete response (cCR) were treated with the watch-and-wait (WW) protocol. Patients who could not achieve cCR were treated with total mesorectal excision (TME) or local excision (LE).
Results
Thirty-nine (65%) patients who achieved cCR were treated with the WW protocol. TME was performed in 15 (25%) patients and LE was performed in 6 (10%) patients. During the follow-up period, 10 (25.6%) patients in the WW group had regrowth (RG) and 3 (7.7%) had distant metastasis (DM). Five-year overall survival (OS) and disease-free survival (DFS) were 90.1% and 71.6%, respectively, in the WW group. Five-year OS and DFS were 94.9% (95% CI: 88–100%) and 80% (95% CI: 55.2–100%), respectively, in the RG group. For all patients (n=60), 5-year TME-free DFS was 57.3% (95% CI: 44.3–70.2%) and organ preservation-adapted DFS was 77.5% (95% CI: 66.4–88.4%). For the WW group (n=39), 5-year TME-free DFS was 77.5% (95% CI: 63.2–91.8%) and organ preservation-adapted DFS was 85.0% (95% CI: 72.3–97.8%).
Conclusion
CRT-CNCT provides cCR as high as 2/3 of LARC patients. Regrowths, developed during follow-up, can be successfully salvaged without causing oncological disadvantage if strict surveillance is performed.
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21
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Dinger TL, Kroon HM, Traeger L, Bedrikovetski S, Hunter A, Sammour T. Regional variance in treatment and outcomes of locally invasive (T4) rectal cancer in Australia and New Zealand: analysis of the Bi-National Colorectal Cancer Audit. ANZ J Surg 2022; 92:1772-1780. [PMID: 35502647 PMCID: PMC9541368 DOI: 10.1111/ans.17699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/05/2022] [Accepted: 03/30/2022] [Indexed: 12/09/2022]
Abstract
Backgrounds Locally invasive T4 rectal cancer often requires neoadjuvant treatment followed by multi‐visceral surgery to achieve a radical resection (R0), and referral to a specialized exenteration quaternary centre is typically recommended. The aim of this study was to explore regional variance in treatment and outcomes of patients with locally advanced rectal cancer in Australia and New Zealand (ANZ). Methods Data were collected from the Bi‐National Colorectal Cancer Audit (BCCA) database. Rectal cancer patients treated between 2007 and 2019 were divided into six groups based on region (state/country) using patient postcode. A subset analysis of patients with T4 cancer was performed. Primary outcomes were positive circumferential resection margin (CRM+), and positive circumferential and/or distal resection margin (CRM/DRM+). Results A total of 9385 patients with rectal cancer were identified, with an overall CRM+ rate of 6.4% and CRM/DRM+ rate of 8.6%. There were 1350 patients with T4 rectal cancer (14.4%). For these patients, CRM+ rate was 18.5%, and CRM/DRM+ rate was 24.1%. Significant regional variation in CRM+ (range 13.4–26.0%; p = 0.025) and CRM/DRM+ rates (range 16.1–29.3%; p = 0.005) was identified. In addition, regions with higher CRM+ and CRM/DRM+ rates reported lower rates of multi‐visceral resections: range 24.3–26.8%, versus 32.6–37.3% for regions with lower CRM+ and CRM/DRM+ rates (p < 0.0001). Conclusion Positive resection margins and rates of multi‐visceral resection vary between the different regions of ANZ. A small subset of patients with T4 rectal cancer are particularly at risk, further supporting the concept of referral to specialized exenteration centres for potentially curative multi‐visceral resection.
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Affiliation(s)
- Tessa L Dinger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Medical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Luke Traeger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew Hunter
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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22
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Chen X, Chen J, He X, Xu L, Liu W, Lin D, Luo Y, Feng Y, Lian L, Hu J, Lan P. Endoscopy-Based Deep Convolutional Neural Network Predicts Response to Neoadjuvant Treatment for Locally Advanced Rectal Cancer. Front Physiol 2022; 13:880981. [PMID: 35574447 PMCID: PMC9091815 DOI: 10.3389/fphys.2022.880981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: Although the wait and watch (W&W) strategy is a treatment choice for locally advanced rectal cancer (LARC) patients who achieve clinical complete response (cCR) after neoadjuvant therapy (NT), the issue on consistency between cCR and pathological CR (pCR) remains unsettled. Herein, we aimed to develop a deep convolutional neural network (DCNN) model using endoscopic images of LARC patients after NT to distinguish tumor regression grade (TRG) 0 from non-TRG0, thus providing strength in identifying surgery candidates. Methods: A total of 1000 LARC patients (6,939 endoscopic images) who underwent radical surgery after NT from April 2013 to April 2021 at the Sixth Affiliated Hospital, Sun Yat-sen University were retrospectively included in our study. Patients were divided into three cohorts in chronological order: the training set for constructing the model, the validation set, and the independent test set for validating its predictive capability. Besides, we compared the model's performance with that of three endoscopists on a class-balanced, randomly selected subset of 20 patients' LARC images (10 TRG0 patients with 70 images and 10 non-TRG0 patients with 72 images). The measures used to evaluate the efficacy for identifying TRG0 included overall accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating characteristic curve (AUROC). Results: There were 219 (21.9%) cases of TRG0 in the included patients. The constructed DCNN model in the training set obtained an excellent performance with good accuracy of 94.21%, specificity of 94.39%, NPV of 98.11%, and AUROC of 0.94. The validation set showed accuracy, specificity, NPV, and AUROC of 92.13%, 93.04%, 96.69%, and 0.95, respectively; the corresponding values in the independent set were 87.14%, 92.98%, 91.37%, and 0.77, respectively. In the reader study, the model outperformed the three experienced endoscopists with an AUROC of 0.85. Conclusions: The proposed DCNN model achieved high specificity and NPV in detecting TRG0 LARC tumors after NT, with a better performance than experienced endoscopists. As a supplement to radiological images, this model may serve as a useful tool for identifying surgery candidates in LARC patients after NT.
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Affiliation(s)
- Xijie Chen
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Junguo Chen
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaosheng He
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liang Xu
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Pathology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Liu
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dezheng Lin
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuxuan Luo
- Tianjin Economic-Technological Development Area, Yujin Digestive Health Industry Research Institute, Tianjin, China
| | - Yue Feng
- Tianjin Economic-Technological Development Area, Yujin Digestive Health Industry Research Institute, Tianjin, China
| | - Lei Lian
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiancong Hu
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Network Management, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ping Lan
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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23
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Welten VM, Wanis KN, Madenci AL, Fields AC, Lu PW, Malizia RA, Yoo J, Goldberg JE, Irani JL, Bleday R, Melnitchouk N. The Effect of Facility Volume on Survival Following Proctectomy for Rectal Cancer. J Gastrointest Surg 2022; 26:150-160. [PMID: 34291364 DOI: 10.1007/s11605-021-05092-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/01/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Prior studies assessing colorectal cancer survival have reported better outcomes when operations are performed at high-volume centers. These studies have largely been cross-sectional, making it difficult to interpret their estimates. We aimed to assess the effect of facility volume on survival following proctectomy for rectal cancer. METHODS Using data from the National Cancer Database, we included all patients with complete baseline information who underwent proctectomy for non-metastatic rectal cancer between 2004 and 2016. Facility volume was defined as the number of rectal cancer cases managed at the treating center in the calendar year prior to the patient's surgery. Overall survival estimates were obtained for facility volumes ranging from 10 to 100 cases/year. Follow-up began on the day of surgery and continued until loss to follow-up or death. RESULTS A total of 52,822 patients were eligible. Patients operated on at hospitals with volumes of 10, 30, and 50 cases/year had similar distributions of grade, clinical stage, and neoadjuvant therapies. 1-, 3-, and 5-year survival all improved with increasing facility volume. One-year survival was 94.0% (95% CI: 93.7, 94.3) for hospitals that performed 10 cases/year, 94.5% (95% CI: 94.2, 94.7) for 30 cases/year, and 94.8% (95% CI: 94.5, 95.0) for 50 cases/year. Five-year survival was 68.9% (95% CI: 68.0, 69.7) for hospitals that performed 10 cases/year, 70.8% (95% CI: 70.1, 71.5) for 30 cases/year, and 72.0% (95% CI: 71.2, 72.8) for 50 cases/year. CONCLUSIONS Treatment at a higher volume facility results in improved survival following proctectomy for rectal cancer, though the small benefits are less profound than previously reported.
