Effect of hospital volume on quality of care and outcome after rectal cancer surgery

Is centralization for rectal cancer surgery necessary?

Rectal cancer surgery is complex and more technically challenging than colonic surgery. Over the last 30 years internationally, there has been a growing impetus for centralizing care to improve outcomes for rectal cancer. Centralizing care may potentially reduce variations of care, increase standardization and compliance with clinical practice guidelines. However, there are barriers to implementation at a professional, political, governance and resource allocation level. Centralization may increase inequalities to accessing healthcare, particularly impacting socioeconomically disadvantaged and rural populations with difficulties to commuting longer distances to "centres of excellence". Furthermore, it is unclear if centralization actually improves outcomes. Recent studies demonstrate that individual surgeon volume rather than hospital volume may be more important in achieving optimal outcomes. In this review, we examine the literature to assess the value of centralization for rectal cancer surgery.

The impact of surgical volume on outcomes in newly diagnosed colorectal cancer patients receiving definitive surgeries

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.

Patterns of Care and Outcomes of Rectal Cancer Patients from the Iowa Cancer Registry: Role of Hospital Volume and Tumor Location

BACKGROUND

Centralization of rectal cancer surgery has been associated with high-quality oncologic care. However, several patient, disease and system-related factors can impact where patients receive care. We hypothesized that patients with low rectal tumors would undergo treatment at high-volume centers and would be more likely to receive guideline-based multidisciplinary treatment.

METHODS

Adults who underwent proctectomy for stage II/III rectal cancer were included from the Iowa Cancer Registry and supplemented with tumor location data. Multinomial logistic regression was employed to analyze factors associated with receiving care in high-volume hospital, while logistic regression for those associated with ≥ 12 lymph node yield, pre-operative chemoradiation and sphincter-preserving surgery.

RESULTS

Of 414 patients, 38%, 39%, and 22% had low, mid, and high rectal cancers, respectively. Thirty-two percent were > 65 years, 38% female, and 68% had stage III tumors. Older age and rural residence, but not tumor location, were associated with surgical treatment in low-volume hospitals. Higher tumor location, high-volume, and NCI-designated hospitals had higher nodal yield (≥ 12). Hospital-volume was not associated with neoadjuvant chemoradiation rates or circumferential resection margin status. Sphincter-sparing surgery was independently associated with high tumor location, female sex, and stage III cancer, but not hospital volume.

CONCLUSIONS

Low tumor location was not associated with care in high-volume hospitals. High-volume and NCI-designated hospitals had higher nodal yields, but not significantly higher neoadjuvant chemoradiation, negative circumferential margin, or sphincter preservation rates. Therefore, providing educational/quality improvement support in lower volume centers may be more pragmatic than attempting to centralize rectal cancer care among high-volume centers.

The Multidisciplinary Approach of Rectal Cancer: The Experience of "COMRE Group" Model

Background: Total mesorectal excision (TME) is the gold standard to treat locally advanced rectal cancer. This monocentric retrospective study evaluates the results of laparotomic, laparoscopic and robotic surgery in “COMRE GROUP” (REctalCOMmittee). Methods: 327 selected stage I-II-III patients (pts) underwent TME between November 2005 and April 2020 for low or middle rectal cancer; 91 pts underwent open, 200 laparoscopic and 36 robotic TME. Of these, we analyzed the anthropomorphic, intraoperative, anatomopathological parameters and outcome during the follow up. Results: The length of hospital stay was significantly different between robotic TME and the other two groups (8.47 ± 3.54 days robotic vs. 11.93 ± 5.71 laparotomic, p < 0.001; 8.47 ± 3.54 robotic vs. 11.10 ± 7.99 laparoscopic, p < 0.05). The mean number of harvested nodes was higher in the laparotomic group compared to the other two groups (19 ± 9 laparotomic vs. 15 ± 8 laparoscopic, p < 0.001; 19 ± 9 laparotomic vs. 15 ± 7 robotic, p < 0.05). Median follow-up was 52 months (range: 1−169). Overall survival was significantly shorter in the open TME group compared with the laparoscopic one (Chi2 = 13.36, p < 0.001). Conclusions: In the experience of the “COMRE” group, laparoscopic TME for rectal cancer is a better choice than laparotomy in a multidisciplinary context. Robotic TME has a significant difference in terms of hospital stay compared to the other two groups.

