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de'Angelis N, Schena CA, Espin-Basany E, Piccoli M, Alfieri S, Aisoni F, Coccolini F, Frontali A, Kraft M, Lakkis Z, Le Roy B, Luzzi AP, Milone M, Pattacini GC, Pellino G, Petri R, Piozzi GN, Quero G, Ris F, Winter DC, Khan J. Robotic versus laparoscopic right colectomy for nonmetastatic pT4 colon cancer: A European multicentre propensity score-matched analysis. Colorectal Dis 2024. [PMID: 38978153 DOI: 10.1111/codi.17089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/14/2024] [Accepted: 04/16/2024] [Indexed: 07/10/2024]
Abstract
AIM Minimally invasive surgery has been increasingly adopted for locally advanced colon cancer. However, evidence comparing robotic (RRC) versus laparoscopic right colectomy (LRC) for nonmetastatic pT4 cancers is lacking. METHODS This was a multicentre propensity score-matched (PSM) study of a cohort of consecutive patients with pT4 right colon cancer treated with RRC or LRC. The two surgical approaches were compared in terms of R0, number of lymph nodes harvested, intra- and postoperative complication rates, overall (OS), and disease-free survival (DFS). RESULTS Among a total of 200 patients, 39 RRC were compared with 78 PS-matched LRC patients. The R0 rate was similar between RRC and LRC (92.3% vs. 96.2%, respectively; p = 0.399), as was the odds of retrieving 12 or more lymph nodes (97.4% vs. 96.2%; p = 1). No significant difference was noted for the mean operating time (192.9 min vs. 198.3 min; p = 0.750). However, RRC was associated with fewer conversions to laparotomy (5.1% vs. 20.5%; p = 0.032), less blood loss (36.9 vs. 95.2 mL; p < 0.0001), fewer postoperative complications (17.9% vs. 41%; p = 0.013), a shorter time to flatus (2 vs. 2.8 days; p = 0.009), and a shorter hospital stay (6.4 vs. 9.5 days; p < 0.0001) compared with LRC. These results were confirmed even when converted procedures were excluded from the analysis. The 1-, 3- and 5-year OS (p = 0.757) and DFS (p = 0.321) did not significantly differ between RRC and LRC. CONCLUSION Adequate oncological outcomes are observed for RRC and LRC performed for pT4 right colon cancer. However, RRC is associated with lower conversion rates and improved short-term postoperative outcomes.
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Affiliation(s)
- Nicola de'Angelis
- Unit of Robotic and Minimally Invasive Surgery, Department of Surgery, Ferrara University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Carlo Alberto Schena
- Unit of Robotic and Minimally Invasive Surgery, Department of Surgery, Ferrara University Hospital, Ferrara, Italy
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eloy Espin-Basany
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital Vall d'Hebron-Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Micaela Piccoli
- Unit of General, Emergency Surgery and New Technologies, Ospedale Civile Baggiovara, Azienda Ospedaliero Universitaria Di Modena, Modena, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Filippo Aisoni
- Unit of General Surgery, Department of Surgery, Ferrara University Hospital, Ferrara, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Alice Frontali
- Department of General Surgery, Department of Biomedical and Clinical Sciences 'L. Sacco', University of Milan, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Miquel Kraft
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital Vall d'Hebron-Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Zaher Lakkis
- Department of Digestive Surgical Oncology, Liver Transplantation Unit, University Hospital of Besançon, Besançon, France
| | - Bertrand Le Roy
- Department of Digestive and Oncologic Surgery, Hospital Nord, CHU Saint-Etienne, Saint-Etienne, France
| | | | - Marco Milone
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Gianmaria Casoni Pattacini
- Unit of General, Emergency Surgery and New Technologies, Ospedale Civile Baggiovara, Azienda Ospedaliero Universitaria Di Modena, Modena, Italy
| | - Gianluca Pellino
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital Vall d'Hebron-Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Roberto Petri
- General Surgery Department, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | | | - Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Frederic Ris
- Division of Abdominal and Transplantation Surgery, Department of Surgery, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Des C Winter
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Jim Khan
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
- University of Portsmouth, Portsmouth, UK
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Hazen SMJA, van Geffen EGM, Sluckin TC, Beets GL, Belgers HJ, Borstlap WAA, Consten ECJ, Dekker JWT, Hompes R, Tuynman JB, van Westreenen HL, de Wilt JHW, Tanis PJ, Kusters M. Long-term restoration of bowel continuity after rectal cancer resection and the influence of surgical technique: A nationwide cross-sectional study. Colorectal Dis 2024; 26:1153-1165. [PMID: 38706109 DOI: 10.1111/codi.17015] [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: 10/02/2023] [Revised: 01/10/2024] [Accepted: 04/02/2024] [Indexed: 05/07/2024]
Abstract