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Affiliation(s)
- Vanessa M Welten
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA. .,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont St, MA, 02120, Boston, USA.
| | - Kerollos N Wanis
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, MA, 02115, Boston, USA
| | - Arin L Madenci
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Adam C Fields
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Pamela W Lu
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Robert A Malizia
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - James Yoo
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Joel E Goldberg
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Jennifer L Irani
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Ronald Bleday
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Nelya Melnitchouk
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont St, MA, 02120, Boston, USA
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24
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Predicting pathologic complete response in locally advanced rectal cancer patients after neoadjuvant therapy: a machine learning model using XGBoost. Int J Colorectal Dis 2022; 37:1621-1634. [PMID: 35704090 PMCID: PMC9262764 DOI: 10.1007/s00384-022-04157-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Watch and wait strategy is a safe and effective alternative to surgery in patients with locally advanced rectal cancer (LARC) who have achieved pathological complete response (pCR) after neoadjuvant therapy (NAT); present restaging methods do not meet clinical needs. This study aimed to construct a machine learning (ML) model to predict pCR preoperatively. METHODS LARC patients who received NAT were included to generate an extreme gradient boosting-based ML model to predict pCR. The group was divided into a training set and a tuning set at a 7:3 ratio. The SHapley Additive exPlanations value was used to quantify feature importance. The ML model was compared with a nomogram model developed using independent risk factors identified by conventional multivariate logistic regression analysis. RESULTS Compared with the nomogram model, our ML model improved the area under the receiver operating characteristics from 0.72 to 0.95, sensitivity from 43 to 82.2%, and specificity from 87.1 to 91.6% in the training set, the same trend applied to the tuning set. Neoadjuvant radiotherapy, preoperative carbohydrate antigen 125 (CA125), CA199, carcinoembryonic antigen level, and depth of tumor invasion were significant in predicting pCR in both models. CONCLUSION Our ML model is a potential alternative to the existing assessment tools to conduct triage treatment for patients and provides reference for clinicians in tailoring individual treatment: the watch and wait strategy is used to avoid surgical trauma in pCR patients, and non-pCR patients receive surgical treatment to avoid missing the optimal operation time window.
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25
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Verseveld M, Verver D, Noordman BJ, Pouwels S, Elferink MAG, de Graaf EJR, Verhoef C, Doornebosch PG, de Wilt JHW. Treatment of clinical T1 rectal cancer in the Netherlands; a population-based overview of clinical practice. Eur J Surg Oncol 2021; 48:1153-1160. [PMID: 34799230 DOI: 10.1016/j.ejso.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 10/22/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Local excision is increasingly used as an alternative treatment for radical surgery in patients with early stage clinical T1 (cT1) rectal cancer. This study provides an overview of incidence, staging accuracy and treatment strategies in patients with cT1 rectal cancer in the Netherlands. MATERIALS AND METHODS Patients with cT1 rectal cancer diagnosed between 2005 and 2018 were included from the Netherlands Cancer Registry. An overview per time period (2005-2009, 2010-2014 and 2015-2018) of the incidence and various treatment strategies used, e.g. local excision (LE) or major resection, with/without neoadjuvant treatment (NAT), were given and trends over time were analysed using the Chi Square for Trend test. In addition, accuracy of tumour staging was described, compared and analysed over time. RESULTS In total, 3033 patients with cT1 rectal cancer were diagnosed. The incidence of cT1 increased from 540 patients in 2005-2009 to 1643 patients in 2015-2018. There was a significant increased use of LE. In cT1N0/X patients, 9.2% received NAT, 25.5% were treated by total mesorectal excision (TME) and 11.4% received a completion TME (cTME) following prior LE. Overall accuracy in tumour staging (cT1 = pT1) was 77.3%, yet significantly worse in cN1/2 patients, as compared to cN0 patients (44.8% vs 77.9%, respectively, p < 0.001). CONCLUSION Over time, there was an increase in the incidence of cT1 tumours. Both the use of neoadjuvant therapy and TME surgery in clinically node negative patients decreased significantly. Clinical accuracy in T1 tumour staging improved over time, but remained significantly worse in clinical node positive patients.
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Affiliation(s)
- M Verseveld
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, the Netherlands; Department of Surgery, division of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - D Verver
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, the Netherlands
| | - B J Noordman
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, the Netherlands; Department of Surgery, division of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - S Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - M A G Elferink
- Department of Research & Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - E J R de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - C Verhoef
- Department of Surgery, division of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - P G Doornebosch
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - J H W de Wilt
- Department of Surgery, division of Surgical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
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26
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Assessing the hospital volume-outcome relationship in surgery: a scoping review. BMC Med Res Methodol 2021; 21:204. [PMID: 34627143 PMCID: PMC8502281 DOI: 10.1186/s12874-021-01396-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 09/09/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Many recent studies have investigated the hospital volume-outcome relationship in surgery. In some cases, the results have prompted the centralization of surgical activity. However, the methodologies and interpretations differ markedly from one study to another. The objective of the present scoping review was to describe the various features used to assess the volume-outcome relationship: the analyzed datasets, study population, outcome, covariates, confounders, volume modalities, and statistical methods. Methods and analysis The review was conducted according to a study protocol published in BMJ Open in 2020. Two authors (both of whom had helped to design the study protocol) screened publications independently according to the title, the abstract and then the full text. To ensure exhaustivity, all the papers included by each reviewer went through to the next step. Interpretation The 403 included studies covered 90 types of surgery, 61 types of outcome, and 72 covariates or potential confounders. 191 (47.5%) studies focussed on oncological surgery and 37.8% focussed visceral or digestive tract surgery. Overall, 86.6% of the studies found a statistically significant volume-outcome relationship, although the findings differed from one type of surgery to another. Furthermore, the types of outcome and the covariates were highly diverse. The majority of studies were performed in Western countries, and oncological and visceral surgical procedures were over-represented; this might limit the generalizability and comparability of the studies’ results. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01396-6.
