Learning curve: the surgeon as a prognostic factor in colorectal cancer surgery

Urethral Injury in Rectal Cancer Surgery: A Comprehensive Study Using Cadaveric Dissection, Imaging Analyses, and Clinical Series

Male urethral injury during rectal cancer surgery is rare but significant. Scant information is available about the distances between the rectourethral space and neighboring structures. The aim of this study is to describe the anatomical relations of the male urethra. This three-pronged study included cadaveric dissection, retrospective MRI analysis, and clinical cases. Measurements included the R-Mu distance (shortest distance between the rectum and the membranous urethra), R-Am distance (distance from the anterior rectal wall to anal margin nearest to the membranous urethra), and the anal canal-rectum axis angle. The clinical study analyzed the incidence of urethral injury and associated factors among 244 consecutive men from January 2016 to January 2023. The overall incidence of urethral injury in our series was low (0.73%), but in men with tumors < 10 cm from the anal margin, it was 4% in abdominoperineal resection and 3.2% in TaTME. On preoperative MRI, the median R-Mu distance was 1 cm (IQR, range, 0.2-2.3), the median R-Am distance was 4.3 cm (range, 2-7.3), and the median anorectal angle was 128° (range, 87-160). In the cadaveric study (nine adult male pelvises), the mean R-Mu distance was 1.18 cm (range 0.8-2), and the mean R-Am distance was 2.64 cm (range 2.1-3). Avoiding urethral injury is crucial. The critical point for injury lies 2-7.3 cm from the anal margin, with a 0.2-2.3 cm distance between the rectum and the membranous urethra. Collaborating with anatomists and radiologists improves surgeons' anatomy knowledge.

Eugene Nicholas Myers' Lecture on Head and Neck Cancer, 2020: The Surgeon as a Prognostic Factor in Head and Neck Cancer Patients Undergoing Surgery

This paper is a transcript of the 29 th Eugene N. Myers, MD International Lecture on Head and Neck Cancer presented at the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in 2020. By the end of the 19 th century, the survival rate in treated patients was 10%. With the improvements in surgical techniques, currently, about two thirds of patients survive for > 5 years. Teamwork and progress in surgical reconstruction have led to advancements in ablative surgery; the associated adjuvant treatments have further improved the prognosis in the last 30 years. However, prospective trials are lacking; most of the accumulated knowledge is based on retrospective series and some real-world data analyses. Current knowledge on prognostic factors plays a central role in an efficient treatment decision-making process. Although the influence of most tumor- and patient-related prognostic factors in head and neck cancer cannot be changed by medical interventions, some environmental factors-including treatment, decision-making, and quality-can be modified. Ideally, treatment strategy decisions should be taken in dedicated multidisciplinary team meetings. However, evidence suggests that surgeons and hospital volume and specialization play major roles in patient survival after initial or salvage head and neck cancer treatment. The metrics of surgical quality assurance (surgical margins and nodal yield) in neck dissection have a significant impact on survival in head and neck cancer patients and can be influenced by the surgeon's expertise. Strategies proposed to improve surgical quality include continuous performance measurement, feedback, and dissemination of best practice measures.

Challenges and Learning Curves in Adopting TaTME and Robotic Surgery for Rectal Cancer: A Cusum Analysis

Simple Summary

Rectal cancer surgery remains a challenge and information about the learning curve in adopting new techniques is lacking. This paper analyzes our experience in taTME (since 2015) and robotic surgery (since 2018) at a fully accredited referral center for the treatment of rectal cancer in Spain. In this retrospective study, we aim to analyze the learning curves for taTME and robot-assisted rectal procedures in the incorporation of these platforms into our practice. We sought to describe our team’s experience in incorporating these techniques and to analyze the difficulties that we have had. Hoping that sharing our experience can help other groups improve their results during the difficult initial phase of incorporating new techniques.

Abstract

New techniques are being developed to improve the results of laparoscopic surgery for rectal cancer. This paper analyzes the learning curves for transanal total mesorectal excision (taTME) and robot-assisted surgery in our colorectal surgery department. We analyzed retrospectively data from patients undergoing curative and elective surgery for rectal cancer ≤12 cm from the anal verge. We excluded extended surgeries. We used cumulative sum (CUSUM) curve analysis to identify inflection points. Between 2015 and 2021, 588 patients underwent surgery for rectal cancer at our center: 67 taTME and 79 robot-assisted surgeries. To overcome the operative time learning curve, 14 cases were needed for taTME and 53 for robot-assisted surgery. The morbidity rate started to decrease after the 17th case in taTME and after the 49th case in robot-assisted surgery, but it is much less abrupt in robot-assisted group. During the initial learning phase, the rate of anastomotic leakage was higher in taTME (35.7% vs. 5.7%). Two Urological lesions occurred in taTME but not in robot-assisted surgery. The conversion rate was higher in robot-assisted surgery (1.5% vs. 10.1%). Incorporating new techniques is complex and entails a transition period. In our experience, taTME involved a higher rate of serious complications than robot-assisted surgery during initial learning period but required a shorter learning curve.