European Society of Gynaecological Oncology quality indicators for the surgical treatment of endometrial carcinoma

BACKGROUND

Quality of surgical care as a crucial component of a comprehensive multi-disciplinary management improves outcomes in patients with endometrial carcinoma, notably helping to avoid suboptimal surgical treatment. Quality indicators (QIs) enable healthcare professionals to measure their clinical management with regard to ideal standards of care.

OBJECTIVE

In order to complete its set of QIs for the surgical management of gynecological cancers, the European Society of Gynaecological Oncology (ESGO) initiated the development of QIs for the surgical treatment of endometrial carcinoma.

METHODS

QIs were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for the identification of potential QIs and documentation of the scientific evidence, two consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians and patient representatives. QIs were defined using a structured format comprising metrics specifications, and targets. A scoring system was then developed to ensure applicability and feasibility of a future ESGO accreditation process based on these QIs for endometrial carcinoma surgery and support any institutional or governmental quality assurance programs.

RESULTS

Twenty-nine structural, process and outcome indicators were defined. QIs 1-5 are general indicators related to center case load, training, experience of the surgeon, structured multi-disciplinarity of the team and active participation in clinical research. QIs 6 and 7 are related to the adequate pre-operative investigations. QIs 8-22 are related to peri-operative standards of care. QI 23 is related to molecular markers for endometrial carcinoma diagnosis and as determinants for treatment decisions. QI 24 addresses the compliance of management of patients after primary surgical treatment with the standards of care. QIs 25-29 highlight the need for a systematic assessment of surgical morbidity and oncologic outcome as well as standardized and comprehensive documentation of surgical and pathological elements. Each QI was associated with a score. An assessment form including a scoring system was built as basis for ESGO accreditation of centers for endometrial cancer surgery.

One-year excess mortality and treatment in surgically treated patients with colorectal cancer: A EURECCA European comparison

BACKGROUND

Mortality in the first postoperative year represents an accurate reflection of the perioperative risk after colorectal cancer surgery. This research compares one-year mortality after surgery divided into three age-categories (18-64, 65-74, ≥75 years), focusing on time trends and comparing treatment strategies.

MATERIAL

Population-based data of all patients diagnosed and treated surgically for stage I-III primary colorectal cancer from 2007 to 2016, were collected from Belgium, the Netherlands, Norway, and Sweden. Stratified for age-category and stage, treatment was evaluated, and 30-day, one-year and one-year excess mortality were calculated for colon and rectal cancer separately. Results were evaluated over two-year time periods.

RESULTS

Data of 206,024 patients were analysed. Postoperative 30-day and one-year mortality reduced significantly over time in all countries and age-categories. Within the oldest age category, in 2015-2016, one-year excess mortality varied from 9% in Belgium to 4% in Sweden for colon cancer and, from 9% in Belgium to 3% in the other countries for rectal cancer. With increasing age, patients were less likely to receive additional therapy besides surgery. In Belgium, colon cancer patients were more often treated with adjuvant chemotherapy (p < 0.001). For neoadjuvant treatment of rectal cancer, patients in Belgium and Norway were mostly treated with chemoradiotherapy. In the Netherlands and Sweden, radiotherapy alone was preferred (p < 0.001).

CONCLUSIONS

Despite improvement over time in all countries and age-categories, substantial variation exists in one-year postoperative mortality. Differences in one-year excess postoperative mortality could be due to differences in treatment strategies, highlighting the consequences of under- and over-treatment on cancer survival.

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

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.

Effect of Influenza Vaccination Against Postoperative Pneumonia and Mortality for Geriatric Patients Receiving Major Surgery: A Nationwide Matched Study

Background

Limited information is available on the association between influenza vaccination and postoperative outcomes.

Methods

Using Taiwan's National Health Insurance Research Database reimbursement claims data from 2008-2013, we conducted a matched cohort study of 16903 patients aged >66 years who received influenza vaccinations and later underwent major surgery. Using a propensity score matching procedure adjusted for sociodemographic characteristics, medical condition, surgery type, and anesthesia type, 16903 controls who underwent surgery but were not vaccinated were selected. Logistic regressions were used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative pneumonia and in-hospital mortality associated with influenza vaccination.