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27
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Sala Hernandez A, Frasson M, García-Granero A, Hervás Marín D, Laiz Marro B, Alonso Pardo R, Aldrey Cao I, Alvarez Perez JA, Roque Castellano C, García González JM, Tabet Almeida J, García-Granero E. Diagnostic accuracy of C-reactive protein, procalcitonin and neutrophils for the early detection of anastomotic leakage after colorectal resection: a multicentric, prospective study. Colorectal Dis 2021; 23:2723-2730. [PMID: 34314565 DOI: 10.1111/codi.15845] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/30/2021] [Accepted: 07/20/2021] [Indexed: 12/08/2022]
Abstract
AIM The aim was to determine the accuracy of C-reactive protein (CRP), procalcitonin and neutrophils in the early detection (fourth postoperative day) of anastomotic leakage (AL) after colorectal surgery. METHODS We conducted a multicentre, prospective study that included a consecutive series of patients who underwent colorectal resection with anastomosis without ostomy (September 2015 to December 2017). CRP, procalcitonin and neutrophil values on the fourth postoperative day after colorectal resection along with the postoperative outcome (60-day AL, morbidity and mortality) were prospectively included in an online, anonymous database. RESULTS The analysis ultimately included 2501 cases. The overall morbidity and mortality was 30.1% and 1.6%, respectively, and the AL rate was 8.6%. The area under the receiver operating characteristic curve values (95% CI) for detecting AL were 0.84 (0.81-0.87), 0.75 (0.72-0.79) and 0.70 (0.66-0.74) for CRP, procalcitonin and neutrophils, respectively. The best cut-off level for CRP was 119 mg/l, resulting in 70% sensitivity, 81% specificity and 97% negative predictive value. After laparoscopic resection, the accuracy for CRP and procalcitonin was increased, compared with open resection. The combination of two or three of these biomarkers did not significantly increase their accuracy. CONCLUSION On the fourth postoperative day, CRP was the most reliable marker for excluding AL. Its high negative predictive value, especially after laparoscopic resection, allows for safe hospital discharge on the fourth postoperative day. The routine use of procalcitonin or neutrophil counts does not seem to increase the diagnostic accuracy.
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Affiliation(s)
- Angela Sala Hernandez
- Colorectal Surgery Unit, Hospital Universitario y Politecnico la Fe, Valencia, Spain
| | - Matteo Frasson
- Colorectal Surgery Unit, Hospital Universitario y Politecnico la Fe, Valencia, Spain
| | - Alvaro García-Granero
- Colorectal Surgery Unit, Hospital Universitario y Politecnico la Fe, Valencia, Spain
| | - David Hervás Marín
- Biostatistical Unit, Hospital Universitario y Politecnico la Fe, Valencia, Spain
| | - Begoña Laiz Marro
- Clinical Laboratory, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Ricardo Alonso Pardo
- Clinical Laboratory, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Inés Aldrey Cao
- Colorectal Surgery Unit, Complexo Hospitalario Universitario de Ourense, Galicia, Spain
| | | | - Cristina Roque Castellano
- Colorectal Surgery Unit, Islas Canarias, Hospital Universitario de Gran Canaria Doctor Negrín, Spain
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Cui CL, Luo WY, Cosman BC, Eisenstein S, Simpson D, Ramamoorthy S, Murphy J, Lopez N. Cost Effectiveness of Watch and Wait Versus Resection in Rectal Cancer Patients with Complete Clinical Response to Neoadjuvant Chemoradiation. Ann Surg Oncol 2021; 29:1894-1907. [PMID: 34529175 PMCID: PMC8810473 DOI: 10.1245/s10434-021-10576-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 06/22/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Watch and wait (WW) protocols have gained increasing popularity for patients diagnosed with locally advanced rectal cancer and presumed complete clinical response after neoadjuvant chemoradiation. While studies have demonstrated comparable survival and recurrence rates between WW and radical surgery, the decision to undergo surgery has significant effects on patient quality of life. We sought to conduct a cost-effectiveness analysis comparing WW with abdominoperineal resection (APR) and low anterior resection (LAR) among patients with stage II/III rectal cancer. METHODS In this comparative-effectiveness study, we built Markov microsimulation models to simulate disease progression, death, costs, and quality-adjusted life-years (QALYs) for WW or APR/LAR. We assessed cost effectiveness using the incremental cost-effectiveness ratio (ICER), with ICERs under $100,000/QALY considered cost effective. Probabilities of disease progression, death, and health utilities were extracted from published, peer-reviewed literature. We assessed costs from the payer perspective. RESULTS WW dominated both LAR and APR at a willingness to pay (WTP) threshold of $100,000. Our model was most sensitive to rates of distant recurrence and regrowth after WW. Probabilistic sensitivity analysis demonstrated that WW was the dominant strategy over both APR and LAR over 100% of iterations across a range of WTP thresholds from $0-250,000. CONCLUSIONS Our study suggests WW could reduce overall costs and increase effectiveness compared with either LAR or APR. Additional clinical research is needed to confirm the clinical efficacy and cost effectiveness of WW compared with surgery in rectal cancer.
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Affiliation(s)
- Christina Liu Cui
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - William Yu Luo
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Bard Clifford Cosman
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, San Diego Health Systems, La Jolla, CA, 92093-0987, USA.,Veterans Affairs San Diego Medical Center, San Diego, CA, USA
| | - Samuel Eisenstein
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, San Diego Health Systems, La Jolla, CA, 92093-0987, USA
| | - Daniel Simpson
- Department of Radiation Medicine and Applied Science, University of California, San Diego, La Jolla, CA, USA
| | - Sonia Ramamoorthy
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, San Diego Health Systems, La Jolla, CA, 92093-0987, USA
| | - James Murphy
- Department of Radiation Medicine and Applied Science, University of California, San Diego, La Jolla, CA, USA
| | - Nicole Lopez
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, San Diego Health Systems, La Jolla, CA, 92093-0987, USA.
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Lazzaron AR, Silveira I, Machado PS, Damin DC. The role of Hartmann's procedure in the elective management of rectal cancer: results of a Brazilian cohort study. Rev Col Bras Cir 2021; 48:e20212977. [PMID: 34378751 PMCID: PMC10683413 DOI: 10.1590/0100-6991e-20212977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/13/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND although preservation of bowel continuity is a major goal in rectal cancer surgery, a colorectal anastomosis may be considered an unacceptably high-risk procedure, particularly for patients with multiple comorbidities. We aimed to assess rates of surgical complications in rectal cancer patients according to the type of procedure they had undergone. MATERIALS AND METHODS this cohort included all rectal cancer patients undergoing elective resection at a referral academic hospital over 16 years. There were three study groups according to the type of performed operation: (1) rectal resection with anastomosis without defunctioning stoma (DS); (2) rectal resection with anastomosis and DS; and (3) Hartmann's procedure (HP). Postoperative complications and clinical outcomes were assessed. RESULTS four-hundred and two patients were studied. The 118 patients in group 3 were significantly older (>10 years), had higher Charlson Comorbidity Index scores, and more ASA class ≥3 than patients in the other two groups. Sixty-seven patients (16.7%) had Clavien-Dindo complications grade ≥ III, corresponding to an incidence of 11.8%, 20.9%, and 14.4% in groups 1, 2, and 3, respectively (p=0.10). Twenty-nine patients (7.2%) had major septic complications that required reoperation, with an incidence of 10.8%, 8.2% and 2.5% in groups 1, 2 and 3, respectively (p=0.048). Twenty-one percent of the group 2 patients did not undergo the stoma closure after a 24-month follow-up. CONCLUSION HP was associated with a lower incidence of reoperation due to intra-abdominal septic complications. This procedure remains an option for patients in whom serious surgical complications are anticipated.
