Surgical quality assurance in breast, gastric and rectal cancer

Standardized surgical strategy for the treatment of preauricular sinus to reduce recurrence

BACKGROUND

Preauricular sinus (PAS) is a common congenital anomaly, and complete excision is recommended to prevent recurrence. However, PAS has a high recurrence rate as a result of incomplete removal due to the high variability of the sinus ramifications, making its treatment challenging. In this study, we standardized the surgical procedure to reduce the complications and recurrence rate and compared the postoperative results between the non-standardized and the standardized groups.

METHODS

This retrospective study included 97 patients (120 ears) who had undergone PAS excision by a single surgeon between October 2014 and September 2022 and underwent at least 6 months of follow-up. After October 2018, all patients were treated using the standardized method, which comprised the use of magnifying glasses, exploration with a lacrimal probe, the use of methylene blue staining, and excision of a piece of surrounding normal tissue and related cartilage in continuity with the specimen. There were 38 patients (45 ears) in the non-standardized group and 59 patients (75 ears) in the standardized group.

RESULTS

Recurrence was observed in six of 120 ears, indicating an overall recurrence rate of 5.0%. Recurrence occurred in five ears (11.1%) in the non-standardized group and one ear (1.3%) in the standardized group. The standardized group had a significantly lower recurrence rate (p= 0.027) than the non-standardized group.

CONCLUSION

We defined a standardized sinectomy protocol and used it for the surgical treatment of PAS. With this standardized method, we were able to reduce the rates of complications and recurrence without the use of a long incision.

Quality performance indicators for the surgical treatment of gastric adenocarcinoma: a systematic review

Background

A systematic review was undertaken to identify existing quality performance indicators (QPI) for the surgical treatment of gastric adenocarcinoma (GA) with the aim of defining a set of QPIs that can be used to assist in the accreditation of institutions for training, allow cross jurisdiction comparison of treatment and outcomes, as well as provide a basis to develop quality improvement programs. These QPI's capture key components of patient care that are fundamental to overall outcome.

Methods

A systematic literature review was conducted searching MEDLINE, PubMed, EMBASE, and SCOPUS with all literature available until the date of 1 August 2021 included. Search terms utilized were ‘Quality of health care OR Quality improvement or Quality control OR Quality indicators’, AND ‘Gastrectomy’ OR ‘Stomach neoplasm’ OR ‘Adenocarcinoma’ OR ‘Gastric resection’ OR ‘Gastric cancer’.

Results

Twelve articles were included in the final analysis. The selected studies included editorials (n = 2), retrospective review of institutional experience (n = 5), cohort studies (n = 2), survey methodology (n = 1), expert guidelines (n = 1) and consensus statement (n = 1). For GC QPIs, process measures included patient discussion at multi‐disciplinary meetings, access to perioperative multimodal diagnostic pathways, and specific surgical metrics (margin negative resections and adequate lymphadenectomy). Outcome measures included the RO resection rate, reoperation, readmission rate, and length of hospital stay.

Conclusions

There is a relative paucity of internationally agreed QPI for the surgical management of gastric adenocarcinoma. The data from this review will form the basis of a project to develop internationally agreed and feasible QPI for gastric cancer resections.

Vascularizing lymph node dissection for advanced gastric cancer: A single-institution experience

AIM: To compare the short- and long-term outcomes of vascularizing lymph node dissection (VLND) and non-vascularizing lymph node dissection (NVLND) from a single institution.

METHODS: Data of 315 patients with advanced gastric cancer who underwent standard D2 lymphadenectomy with curative intent was collected between January 1994 and December 2006. One hundred and fifty-two patients received VLND while 163 patients received NVLND. Short- and long-term clinical outcomes were compared between the two groups.

RESULTS: The median followed-up time was 82 mo. The rate of postoperative complications in the VLND group was 13.2%, while that in the NVLND group was 11.7% (P = 0.686). The overall 5-year survival rate was 64% in the VLND group and 59% in the NVLND group (P = 0.047). When subgroup analyses were performed according to Bormann type, type of differentiation and lymph node status, survival benefit was demonstrated in patients with Bormann type III or IV (59% vs 50%, P = 0.032), undifferentiated type (63% vs 49%, P = 0.021) or presence of lymph node metastasis (53% vs 38%, P = 0.010) in the VLND group.

CONCLUSION: D2 VLND in advanced gastric cancer treatment allows survival benefit with acceptable morbidity and mortality. VLND for patients with potentially curable advanced gastric cancer is feasible and safe when performed by a well-trained surgical team.

Clinical relevance of conversion rate and its evaluation in laparoscopic hysterectomy

STUDY OBJECTIVES

To estimate the current conversion rate in laparoscopic hysterectomy (LH); to estimate the influence of patient, procedure, and performer characteristics on conversion; and to hypothesize the extent to which conversion rate can act as a means of evaluation in LH.