AIM Literature on nationwide long-term permanent stoma rates after rectal cancer resection in the minimally invasive era is scarce. The aim of this population-based study was to provide more insight into the permanent stoma rate with interhospital variability (IHV) depending on surgical technique, with pelvic sepsis, unplanned reinterventions and readmissions as secondary outcomes. METHOD Patients who underwent open or minimally invasive resection of rectal cancer (lower border below the sigmoid take-off) in 67 Dutch centres in 2016 were included in this cross-sectional cohort study. RESULTS Among 2530 patients, 1470 underwent a restorative resection (58%), 356 a Hartmann's procedure (14%, IHV 0%-42%) and 704 an abdominoperineal resection (28%, IHV 3%-60%). Median follow-up was 51 months. The overall permanent stoma rate at last follow-up was 50% (IHV 13%-79%) and the unintentional permanent stoma rate, permanent stoma after a restorative procedure or an unplanned Hartmann's procedure, was 11% (IHV 0%-29%). A total of 2165 patients (86%) underwent a minimally invasive resection: 1760 conventional (81%), 170 transanal (8%) and 235 robot-assisted (11%). An anastomosis was created in 59%, 80% and 66%, with corresponding unintentional permanent stoma rates of 12%, 24% and 14% (p = 0.001), respectively. When corrected for age, American Society of Anesthesiologists classification, cTNM, distance to the anorectal junction and neoadjuvant (chemo)radiotherapy, the minimally invasive technique was not associated with an unintended permanent stoma (p = 0.071) after a restorative procedure. CONCLUSION A remarkable IHV in the permanent stoma rate after rectal cancer resection was found. No beneficial influence of transanal or robot-assisted laparoscopy on the unintentional permanent stoma rate was found, although this might be caused by the surgical learning curve. A reduction in IHV and improving preoperative counselling for decision-making for restorative procedures are required.
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Affiliation(s)
- Sanne-Marije J A Hazen
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Eline G M van Geffen
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Tania C Sluckin
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Geerard L Beets
- Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School of Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands
| | | | - Wernard A A Borstlap
- Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Esther C J Consten
- Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Roel Hompes
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Johannes H W de Wilt
- Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pieter J Tanis
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Miranda Kusters
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
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3
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van der Graaf SH, Hagens MJ, Veerman H, Roeleveld TA, Nieuwenhuijzen JA, Wit EMK, W J M Wouters M, van der Mierden S, van Moorselaar RJA, Beerlage HP, Vis AN, van Leeuwen PJ, van der Poel HG. A Systematic Review on the Impact of Quality Assurance Programs on Outcomes after Radical Prostatectomy. Eur Urol Focus 2024:S2405-4569(24)00048-8. [PMID: 38631992 DOI: 10.1016/j.euf.2024.03.004] [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: 12/05/2023] [Revised: 01/23/2024] [Accepted: 03/15/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND AND OBJECTIVE The implementation of quality assurance programs (QAPs) within urological practice has gained prominence; yet, their impact on outcomes after radical prostatectomy (RP) remains uncertain. This paper aims to systematically review the current literature regarding the implementation of QAPs and their impact on outcomes after robot-assisted RP, laparoscopic RP, and open prostatectomy, collectively referred to as RP. METHODS A systematic Embase, Medline (OvidSP), and Scopus search was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) process, on January 12, 2024. Studies were identified and included if these covered implementation of QAPs and their impact on outcomes after RP. QAPs were defined as any intervention seeking quality improvement through critically reviewing, analyzing, and discussing outcomes. Included studies were assessed critically using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool, with results summarized narratively. KEY FINDINGS AND LIMITATIONS Ten included studies revealed two methodological strategies: periodic performance feedback and surgical video assessments. Despite conceptual variability, QAPs improved outcomes consistently (ie, surgical margins, urine continence, erectile function, and hospital readmissions). Of the two strategies, video assessments better identified suboptimal surgical practice and technical errors. Although the extent of quality improvements did not appear to correlate with the frequency of QAPs, there was an apparent correlation with whether or not outcomes were evaluated collectively. CONCLUSIONS AND CLINICAL IMPLICATIONS Current findings suggest that QAPs have a positive impact on outcomes after RP. Caution in interpretation due to limited data is advised. More extensive research is required to explore how conceptual differences impact the extent of quality improvements. PATIENT SUMMARY In this paper, we review the available scientific literature regarding the implementation of quality assurance programs and their impact on outcomes after radical prostatectomy. The included studies offered substantial support for the implementation of quality assurance programs as an incentive to improve the quality of care continuously.