Surgical Unit volume and 30-day reoperation rate following primary resection for colorectal cancer in the Veneto Region (Italy)

BACKGROUND

The aim of this study was to evaluate the impact of Surgical Unit volume on the 30-day reoperation rate in patients with CRC.

METHODS

Data were extracted from the regional Hospital Discharge Dataset and included patients who underwent elective resection for primary CRC in the Veneto Region (2005-2013). The primary outcome measure was any unplanned reoperation performed within 30 days from the index surgery. Independent variables were: age, gender, comorbidity, previous abdominal surgery, site and year of the resection, open/laparoscopic approach and yearly Surgical Unit volume for colorectal resections as a whole, and in detail for colonic, rectal and laparoscopic resections. Multilevel multivariate regression analysis was used to evaluate the impact of variables on the outcome measure.

RESULTS

During the study period, 21,797 elective primary colorectal resections were performed. The 30-day reoperation rate was 5.5% and was not associated with Surgical Unit volume. In multivariate multilevel analysis, a statistically significant association was found between 30-day reoperation rate and rectal resection volume (intermediate-volume group OR 0.75; 95% CI 0.56-0.99) and laparoscopic approach (high-volume group OR 0.69; 95% CI 0.51-0.96).

CONCLUSIONS

While Surgical Unit volume is not a predictor of 30-day reoperation after CRC resection, it is associated with an early return to the operating room for patients operated on for rectal cancer or with a laparoscopic approach. These findings suggest that quality improvement programmes or centralization of surgery may only be required for subgroups of CRC patients.

Surgical quality surrogates do not predict colon cancer survival in the setting of technical credentialing: a report from the prospective COST trial

OBJECTIVE

We tested the hypothesis that the 12 lymph node (LN) count and other surgical variables would not predict survival in a setting where surgical techniques were standardized and surgeons were credentialed and audited.

BACKGROUND

The National Quality Forum has adopted the 12-node minimum as a surgical quality metric due to the strong association between node count and survival.

METHODS

We performed a secondary analysis of data from the Clinical Outcomes of Surgical Therapy (COST) multicenter randomized trial testing laparoscopic versus open colectomy. Surgeons were credentialed and video-audited for adherence to technical standards. Patients with noninvasive and stage IV disease were excluded, leaving 787 subjects (267 stage I, 284 stage II, and 236 stage III). Median age was 70 years and 50% were male. The overall 5-year survival was 77.2%.

RESULTS

Five-year overall and disease-free survival was not influenced by LN count (< 12 vs ≥ 12), sex, tumor location (right vs left vs sigmoid), surgical technique (laparoscopic vs open), total bowel length, proximal margin, distal margin, radial margin, or mesenteric length (P > 0.05 for all). Univariate predictors of survival included age and cancer stage, and these remained significant in the multivariate model. Across all stages of disease, after adjusting for age and stage, LN count did not predict overall or disease-free survival (P = 0.60).

CONCLUSIONS

Despite the known association between LN count and survival, we could not confirm an association between surgical surrogates and cancer outcomes. We postulate that standardization, credentialing, and monitoring may be more important than traditional surgical quality surrogates.

Quality assessment of colorectal cancer care: an international online model

AIM

We present an alternative approach to quality assessment in colorectal cancer, enabling a direct comparison of improvement at the level of the care provider.

METHOD

In 2000, a quality assessment project in colorectal cancer in Germany was started. Data were provided for every patient treated for colorectal cancer. The enrolment questionnaire described patient data, risk factors, reason for hospitalization, diagnostics prior to surgery, surgical procedures, intraoperative complications, general and surgical complications in postoperative period, pathological report and discharge status.

RESULTS

From 2000 to 2007, there were 57 429 patients included in the study. The total number of 372 hospitals that took part in the project varied from 153 to 281 per year. The overall resection rate for colon cancer was 97.1% and 94.8% for rectal cancer. Although the localization of rectal tumours did not vary, the percentage of abdominoperineal excisions fell from 26.1% in 2000 to 21.3% in 2008 (P < 0.001). Hospital mortality for colon cancer varied between 3.2% and 4.2% (P Pearson chi-square 0.032, linear-by-linear 0.257) and for rectal cancer between 2.7% and 3.7% (P Pearson chi-square 0.233). Patient age was not related to in-hospital mortality.