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Affiliation(s)
- Anderson Rech Lazzaron
- - Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Serviço de Coloproctologia - Pós-graduação em Cirurgia (UFRGS) - Porto Alegre - RS - Brasil
| | - Ingrid Silveira
- - Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Serviço de Coloproctologia - Pós-graduação em Cirurgia (UFRGS) - Porto Alegre - RS - Brasil
| | - Pauline Simas Machado
- - Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Serviço de Coloproctologia - Pós-graduação em Cirurgia (UFRGS) - Porto Alegre - RS - Brasil
| | - Daniel C Damin
- - Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Serviço de Coloproctologia - Pós-graduação em Cirurgia (UFRGS) - Porto Alegre - RS - Brasil
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The impact of the affordable care act on surgeon selection amongst colorectal surgery patients. Am J Surg 2021; 222:256-261. [DOI: 10.1016/j.amjsurg.2021.01.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 01/19/2021] [Accepted: 01/31/2021] [Indexed: 12/13/2022]
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The Affordable Care Act: A success? Am J Surg 2021; 222:254-255. [DOI: 10.1016/j.amjsurg.2021.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/03/2021] [Accepted: 02/03/2021] [Indexed: 02/01/2023]
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Robertson RL, Karimuddin A, Phang T, Raval M, Brown C. Transanal versus conventional total mesorectal excision for rectal cancer using the IDEAL framework for implementation. BJS Open 2021; 5:6246778. [PMID: 33889949 PMCID: PMC8062257 DOI: 10.1093/bjsopen/zrab002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/11/2020] [Accepted: 01/01/2021] [Indexed: 01/04/2023] Open
Abstract
Background Transanal total mesorectal excision (TaTME) is an innovative technique for distal rectal cancer dissection. It has been shown to have similar short-term outcomes to conventional open and laparoscopic total mesorectal excision (cTME), but recent studies have raised concern about increased morbidity and local recurrence rates. The aim of this study was to assess outcomes after TaTME versus cTME for rectal cancer. Methods TaTME was implemented in 2014 using IDEAL principles in a single institution. The institution maintains databases for all patients undergoing rectal cancer surgery. This retrospective review compared data collected from all patients who had TaTME with those from a propensity-matched cohort of patients who underwent cTME. The primary outcome was a composite pathological measure combining margin status and quality of total mesorectal excision (TME). Short-term clinical and survival outcomes were also measured. Results Propensity matching created 109 matched pairs for analysis. Nine patients (8.3 per cent) undergoing TaTME had positive margins and/or incomplete TME, compared with 11 (10.5 per cent) undergoing cTME (P = 0.65). There were no significant differences in morbidity between the TaTME and cTME groups, including number of anastomotic leaks (13.8 versus 18.3 per cent; P = 0.37). The estimated 3-year local recurrence-free survival rate was 96.3 per cent in both groups (P = 0.39). Estimated 3-year overall (93.6 per cent for TaTME versus 94.5 per cent for cTME; P = 0.09) and disease-free (88.1 versus 76.1 per cent; P = 0.90) survival rates were similar. Conclusion TaTME provided similar outcomes to cTME for rectal cancer with the application of IDEAL principles.
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Affiliation(s)
- R L Robertson
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - A Karimuddin
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - T Phang
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - M Raval
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - C Brown
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Li W, Deng X, Chen T. Exploring the Modulatory Effects of Gut Microbiota in Anti-Cancer Therapy. Front Oncol 2021; 11:644454. [PMID: 33928033 PMCID: PMC8076595 DOI: 10.3389/fonc.2021.644454] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/18/2021] [Indexed: 12/16/2022] Open
Abstract
In the recent decade, gut microbiota has received growing interest due to its role in human health and disease. On the one hand, by utilizing the signaling pathways of the host and interacting with the immune system, the gut microbiota is able to maintain the homeostasis in human body. This important role is mainly modulated by the composition of microbiota, as a normal microbiota composition is responsible for maintaining the homeostasis of human body, while an altered microbiota profile could contribute to several pathogenic conditions and may further lead to oncogenesis and tumor progression. Moreover, recent insights have especially focused on the important role of gut microbiota in current anticancer therapies, including chemotherapy, radiotherapy, immunotherapy and surgery. Research findings have indicated a bidirectional interplay between gut microbiota and these therapeutic methods, in which the implementation of different therapeutic methods could lead to different alterations in gut microbiota, and the presence of gut microbiota could in turn contribute to different therapeutic responses. As a result, manipulating the gut microbiota to reduce the therapy-induced toxicity may provide an adjuvant therapy to achieve a better therapeutic outcome. Given the complex role of gut microbiota in cancer treatment, this review summarizes the interactions between gut microbiota and anticancer therapies, and demonstrates the current strategies for reshaping gut microbiota community, aiming to provide possibilities for finding an alternative approach to lower the damage and improve the efficacy of cancer therapy.
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Affiliation(s)
- Wenyu Li
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Queen Mary School, Nanchang University, Nanchang, China
| | - Xiaorong Deng
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Tingtao Chen
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- National Engineering Research Center for Bioengineering Drugs and the Technologies, Institute of Translational Medicine, The First Affiliated Hospital, Nanchang University, Nanchang, China
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Khan S, Kaltenmeier C, Hrebinko K, Nassour I, Hoehn RS, Medich DS, Zureikat A, Tohme S. Readmission After Surgical Resection for Colon and Rectal Cancers: A Retrospective Cohort Study. Am Surg 2021; 88:1118-1130. [PMID: 33517684 DOI: 10.1177/0003134820988810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Colorectal adenocarcinoma is a leading cause of cancer mortality worldwide, often requiring patients to undergo anatomy-altering surgical interventions leading to increased postoperative readmission. Hospital readmission rates have been correlated with increased mortality. Therefore, it is important to understand the association between 30-day readmission rates and mortality as well as the factors associated with increased readmission rates. STUDY DESIGN This is a retrospective review utilizing data from the National Cancer Database. Our primary outcomes of interest were 30- and 90-day mortality rates. Our primary independent variable of interest was 30-day readmission. RESULTS Between 2010 and 2016, 207 299 patients underwent surgery for rectal cancer and 754 895 for colon cancer. The readmission rates within 30 days of discharge were 5.4% and 5.5% for patients after surgery for rectal or colon cancer, respectively. 30-day readmission was not associated with 30-day mortality, but it was independently associated with increased 90-day mortality and inferior long-term survival for both cohorts (P = .001). Independent risk factors significantly associated with increased readmission included race, non-private insurance, and low income. CONCLUSION This study provides a large, up-to-date, and comprehensive analysis of readmission rates for colon and rectal cancers. We demonstrate that socioeconomic factors are associated with increased 30-day readmission. 30-day readmission is also independently associated with increased 90-day mortality as well as lower overall survival rates. Our study supports the need for implementation of programs that support patients of lower socioeconomic status undergoing surgery to further decrease readmission rates and mortality.