DESIGN

Prospective cohort study (Canadian Task Force classification II-2).

SETTING

The study included 79 gynecologists representing 42 hospitals throughout the Netherlands. This reflects 75% of all gynecologists performing LH in the Netherlands, and 68% of all hospitals.

PATIENTS

Data from 1534 LH procedures were collected between 2008 and 2010.

INTERVENTION

All participants in the nationwide LapTop registration study recorded each consecutive LH they performed during 1 year.

MEASUREMENTS AND MAIN RESULTS

Conversion rate and odds ratios (OR) of risk factors for conversion were calculated. Conversions were described as reactive or strategic. The literature reported a conversion rate for LH of 0% to 19% (mean, 3.5%). In our cohort, 70 LH procedures (4.6%) were converted. Using a mixed-effects logistic regression model, we estimated independent risk factors for conversion. Body mass index (BMI) (p = .002), uterus weight (p < .001), type of LH (p = .004), and age (p = .02) had a significant influence on conversion. The risk of conversion was increased at BMI >35 (OR, 6.53; p < .001), age >65 years (OR, 6.97; p = .007), and uterus weight 200 to 500 g (OR, 4.05; p < .001) and especially >500 g (OR, 30.90; p < .001). A variation that was not explained by the covariates included in our model was identified and referred to as the "surgical skills factor" (average OR, 2.79; p = .001).

CONCLUSION

Use of estimated risk factors (BMI, age, uterus weight, and surgical skills) provides better insight into the risk of conversion. Conversion rate can be used as a means of evaluation to ensure better outcomes of LH in future patients.

Quality assurance through outcome registration in colorectal cancer: An ECCO initiative for Europe

In recent years there have been significant improvements in outcome of rectal cancer treatment. Both new surgical techniques as well as effective neoadjuvant treatment regimens have contributed to these improvements. It is key to spread these advances towards every rectal cancer patient and to make sure that not only patients who are treated within the framework of clinical trials may benefit from these advancements. Throughout Europe there have been interesting quality programs that have proved to facilitate the spread of up to date knowledge and skills among medical professionals resulting in improved treatment outcome. Nevertheless, between European countries remain differences in outcome and treatment schedules that cannot be easily explained. The European CanCer Organisation (ECCO) has recognised these importances's and created the 'European Registration of Cancer Care' (EURECCA) framework to develop a European colorectal audit structure. EURECCA will advance future treatment improvements and spread these to all European cancer patients. It provides opportunities to treat elderly and comorbid patients evidence based while it offers an unique insight in social-economical healthcare matters. As such, ECCO has established the basis for a strong, multidisciplinary audit structure with the commitment to improve cancer care for every European cancer patient.

Sentinel lymph node biopsy in breast cancer: what a physician should know, a decade after its introduction in clinical practice

In the era of breast conservation surgery, sentinel lymph node biopsy is increasingly used. Sentinel lymph node biopsy can be performed by using the blue dye technique, lymphoscintigraphy and the combined method. Sentinel lymph node biopsy is a minimally invasive technique which has many advantages over the classical axillary (level I and II) lymph node dissection. However, false negative results - albeit rare in experienced hands - may be a serious limitation. The physician should be familiar with this new technique. This will allow him or her to be more actively involved in the management of breast cancer patients and to understand the available management options for these patients.

Pre-operative imaging of rectal cancer and its impact on surgical performance and treatment outcome

AIM

To discuss the ability of pre-operative MRI to have a beneficial effect on surgical performance and treatment outcome in patients with rectal cancer.

METHODS

A description on how MRI can be used as a tool so select patients for differentiated neoadjuvant treatment, how it can be used as an anatomical road map for the resection of locally advanced cases, and how it can serve as a tool for quality assurance of both the surgical procedure and overall patient management. As an illustration the proportion of microscopically complete resections of the period 1993-1997, when there was no routine pre-operative imaging, is compared to that of the period 1998-2002, when pre-operative MR imaging was standardized.

RESULTS

The proportion of R0 resections increased from 92.5 to 97% (p=0.08) and the proportion of resections with a lateral tumour free margin of >1mm increased from 84.4 to 92.1% (p=0.03). The incomplete resections in the first period were mainly due to inadequate surgical management of unsuspected advanced or bulky tumours, whereas in the second period insufficient consideration was given to extensive neoadjuvant treatment when the tumour was close to or invading the mesorectal fascia on MR.

CONCLUSIONS

There are good indications that in our setting pre-operative MR imaging, along with other improvements in rectal cancer management, had a beneficial effect on patient outcome. Audit and discussion of the incomplete resections can lead to an improved operative and perioperative management.