Results

Patients who received preoperative influenza vaccination had a lower risk of postoperative pneumonia (OR, 0.60; 95% CI, .56-.64) and in-hospital mortality (OR, 0.46; 95% CI, .39-.56), compared with unvaccinated patients, in both sexes and every age group. Vaccinated patients who underwent surgery also had a decreased risk of postoperative intensive care unit admission (OR, 0.56; 95% CI, .53-.60), shorter hospital stays (P < .0001), and lower medical expenditures (P < .0001) than nonvaccinated controls.

Conclusions

Vaccinated geriatric patients who underwent surgery had lower risks of pneumonia and in-hospital mortality, compared with unvaccinated patients who underwent similar major surgeries. Further studies are needed to explain how preoperative influenza vaccination improves perioperative outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

INTERVENTION

Rectal cancer resection was the study intervention.

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

Some articles included rectosigmoid cancers.

CONCLUSIONS

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

Relationship between hospital volume and short-term outcomes: a nationwide population-based study including 75,280 rectal cancer surgical procedures

There is growing interest on the potential relationship between hospital volume (HV) and outcomes as it might justify the centralization of care for rectal cancer surgery. From the National Italian Hospital Discharge Dataset, data on 75,280 rectal cancer patients who underwent elective major surgery between 2002 and 2014 were retrieved and analyzed. HV was grouped into tertiles: low-volume performed 1-12, while high-volume hospitals performed 33+ procedures/year. The impact of HV on in-hospital mortality, abdominoperineal resection (APR), 30-day readmission, and length of stay (LOS) was assessed. Risk factors were calculated using multivariate logistic regression. The proportion of procedures performed in low-volume hospitals decreased by 6.7 percent (p<0.001). The rate of in-hospital mortality, APR and 30-day readmission was 1.3%, 16.3%, and 7.2%, respectively, and the median LOS was 13 days. The adjusted risk of in-hospital mortality (OR = 1.49, 95% CI = 1.25-1.78), APR (OR 1.10, 95%CI 1.02-1.19), 30-day readmission (OR 1.49, 95%CI 1.38-1.61), and prolonged LOS (OR 2.29, 95%CI 2.05-2.55) were greater for low-volume hospitals than for high-volume hospitals. This study shows an independent impact of HV procedures on all short-term outcome measures, justifying a policy of centralization for rectal cancer surgery, a process which is underway.

The effect of hospital familiarity with complex procedures on overall healthcare burden

BACKGROUND

This study aimed to evaluate variations in prolonged outcome after proctectomy based on hospital volume.

STUDY DESIGN

From the Premier Perspective database (2012-2014), hospital volumes for proctectomy of benign and malignant conditions were classified as low, intermediate and high. Hospitals were grouped into tertiles. Impact of procedure volume on in-hospital as well as 90-day post-discharge complications, length of stay, discharge destination and costs was evaluated.

RESULTS

Of 9306 proctectomy procedures, 6960 occurred at high, 1695 at intermediate and 651 at low volume hospitals. After adjustment, high volume institutions were associated with lower in-hospital surgical complications while low volume centers had higher ninety-day post-discharge medical and surgical complications (p < .05 for all). High volume centers had a shorter hospital stay while the need for extended care facility was higher in low volume centers (p < .05 for all). Healthcare costs were higher for low volume hospitals.

CONCLUSION

These data suggest that variations in outcomes and costs after complex procedures such as proctectomy exist and are related to institutional familiarity with a procedure.

The influence of hospital volume on long-term oncological outcome after rectal cancer surgery

PURPOSE

The association between hospital volume and outcome in rectal cancer surgery is still subject of debate. The purpose of this study was to assess the impact of hospital volume on outcomes of rectal cancer surgery in the Netherlands in 2011.

METHODS

In this collaborative research with a cross-sectional study design, patients who underwent rectal cancer resection in 71 Dutch hospitals in 2011 were included. Annual hospital volume was stratified as low (< 20), medium (20-50), and high (≥ 50).

RESULTS

Of 2095 patients, 258 patients (12.3%) were treated in 23 low-volume hospitals, 1329 (63.4%) in 40 medium-volume hospitals, and 508 (24.2%) in 8 high-volume hospitals. Median length of follow-up was 41 months. Clinical tumor stage, neoadjuvant therapy, extended resections, circumferential resection margin (CRM) positivity, and 30-day or in-hospital mortality did not differ significantly between volume groups. Significantly, more laparoscopic procedures were performed in low-volume hospitals, and more diverting stomas in high-volume hospitals. Three-year disease-free survival for low-, medium-, and high-volume hospitals was 75.0, 74.8, and 76.8% (p = 0.682). Corresponding 3-year overall survival rates were 75.9, 79.1, and 80.3% (p = 0.344). In multivariate analysis, hospital volume was not associated with long-term risk of mortality.