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Affiliation(s)
- Sidrah Khan
- Department of Surgery, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Katherine Hrebinko
- Department of Surgery, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Ibrahim Nassour
- Department of Surgery, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Richard S Hoehn
- Department of Surgery, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - David S Medich
- Department of Surgery, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer Zureikat
- Department of Surgery, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Samer Tohme
- Department of Surgery, 6614University of Pittsburgh, Pittsburgh, PA, USA
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Improvement of Survival over Time for Colorectal Cancer Patients: A Population-Based Study. J Clin Med 2020; 9:jcm9124038. [PMID: 33327538 PMCID: PMC7765021 DOI: 10.3390/jcm9124038] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/24/2020] [Accepted: 12/08/2020] [Indexed: 01/04/2023] Open
Abstract
Purpose: In this study, we analyzed the mortality and survival of colorectal cancer patients in Lithuania. Methods: This was a national cohort study. Population-based data from the Lithuanian Cancer Registry and period analyses were collected. Overall, 20,980 colorectal cancer patients were included. We examined the changes in colorectal cancer mortality and survival rates between 1998 and 2012 according to cancer anatomical sub-sites and stages. We calculated the 5-year relative survival estimates using period analysis. Results: Overall, 20,980 colorectal cancer cases reported from 1998 to 2012 were included in the study. The total number of newly diagnosed colorectal cancers increased from 1998–2002 to 2008–2012 by 12.1%. The highest number of colorectal cancers was localized and increased from 33.9% to 42.0%. The number of cancers with regional metastases and advanced cancers decreased by 11.1% and 15.5%, respectively. An increased number of new cases was observed for almost all colon cancer sub-sites. The overall 5-year relative survival rate increased from 37.9% in 1998–2002 to 51.5% in 2008–2012. We showed an increase in survival rates for all stages and all sub-sites. In the most recent period, patients with a localized disease had a 5-year survival rate of 78.6%, while survival estimates for advanced cancer patients remained low at 6.6%. Conclusion: Although survival rates variated in colorectal cancer patients according to disease stages and sub-sites, we showed increased survival rates for all patients.
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Gilshtein H, Wexner SD. National Accreditation Program for Rectal Cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Beard BW, Rettig RL, Ryoo JJ, Parker RA, McLemore EC, Attaluri V. Watch-and-Wait Compared to Operation for Patients with Complete Response to Neoadjuvant Therapy for Rectal Cancer. J Am Coll Surg 2020; 231:681-692. [PMID: 33121903 DOI: 10.1016/j.jamcollsurg.2020.08.775] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/24/2020] [Accepted: 08/24/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Trimodality therapy with neoadjuvant chemoradiation (nCRT), surgery, and adjuvant chemotherapy is the standard treatment for locally advanced rectal cancer. There is evidence that surgery can be deferred in patients with complete response (CR) to nCRT, a strategy termed "watch-and-wait" (WW). We compare WW to surgery in patients with CR to nCRT. STUDY DESIGN We reviewed records of patients treated with nCRT for nonmetastatic rectal cancer at our institution. Complete endoscopic response (CER) was defined as negative digital rectal exam and negative endoscopy at the end of neoadjuvant therapy (NAT). Clinical complete response (cCR) was defined as CER with negative rectal MRI. Patients with CER refusing surgery were offered WW, which included strict surveillance with digital rectal exam and endoscopy. RESULTS From January 2015 through February 2019, 465 patients completed nCRT; 406 patients had response assessment, of which 95 (23%) had CER. Of these patients, 53 patients underwent WW and 42 patients had surgery. Median follow-up was 35 months. In the WW group, 3-year freedom from local regrowth was 85%. In the surgical and WW groups, 3-year overall survival, rectal cancer-specific survival, and freedom from nonregrowth recurrence were 100% vs 88% (p = 0.03), 100% vs 95% (p = 0.16), and 92% vs 85% (p = 0.36), respectively. Of the 6 WW patients with local regrowth, 5 (83%) eventually developed distant recurrence. CONCLUSIONS WW in lieu of surgery appears to be a safe and feasible treatment approach for patients achieving CR to nCRT. Careful evaluation to confirm cCR after nCRT is valuable in selecting patients for WW.
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Affiliation(s)
- Bryce W Beard
- Departments of Radiation Oncology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
| | - Robert L Rettig
- Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Joan J Ryoo
- Departments of Radiation Oncology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Rex A Parker
- Radiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | | | - Vikram Attaluri
- Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
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Levaillant M, Marcilly R, Levaillant L, Vallet B, Lamer A. Assessing the hospital volume-outcome relationship in surgery: a scoping review protocol. BMJ Open 2020; 10:e038201. [PMID: 33028556 PMCID: PMC7539612 DOI: 10.1136/bmjopen-2020-038201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Even if a positive volume-outcome correlation in surgery is mostly admitted in many surgical fields, the various ways to assess this relationship make it difficult for researchers and policymakers to use it. Our aim is therefore to provide an overview of the way hospital volume-outcome relationship was assessed. Through this overview, our goal is to identify potential gaps in the assessment of this relationship, to help researchers who want to pursue work in this field and, ultimately, to help policy makers interpret such analyses. METHODS AND ANALYSIS This review will be conducted using the six stages of the scoping review method: identifying the research question, searching for relevant studies, selecting studies, data extraction, collating, summarising and reporting the results and concluding. This review will address all the key questions used to assess the volume-outcome relationship in surgery.Primary research papers investigating the hospital volume-outcome relationship from 2009 will be included. Studies only looking at surgeons' volume-outcome relationship or studies were the volume variable is not individualisable will be excluded.Both MEDLINE and Scopus will be searched along with grey literature. Two researchers will perform all the stages of the review: screen the titles and abstracts, review the full text of selected articles to determine final inclusions and extract the data. The results will be summarised quantitatively using numerical counts. ETHICAL CONSIDERATIONS AND DISSEMINATION Reviews of published articles are considered secondary analysis and do not need ethical approval. The findings will be disseminated through multiple channels like conferences and peer-reviewed journals.
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Affiliation(s)
- Mathieu Levaillant
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France
| | - Romaric Marcilly
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, INSERM-CIC-IT 1403/Evalab, F-59000 Lille, France
| | - Lucie Levaillant
- Department of Pediatric Endocrinology and Diabetology, University Hospital Centre Angers, Angers, Pays de la Loire, France
| | - Benoît Vallet
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France
| | - Antoine Lamer
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France
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Lai TY, Yeh CM, Hu YW, Liu CJ. Hospital volume and physician volume in association with survival in patients with nasopharyngeal cancer after radiation therapy. Radiother Oncol 2020; 151:190-199. [DOI: 10.1016/j.radonc.2020.07.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/23/2020] [Accepted: 07/23/2020] [Indexed: 02/08/2023]
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The long-term influence of hospital and surgeon volume on local control and survival in the randomized German Rectal Cancer Trial CAO/ARO/AIO-94. Surg Oncol 2020; 35:200-205. [PMID: 32896776 DOI: 10.1016/j.suronc.2020.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/10/2020] [Accepted: 08/19/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND The association of treatment volume and oncological outcome of rectal cancer patients undergoing multidisciplinary treatment is subject of an ongoing debate. Prospective data on long-term local control and overall survival (OS) are not available so far. This study investigated the long-term influence of hospital and surgeon volume on local recurrence (LR) and OS in patients with locally advanced rectal cancers. METHODS In a post-hoc analysis of the randomized phase III CAO/ARO/AIO-94 trial after a follow-up of more than 10 years, 799 patients with stage II/III rectal cancers were evaluated. LR-rates and OS were stratified by hospital recruitment volume (≤20 vs. 21-90 vs. >90 patients) and by surgeon volume (≤10 vs. 11-50 vs. >50 procedures). RESULTS Patients treated in high-volume hospitals had a longer OS than those treated in hospitals with medium or low treatment volume (p = 0.03). The surgeon volume was adversely associated with LR (p = 0.01) but had no influence on overall survival. The positive effect of neoadjuvant chemoradiation (CRT) on local control was the strongest in patients being operated by medium-volume surgeons, less in patients being operated by high-volume surgeons and missing in those being operated by low-volume surgeons. CONCLUSIONS Patients with locally advanced rectal cancers might benefit from treatment in specialized high-volume hospitals. In particular, the surgeon volume had significant influence on long-term local tumour control. The effect of neoadjuvant CRT on local tumour control may likewise depend on the surgeon volume.