CONCLUSION

The proposed model of quality assessment shows validity and results comparable to population-based studies. It does not require support from the health care system, making its implementation possible in every hospital worldwide.

RODENT STROKE MODEL GUIDELINES FOR PRECLINICAL STROKE TRIALS (1ST EDITION)

Translational stroke research is a challenging task that needs long term team work of the stroke research community. Highly reproducible stroke models with excellent outcome consistence are essential for obtaining useful data from preclinical stroke trials as well as for improving inter-lab comparability. However, our review of literature shows that the infarct variation coefficient of commonly performed stroke models ranges from 5% to 200%. An overall improvement of the commonly used stroke models will further improve the quality for experimental stroke research as well as inter-lab comparability. Many factors play a significant role in causing outcome variation; however, they have not yet been adequately addressed in the Stroke Therapy Academic Industry Roundtable (STAIR) recommendations and the Good Laboratory Practice (GLP). These critical factors include selection of anesthetics, maintenance of animal physiological environment, stroke outcome observation, and model specific factors that affect success rate and variation. The authors have reviewed these major factors that have been reported to influence stroke model outcome, herewith, provide the first edition of stroke model guidelines so to initiate active discussion on this topic. We hope to reach a general agreement among stroke researchers in the near future with its successive updated versions.

The influence of the surgeon’s and the hospital’s caseload on survival and local recurrence after colorectal cancer surgery

BACKGROUND

Past studies have identified surgeon- and institution- related characteristics as prognostic factors in colorectal cancer surgery. The present work assesses the influence of the surgeon's and the hospital's caseload on long-term results of colorectal cancer surgery.

METHODS

The data on 2706 patients from 2, randomized, colorectal cancer trials (Swiss Group for Clinical Cancer Research [SAKK] 40/81, SAKK 40/87) investigating adjuvant intraportal and systemic chemotherapy and 1 concurrent registration study (SAKK 40/88) were reviewed. A first analysis included 1809 eligible, nonmetastatic patients from all 3 studies. A subsequent subgroup analysis included 915 eligible patients from both randomized trials. Overall survival (OS), disease-free survival (DFS), and local recurrence (LR) were analyzed in multivariate models taking into account the possible effect of clustering. The main potential covariates were surgeon's annual caseload (>5 operations/year vs < or =5 operations/year), hospital's annual caseload (>26 operations/year vs < or =26 operations/year), tumor site, T stage, and nodal status.

RESULTS

Primary analysis of all 3 studies combined found a high surgeon's caseload to be positively associated with OS (P = .025) and marginally with DFS (P = .058). Separate analysis for each trial, however, showed that a high surgeon's caseload was beneficial for outcome in both randomized trials but not in the registration study. A subgroup analysis of 915 patients with 376 rectal and 539 colonic primaries from both randomized trials, therefore, was performed. Neither age, gender, year of operation, adjuvant chemotherapy (intraportal vs systemic vs operation alone), hospital academic status (university vs non-university), training status of the surgeon (certified surgeon vs surgeon-in-training), nor inclusion in 1 of the 2 randomized trials (SAKK 40/81 vs SAKK 40/87) was a significant predictor of outcome. However, both high surgeon's and high hospital's annual caseloads were independent, beneficial prognostic factors for OS (P = .0003, P = .044) and DFS (P = .0008, P = .020), and marginally significant factors for LR (P = .057, P = .055).

CONCLUSIONS

High surgeon's and hospital's annual caseloads are strong, independent prognostic factors for extending overall and disease-free survival and reducing the rate of local recurrence in 2 randomized colorectal cancer trials.

Estudio de la estancia tras laringuectomía total: análisis retrospectivo multivariable de 442 laringuectomías totales

INTRODUCTION

Pharyngocutaneous salivary fistula is the most common complication following total laryngectomy. Fistulae can lead to prolonged hospitalization and increased patient morbidity.

OBJECTIVE

To investigate those factors related to increased length of stay following total laryngectomy. To further analyze those related with fistula after surgery.

MATERIAL AND METHODS

Retrospective study on 442 patients who undenwent total laryngectomy. Study of the covariance (ANCOVA). Uni and multivariate analysis of factors related to salivary fistula.

RESULTS

We identified alcohol intake, year of surgery and salivaly fistula as factors independently related with increased length of stay at the hospital. Factors independently related with fistula were alcohol intake, tumors affecting tongue base or pyriform sinus, surgeon, fever in the inmediate postoperative period, or wound closure using fibrin blue (negative association with the later).

CONCLUSIONS

Pharyngocutaneous salivary fistula increases three times hospital length of stay in patients undergoing total laryngectomy. We identified the surgeon as the factor more closely related with this complication, and we suggest the need to create well-defined head and neck cancer groups to deal with these surgical procedures.