CONCLUSIONS

No significant impact of hospital volume on rectal cancer surgery outcome could be observed among 71 Dutch hospitals after implementation of a national audit, with the majority of patients being treated at medium-volume hospitals.

Effect of abdominopelvic sepsis on cancer outcome in patients undergoing sphincter saving surgery for rectal cancer

BACKGROUND

In rectal cancer, the significance of abdominopelvic sepsis (APS) on metastatic tumor growth remains uncertain. We aimed to analyze the effect of abdominopelvic sepsis on long-term survival in patients undergoing restorative rectal cancer surgery.

METHODS

Data were used from the Belgian PROCARE rectal cancer registry. The effect of abdominopelvic infection on survival was assessed in uni- and multivariable Cox regression models. The effect of clinical and pathological covariates was controlled by propensity score-based matching of cases with controls. The effect of abdominopelvic sepsis on the rate of local and metastatic recurrence was evaluated using crosstabulation and the Pearson χ² test.

RESULTS

In univariable analysis, the presence of APS was associated with significantly worse overall survival (HR 1.3, P = 0.025). After propensity score matching including age, BMI, tumor level, pTstage, pN stage, CRM, tumor grade, number of lymph nodes, and presence of lymphovascular invasion, the association of APS with OS was no longer significant (HR 1.26, 95%CI 0.92-1.74, P = 0.15). No differences were observed in the risk of local or metastatic recurrence (3.6% vs 2.9% and 13% vs 16.5%).

CONCLUSIONS

In this analysis APS after rectal cancer resection was not significantly associated with OS, metastatic, or local recurrence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk factors, short and long term outcome of anastomotic leaks in rectal cancer

Background

An anastomotic leak (AL) after colorectal surgery is one major reason for postoperative morbidity and mortality. There is growing evidence that AL affects short and long term outcome. This prospective German multicentre study aims to identify risk factors for AL and quantify effects on short and long term course after rectal cancer surgery.

Methods

From 1 January 2000 to 31 December 2010 381 hospitals attributed patients to the prospective multicentre study Quality Assurance in Colorectal Cancer managed by the Otto-von-Guericke-University Magdeburg (Germany). Included were 17 867 patients with histopathologically confirmed rectal carcinoma and primary anastomosis. Risk factor analysis included 13 items of demographic patient data, surgical course, hospital volume und tumour stage.

Results

In 2 134 (11.9%) patients an AL was diagnosed. Overall hospital mortality was 2.1% (with AL 7.5%, without AL 1.4%; p < 0.0001). In multivariate analysis male gender, ASA-classification ≥III, smoking history, alcohol history, intraoperative blood transfusion, no protective ileostomy, UICC-stage and height of tumour were independent risk factors. Overall survival (OS) was significantly shorter for patients with AL (UICC I-III; UICC I, II or III - each p < 0.0001). Disease free survival (DFS) was significantly shorter for patients with AL in UICC I-III; UICC II or UICC III (each p < 0.001). Rate of local relapse was not significantly affected by occurrence of AL.

Conclusion

In this study patients with AL had a significantly worse OS. This was mainly due to an increased in hospital mortality. DFS was also negatively affected by AL whereas local relapse was not. This emphasizes the importance of successful treatment of AL related problems during the initial hospital stay.

The surgical defect after transanal endoscopic microsurgery: open versus closed management

BACKGROUND

To determine whether closure of the defect created during full thickness excision of a rectal lesion with transanal endoscopic microsurgery (TEM) leads to fewer complications when compared to leaving the defect unsutured.

METHODS

This is a single-center cohort study using a prospectively maintained database. All patients ≥18 years old treated with full thickness TEM with no compromise of the peritoneal cavity were included. Two cohorts were established: patients with the defect sutured and patients with the defect left open. Demographic, operative, and pathologic data were compared. The main outcome analyzed was early (<30 day postoperative) complications, including bleeding that required investigation and readmission, infection, and reoperation.