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Outmani L, IJzermans JNM, Minnee RC. Surgical learning curve in kidney transplantation: A systematic review and meta-analysis. Transplant Rev (Orlando) 2020; 34:100564. [PMID: 32624245 DOI: 10.1016/j.trre.2020.100564] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 01/09/2023]
Abstract
AIM To assess the impact of the learning curve of kidney transplantation on operative and postoperative complications. METHODS A literature search was systematically conducted to evaluate the significance of the learning curve on complications in kidney transplantation. Meta-analyses of the effect of the learning curve on warm ischemic time, total operating time (TOT), vascular and urological complications, postoperative bleeding, lymphocele and infection. RESULTS Nine studies met the inclusion criteria and 2762 patients were included in the present meta-analyses. Surgeons at the beginning of the learning curve were found to have longer TOT (mean difference 41.77 (95% CI: 4.48-79.06; P = .03) and more urological complications (risk ratio 3.93; 95% CI: 1.87-8.25; P < .01). No differences were seen in warm ischemic time, postoperative bleeding, lymphocele, and vascular complications. CONCLUSION Surgeons at the beginning of their learning curve have a longer TOT and more urological complications, without an effect on postoperative bleeding, lymphocele, infection and vascular complications. For interpretation of the outcomes, the quality and sample size of the evidence should be taken into consideration.
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Affiliation(s)
- Loubna Outmani
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus University Medical Center (Erasmus MC), Doctor Molenwaterplein 40, 3015GD Rotterdam, Netherlands
| | - Jan N M IJzermans
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus University Medical Center (Erasmus MC), Doctor Molenwaterplein 40, 3015GD Rotterdam, Netherlands
| | - Robert C Minnee
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus University Medical Center (Erasmus MC), Doctor Molenwaterplein 40, 3015GD Rotterdam, Netherlands.
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Canadian taTME expert collaboration (CaTaCO) position statement. Surg Endosc 2020; 34:3748-3753. [PMID: 32504263 PMCID: PMC7395021 DOI: 10.1007/s00464-020-07680-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/27/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community due to the promising ability to overcome technical difficulties related to the access of the distal pelvis. Recently, Norwegian surgeons issued a local moratorium related to potential issues with the safety of the procedure. Early adopters of taTME in Canada have recognized the need to create guidelines for its adoption and supervision. The objective of the statement is to provide expert opinion based on the best available evidence and authors' experience. METHODS The procedure has been performed in Canada since 2014 at different institutions. In 2016, the first Canadian taTME congress was held in the city of Toronto, organized by two of the authors. In early 2019, a multicentric collaborative was established [The Canadian taTME expert Collaboration] which aimed at ensuring safe performance and adoption of taTME in Canada. Recently surgeons from 8 major Canadian rectal cancer centers met in the city of Toronto on December 7 of 2019, to discuss and develop a position statement. There in person, meeting was followed by 4 rounds of Delphi methodology. RESULTS The generated document focused on the need to ensure a unified approach among rectal cancer surgeons across the country considering its technical complexity and potential morbidity. The position statement addressed four domains: surgical setting, surgeons' requirements, patient selection, and quality assurance. CONCLUSIONS Authors agree transanal total mesorectal excision is technically demanding and has a significant risk for morbidity. As of now, there is uncertainty for some of the outcomes. We consider it is possible to safely adopt this operation and obtain adequate results, however for this purpose it is necessary to meet specific requirements in different domains.
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Wang XT, Li L, Kong FB, Zhong XG, Mai W. Surgical-related risk factors associated with anastomotic leakage after resection for rectal cancer: a meta-analysis. Jpn J Clin Oncol 2020; 50:20-28. [PMID: 31665375 DOI: 10.1093/jjco/hyz139] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 08/13/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Anastomotic leakage (AL) after anterior resection always leads to longer hospital stays, decreased quality of life and even increased mortality. Despite extensive research, no consensus on the world well-concerned surgical-related risk factors exists. We therefore conducted a meta-analysis of the available published literature to identify the effects of surgical-related risk factors for AL after anterior resection for rectal cancer, hoping to provide more information and improved guidance for clinical workers managing patients with rectal cancer who are at a high risk for AL. METHODS In this study, the relevant articles were systematically searched from EMBASE, MEDLINE, PubMed, WangFang (Database of Chinese Ministry of Science & Technology), Chinese National Knowledge Infrastructure Database and China Biological Medicine Database. The pooled odds ratio (OR) with 95% confidence interval (95% CI) were calculated. Meta-analysis was performed using of RevMan 5.3 software. RESULTS A total of 26 studies met the inclusion criteria and comprised 34238 cases. Analysis of these 26 studies showed that no defunctioning stoma was highly correlated with AL (pooled OR = 1.28, 95%CI: 1.05-1.57, P = 0.01, random effect), and intraoperative blood transfusion was significantly associated with AL (pooled OR = 1.64, 95%CI: 1.34-2.02, P = 0.02, random effect). However, the AL was not associated with type of anastomosis, type of surgery, technique of anastomosis, level of inferior mesenteric artery ligation, operation time and splenic flexure mobilization. CONCLUSIONS Depend on this meta-analysis, no defunctioning stoma and intraoperative blood transfusion are the major surgical-related risk factors for AL after resection for rectal cancer. Because of the inherent limitations of the research, future prospective randomized controlled trials will need to confirm this conclusion.
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Affiliation(s)
- Xiao-Tong Wang
- Departments of Gastrointestinal and Peripheral Vascular Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, People's Republic of China
| | - Lei Li
- Departments of Gastrointestinal and Peripheral Vascular Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, People's Republic of China
| | - Fan-Biao Kong
- Departments of Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, People's Republic of China
| | - Xiao-Gang Zhong
- Departments of Gastrointestinal and Peripheral Vascular Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, People's Republic of China
| | - Wei Mai
- Departments of Gastrointestinal and Peripheral Vascular Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, People's Republic of China
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Abstract
BACKGROUND It is unclear what impact centralizing rectal cancer surgery may have on travel burden for patients. OBJECTIVE This study aimed to determine the impact of centralizing rectal cancer surgery to high-volume centers on patient travel distance. DESIGN This is a population-based study. SETTINGS The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for patients with rectal cancer undergoing proctectomy. PATIENTS Patients with stage I to III rectal cancer who underwent surgical resection between 2004 and 2014 were included. MAIN OUTCOME MEASURES The outcome of interest was travel distance calculated as the straight-line distance between the centroid of the patient residence zip code and the hospital zip code. Mean distance was compared by using the Student t test. RESULTS A total of 5860 patients met inclusion criteria. The total number of hospitals performing proctectomies for rectal cancer decreased between 2004 and 2014. The average number of proctectomies performed at high-volume centers (20+ resections/year) increased from 16.6 to 24.4 during this time. The average number of miles traveled by patients was 12.1 miles in 2004, and this increased to 15.4 in 2014. If proctectomies were centralized to high-volume centers, there would be 11 facilities. The mean distance traveled would be 24.5 miles. LIMITATIONS This study is subject to the limitations of an administrative data set. There are no patient preference or referral data. CONCLUSIONS The number of hospitals performing rectal cancer resections in New York State is decreasing and volume by center is increasing. There was a statistically significant difference in the mean distance traveled by patients over time. If rectal cancer resections were centralized to high-volume centers, the mean travel distance would increase by 9.5 miles. There would be a 321% increase in the number of patients having to travel 50+ miles for surgery. Any plan for centralization in New York State will require careful planning to avoid placing undue travel burden on patients. See Video Abstract at http://links.lww.com/DCR/B138. CENTRALIZACIÓN DE LA CIRUGÍA DE CÁNCER RECTAL: ¿CUÁL ES EL IMPACTO DEL VIAJE PARA LOS PACIENTES?: No está claro qué impacto puede tener la centralización de la cirugía de cáncer rectal en la carga de viaje para los pacientes.Determinar el impacto de centralizar la cirugía de cáncer rectal en centros de alto volumen sobre la distancia de viaje del paciente.Este es un estudio basado en cohorte poblacional.El Registro de Cáncer del Estado de Nueva York y el Sistema Cooperativo de Planificación e Investigación Estatal fueron consultados para pacientes con cáncer rectal sometidos a proctectomía.Pacientes con cáncer rectal en estadio I-III que se sometieron a resección quirúrgica entre 2004-2014.El resultado de interés fue la distancia de viaje calculada como la distancia en línea recta entre el centroide de la residencia del paciente y el código postal del hospital. La distancia media se comparó mediante la prueba t de Student.Un total de 5,860 pacientes cumplieron los criterios de inclusión. El número total de hospitales que realizaron proctectomías para cáncer rectal disminuyó entre 2004-2014. El número promedio de proctectomías realizadas en centros de alto volumen (más de 20 resecciones/año) aumentó de 16.6 a 24.4 durante este tiempo. El número promedio de millas recorridas por los pacientes fue de 12.1 millas en 2004 y esto aumentó a 15.4 en 2014. Si las proctectomías se centralizaran en centros de alto volumen, habría 11 instalaciones. La distancia media recorrida sería de 24.5 millas.Limitaciones inherentes a un conjunto de datos administrativos. No existen datos sobre preferencia del paciente o sobre referencia de los mismos.El número de hospitales que realizan resecciones de cáncer rectal en Nueva York está disminuyendo y el volumen por centro está aumentando. Hubo una diferencia estadísticamente significativa en la distancia media recorrida por los pacientes a lo largo del tiempo. Si las resecciones por cáncer rectal se centralizaran en centros de gran volumen, la distancia media de viaje aumentaría 9.5 millas. Habría un aumento del 321% en el número de pacientes que tienen que viajar más de 50 millas para la cirugía. Cualquier plan de centralización en Nueva York requerirá una planificación cuidadosa para evitar imponer una carga de viaje excesiva a los pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B138.
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Klupp F, Schuler S, Kahlert C, Halama N, Franz C, Mayer P, Schmidt T, Ulrich A. Evaluation of the inflammatory markers CCL8, CXCL5, and LIF in patients with anastomotic leakage after colorectal cancer surgery. Int J Colorectal Dis 2020; 35:1221-1230. [PMID: 32307587 PMCID: PMC7320065 DOI: 10.1007/s00384-020-03582-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leakage constitutes a dreaded complication after colorectal surgery, leading to increased morbidity and mortality as well as prolonged hospitalization. Most leakages become clinically apparent about 8 days after surgery; however, early detection is quintessential to reduce complications and to improve patients' outcome. We therefore investigated the significance of specific protein expression profiles as putative biomarkers, indicating anastomotic leakage. METHODS In this single-center prospective cohort study serum and peritoneal fluid samples-from routinely intraoperatively inserted drainages-of colorectal cancer patients were collected 3 days after colorectal resection. Twenty patients without anastomotic leakage and 18 patients with an anastomotic leakage and without other complications were included. Protein expression of seven inflammatory markers in serum and peritoneal fluid was assessed by multiplex ELISA and correlated with patients' clinical data. RESULTS Monocyte chemoattractant protein 2 (CCL8/MCP-2), leukemia-inhibiting factor (LIF), and epithelial-derived neutrophil-activating protein (CXCL5/ENA-78) were significantly elevated in peritoneal fluid but not in serum samples from patients subsequently developing anastomotic leakage after colorectal surgery. No expressional differences could be found between grade B and grade C anastomotic leakages. CONCLUSION Measurement 3 days after surgery revealed altered protein expression patterns of the inflammatory markers CCL8/MCP2, LIF, and CXCL5/ENA-78 in peritoneal fluid from patients developing anastomotic leakage after colorectal surgery. Further studies with a larger patient cohort with inclusion of different variables are needed to evaluate their potential as predictive biomarkers for anastomotic leakage.
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Affiliation(s)
- F. Klupp
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - S. Schuler
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - C. Kahlert
- grid.4488.00000 0001 2111 7257Department of Visceral, Thoracic and Vascular Surgery, University of Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - N. Halama
- grid.7700.00000 0001 2190 4373National Center for Tumor Diseases, Medical Oncology and Internal Medicine VI, Tissue Imaging and Analysis Center, Bioquant, University of Heidelberg, Im Neuenheimer Feld 267, 69120 Heidelberg, Germany
| | - C. Franz
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - P. Mayer
- grid.5253.10000 0001 0328 4908Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - T. Schmidt
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - A. Ulrich
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany ,grid.416164.0Department of General and Visceral Surgery, Lukas Hospital Neuss, Preußenstr. 84, 41464 Neuss, Germany
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Hakakian D, Kong K, Bogdanovski DA, Paglinco SR, Rolandelli RH, Stopper PB, Nemeth ZH. Surgeon Case Volume and Intestinal Anastomotic Leaks. Am Surg 2020. [DOI: 10.1177/000313482008600105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel Hakakian
- Department of Surgery Morristown Medical Center Morristown, New Jersey
| | - Karen Kong
- Department of Surgery Morristown Medical Center Morristown, New Jersey
| | | | | | | | | | - Zoltan H. Nemeth
- Department of Surgery Morristown Medical Center Morristown, New Jersey Department of Anesthesiology Columbia University Medical Center New York, New York
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Springer JE, Doumouras AG, Eskicioglu C, Hong D. Regional Variation in the Utilization of Laparoscopy for the Treatment of Rectal Cancer: The Importance of Fellowship Training Sites. Ann Surg Oncol 2019; 27:2478-2486. [DOI: 10.1245/s10434-019-08115-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Indexed: 01/22/2023]
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Baré M, Mora L, Pera M, Collera P, Redondo M, Escobar A, Anula R, Quintana JM. Type and Consequences of Short-Term Complications in Colon Cancer Surgery, Focusing on the Oldest Old. Clin Colorectal Cancer 2019; 19:e18-e25. [PMID: 31874739 DOI: 10.1016/j.clcc.2019.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 10/23/2019] [Accepted: 11/19/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND While the proportion of colon cancer occurring in older patients is expected to increase, these patients may have more complications that may lead to serious consequences. The aim of this study was assess postoperative complications and their short-term consequences in colon cancer surgery according to age. PATIENTS AND METHODS Patients undergoing surgery for primary invasive colon cancer in 22 centers between June 2010 and December 2012 were included. Presurgical and surgical variables were analyzed, and in-hospital major postoperative complications and its most serious consequence (no relevant, transfusion, reintervention, admission to the intensive care unit, or death) were estimated according to age group. Chi-square tests were used to analyze the possible associations between variables and age groups. RESULTS Data from 1976 patients, mean (range) age 68 (24-97) years, 62% men, were analyzed; 52.2% were aged > 69 years and 17.7% were aged > 79 years. The complication rate was 25.3%, reaching 30.9% in those aged ≥ 80 years. Older age was associated with a higher rate of postoperative infections during the hospital stay. The most common surgical complication in patients aged > 85 years was dehiscence of the anastomosis (11.5%). About 5% of patients with major complications died in the hospital (11.1% of those aged 80-84 years and 14.3% aged > 85 years). Among patients aged > 85 years, 38.1% required transfusions. CONCLUSION Older patients should receive appropriate functional preparation before the intervention, and when the risks of the intervention outweigh the potential benefits, a nonsurgical approach may be preferable.