RESULTS

Between 2007 and 2014, data for all patients treated with TEM have been maintained in the St. Paul's Hospital TEM database. Overall, 236 patients had the TEM defect sutured (TEM-S) and 105 patients had the defect left open (TEM-O). There were no differences between the groups in patient age, gender, tumor size or underlying tumor histology. There was no difference in OR time between the groups, but the most experienced TEM surgeon performed significantly more of the TEM-S procedures (61 vs. 39 %, p < 0.01). There were 40 postoperative complications, affecting 11.7 % of the cohort. The complication rate was higher in the TEM-O group (8.4 vs. 19.0 %, p = 0.03). There was no statistically significant difference in bleeding complications (4.7 vs. 7.6 %, p = 0.27) or infections (2.1 vs. 6.7 %, p = 0.05). Readmissions were less common in the TEM-S group (4.7 vs 12.4 %, p = 0.01).

CONCLUSION

The St. Paul's Hospital TEM experience suggests that while it is safe to leave rectal defects open when a robust mesorectal fat layer is present, there appears to be fewer postoperative complications when the defect is sutured closed.

Effect of Neoadjuvant Radiation Dose and Schedule on Nodal Count and Its Prognostic Impact in Stage II-III Rectal Cancer

BACKGROUND

It is unknown how neoadjuvant treatment schedule affects lymph node count (LNC) and lymph node ratio (LNR) and how these correlate with overall survival (OS) in rectal cancer (RC).

METHODS

Data were used from the Belgian PROCARE rectal cancer registry on RC patients treated with surgery alone, short-term radiotherapy with immediate surgery (SRT), or chemoradiation with deferred surgery (CRT). The effect of neoadjuvant therapy on LNC was examined using Poisson log-linear analysis. The association of LNC and LNR with overall survival (OS) was studied using Cox proportional hazards models.

RESULTS

Data from 4037 patients were available. Compared with surgery alone, LNC was reduced by 12.3 % after SRT and by 31.3 % after CRT (p < 0.001). In patients with surgery alone, the probability of finding node-positive disease increased with LNC, while after SRT and CRT no increase was noted for more than 12 and 18 examined nodes, respectively. Per node examined, we found a decrease in hazard of death of 2.7 % after surgery alone and 1.5 % after SRT, but no effect after CRT. In stage III patients, the LNR but not (y)pN stage was significantly correlated with OS regardless of neoadjuvant therapy. Specifically, a LNR > 0.4 was associated with a significantly worse outcome.

CONCLUSIONS

Nodal counts are reduced in a schedule-dependent manner by neoadjuvant treatment in RC. After chemoradiation, the LNC does not confer any prognostic information. A LNR of >0.4 is associated with a significantly worse outcome in stage III disease, regardless of neoadjuvant therapy type.

Outcomes After Non-neurological Surgery in Patients With Parkinson's Disease: A Nationwide Matched Cohort Study

Patients with Parkinson disease (PD) were known to have increased risk of complications during hospitalization. The purpose of this study is to validate the global features of postoperative adverse outcomes for patients with PD.Using reimbursement claims from Taiwan's National Health Insurance Research Database, we conducted a nationwide retrospective cohort study of 6455 patients with preoperative PD receiving major surgery during 2008 to 2012. With a propensity score matching procedure, 12,910 surgical patients without PD were selected for comparison. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for 9 major postoperative complications and 30-day postoperative mortality associated with preoperative PD were calculated in the multivariate logistic regressions.Patients with PD had increased risk of postoperative pulmonary embolism (OR 2.72, 95% CI 1.45-5.10), stroke (OR 1.77, 95% CI 1.53-2.05), pneumonia (OR 1.98, 95% CI 1.70-2.31), urinary tract infection (OR 1.52, 95% CI 1.35-1.70), septicemia (OR 1.54, 95% CI 1.37-1.73), acute renal failure (OR 1.36, 95% CI 1.07-1.73), and mortality (OR 1.45, 95% CI 1.06-1.98). The association between preoperative PD and postoperative adverse events was significant in both sexes and every age group. Low income, ≥65 years of age, surgery not in medical center, highest quartile of PD medication users, and more medical conditions worsen the risk of postoperative adverse events in patients with PD.This study showed increased postoperative complications and mortality in patients with PD. Our findings suggest that revision of postoperative care protocols for this population is urgently needed.