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Affiliation(s)
- Marisa Baré
- Clinical Epidemiology and Cancer Screening, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain; Health Services Research on Chronic Diseases Network (REDISSEC), Spain.
| | - Laura Mora
- General and Digestive Surgery Department, Parc Taulí University Hospital, Sabadell, Spain
| | - Miguel Pera
- General and Digestive Surgery Department, Parc de Salut Mar, Barcelona, Spain
| | - Pablo Collera
- General and Digestive Surgery Department, Althaia-Xarxa Assistencial Universitaria, Manresa, Spain
| | - Maximino Redondo
- Research Unit, Hospital Costa del Sol, University of Málaga, Marbella, Spain; Health Services Research on Chronic Diseases Network (REDISSEC), Spain
| | - Antonio Escobar
- Research Unit, Hospital Universitario Basurto, Bilbao, Spain; Health Services Research on Chronic Diseases Network (REDISSEC), Spain
| | - Rocío Anula
- General and Digestive Surgery Department, Hospital Universitario Clínico San Carlos, Madrid, Universidad Complutense de Madrid, Madrid, Spain
| | - José María Quintana
- Research Unit, Hospital Galdakao-Usansolo, Galdakao, Spain; Health Services Research on Chronic Diseases Network (REDISSEC), Spain
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Chaudhary MA, Learn PA, Sturgeon DJ, Havens JM, Goralnick E, Koehlmoos T, Haider AH, Schoenfeld AJ. Emergency General Surgery Volume and Its Impact on Outcomes in Military Treatment Facilities. J Surg Res 2019; 247:287-293. [PMID: 31699538 DOI: 10.1016/j.jss.2019.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/26/2019] [Accepted: 08/14/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Low hospital volume for emergency general surgery (EGS) procedures is associated with worse patient outcomes within the civilian health care system. The military maintains treatment facilities (MTFs) in remote locations to provide access to service members and their families. We sought to determine if patients treated at low-volume MTFs for EGS conditions experience worse outcomes compared with high-volume centers. MATERIALS AND METHODS We analyzed TRICARE data from 2006 to 2014. Patients were identified using an established coding algorithm for EGS admission. MTFs were divided into quartiles based on annual EGS volume. Outcomes included 30-d mortality, complications, and readmissions. Logistic regression models adjusting for clinical and sociodemographic differences in case-mix including EGS condition, surgical intervention, and comorbidities were used to determine the influence of hospital volume on outcomes. RESULTS We identified 106,915 patients treated for an EGS condition at 79 MTFs. The overall mortality rate was 0.21%, with complications occurring in 8.55% and readmissions in 4.45%. After risk adjustment, lowest-volume MTFs did not demonstrate significantly higher odds of mortality (OR: 2.02, CI: 0.45-9.06) or readmissions (OR: 0.77, CI: 0.54-1.11) compared with the highest-volume centers. Lowest-volume facilities exhibited a lower likelihood of complications (OR: 0.76, CI: 0.59-0.98). CONCLUSIONS EGS patients treated at low-volume MTFs did not experience worse clinical outcomes when compared with high-volume centers. Remote MTFs appear to provide care for EGS conditions comparable with that of high-volume facilities. Our findings speak against the need to reduce services at small, critical access facilities within the military health care system.
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Affiliation(s)
- Muhammad Ali Chaudhary
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Peter A Learn
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Daniel J Sturgeon
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joaquim M Havens
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric Goralnick
- Department of Emergency Medicine, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tracey Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Adil H Haider
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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50
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Vicendese D, Marvelde LT, McNair PD, Whitfield K, English DR, Taieb SB, Hyndman RJ, Thomas R. Hospital characteristics, rather than surgical volume, predict length of stay following colorectal cancer surgery. Aust N Z J Public Health 2019; 44:73-82. [PMID: 31617657 DOI: 10.1111/1753-6405.12932] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/01/2019] [Accepted: 07/01/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Length of hospital stay (LOS) is considered a vital component for successful colorectal surgery treatment. Evidence of an association between hospital surgery volume and LOS has been mixed. Data modelling techniques may give inconsistent results that adversely impact conclusions. This study applied techniques to overcome possible modelling drawbacks. METHOD An additive quantile regression model formulated to isolate hospital contextual effects was applied to every colorectal surgery for cancer conducted in Victoria, Australia, between 2005 and 2015, involving 28,343 admissions in 90 Victorian hospitals. The model compared hospitals' operational efficiencies regarding LOS. RESULTS Hospital LOS operational efficiencies for colorectal cancer surgery varied markedly between the 90 hospitals and were independent of volume. This result was adjusted for pertinent patient and hospital characteristics. CONCLUSION No evidence was found that higher annual surgery volume was associated with lower LOS for patients undergoing colorectal cancer surgery. Our model showed strong evidence that differences in LOS efficiency between hospitals was driven by hospital contextual effects that were not predicted by provider volume. Further study is required to elucidate these inherent differences between hospitals. Implications for public health: Our model indicated improved efficiency would benefit the patient and medical system by lowering LOS and reducing expenditure by more than $3 million per year.
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Affiliation(s)
- Don Vicendese
- Cancer Epidemiology and Intelligence Division, Cancer Council Victoria.,Cancer Strategy and Development, Department of Health and Human Services, Victoria
| | - Luc Te Marvelde
- Cancer Epidemiology and Intelligence Division, Cancer Council Victoria.,Cancer Strategy and Development, Department of Health and Human Services, Victoria
| | - Peter D McNair
- The Victorian Agency for Health Information, The Department of Health and Human Services, Victoria.,The Melbourne School of Population and Global Health, The University of Melbourne, Victoria
| | - Kathryn Whitfield
- Cancer Strategy and Development, Department of Health and Human Services, Victoria
| | - Dallas R English
- Cancer Epidemiology and Intelligence Division, Cancer Council Victoria.,Centre for Epidemiology and Biostatistics, The University of Melbourne, Victoria
| | - Souhaib Ben Taieb
- Department of Econometrics and Business Statistics, Monash University, Victoria
| | - Rob J Hyndman
- Department of Econometrics and Business Statistics, Monash University, Victoria
| | - Robert Thomas
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Victoria
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