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Affiliation(s)
- Sophia H van der Graaf
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands.
| | - Marinus J Hagens
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Hans Veerman
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Ton A Roeleveld
- Prostate Cancer Network Netherlands, Amsterdam, The Netherlands; Department of Urology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Jakko A Nieuwenhuijzen
- Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Esther M K Wit
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Michel W J M Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Dutch Institute for Clinical Auditing, Leiden, The Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Stevie van der Mierden
- Scientific Information Service, Netherlands Cancer Institute- Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - R Jeroen A van Moorselaar
- Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Harrie P Beerlage
- Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - André N Vis
- Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Pim J van Leeuwen
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
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4
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Mughal NA, Hussain MH, Ahmed KS, Waheed MT, Munir MM, Diehl TM, Zafar SN. Barriers to Surgical Outcomes Research in Low- and Middle-Income Countries: A Scoping Review. J Surg Res 2023; 290:188-196. [PMID: 37269802 DOI: 10.1016/j.jss.2023.04.017] [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: 01/18/2023] [Revised: 04/04/2023] [Accepted: 04/30/2023] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Systematic collection and analysis of surgical outcomes data is a cornerstone of surgical quality improvement. Unfortunately, there remains a dearth of surgical outcomes data from low- and middle-income countries (LMICs). To improve surgical outcomes in LMICs, it is essential to have the ability to collect, analyze, and report risk-adjusted postoperative morbidity and mortality data. This study aimed to review the barriers and challenges to developing perioperative registries in LMIC settings. METHODS We conducted a scoping review of all published literature on barriers to conducting surgical outcomes research in LMICs using PubMed, Embase, Scopus, and GoogleScholar. Keywords included 'surgery', 'outcomes research', 'registries', 'barriers', and synonymous Medical Subject Headings derivatives. Articles found were subsequently reference-mined. All relevant original research and reviews published between 2000 and 2021 were included. The performance of routine information system management framework was used to organize identified barriers into technical, organizational, or behavioral factors. RESULTS Twelve articles were identified in our search. Ten articles focused specifically on the creation, success, and obstacles faced during the implementation of trauma registries. Technical factors reported by 50% of the articles included limited access to a digital platform for data entry, lack of standardization of forms, and complexity of said forms. 91.7% articles mentioned organizational factors, including the availability of resources, financial constraints, human resources, and lack of consistent electricity. Behavioral factors highlighted by 66.6% of the studies included lack of team commitment, job constraints, and clinical burden, which contributed to poor compliance and dwindling data collection over time. CONCLUSIONS There is a paucity of published literature on barriers to developing and maintaining perioperative registries in LMICs. There is an immediate need to study and understand barriers and facilitators to the continuous collection of surgical outcomes in LMICs.
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Affiliation(s)
- Nabiha Akhlaq Mughal
- Department of Surgery, Aga Khan University Medical College, Karachi, Sindh, Pakistan
| | - Muzamil Hamid Hussain
- Department of Surgery, Aga Khan University Medical College, Karachi, Sindh, Pakistan
| | | | - Muhammad Talha Waheed
- Department of Surgery, Aga Khan University Medical College, Karachi, Sindh, Pakistan; Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Muhammad Musaab Munir
- Department of Surgery, Aga Khan University Medical College, Karachi, Sindh, Pakistan
| | - Thomas M Diehl
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
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Faber RA, Tange FP, Galema HA, Zwaan TC, Holman FA, Peeters KCMJ, Tanis PJ, Verhoef C, Burggraaf J, Mieog JSD, Hutteman M, Keereweer S, Vahrmeijer AL, van der Vorst JR, Hilling DE. Quantification of indocyanine green near-infrared fluorescence bowel perfusion assessment in colorectal surgery. Surg Endosc 2023; 37:6824-6833. [PMID: 37286750 PMCID: PMC10462565 DOI: 10.1007/s00464-023-10140-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/16/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Indocyanine green near-infrared fluorescence bowel perfusion assessment has shown its potential benefit in preventing anastomotic leakage. However, the surgeon's subjective visual interpretation of the fluorescence signal limits the validity and reproducibility of the technique. Therefore, this study aimed to identify objective quantified bowel perfusion patterns in patients undergoing colorectal surgery using a standardized imaging protocol. METHOD A standardized fluorescence video was recorded. Postoperatively, the fluorescence videos were quantified by drawing contiguous region of interests (ROIs) on the bowel. For each ROI, a time-intensity curve was plotted from which perfusion parameters (n = 10) were derived and analyzed. Furthermore, the inter-observer agreement of the surgeon's subjective interpretation of the fluorescence signal was assessed. RESULTS Twenty patients who underwent colorectal surgery were included in the study. Based on the quantified time-intensity curves, three different perfusion patterns were identified. Similar for both the ileum and colon, perfusion pattern 1 had a steep inflow that reached its peak fluorescence intensity rapidly, followed by a steep outflow. Perfusion pattern 2 had a relatively flat outflow slope immediately followed by its plateau phase. Perfusion pattern 3 only reached its peak fluorescence intensity after 3 min with a slow inflow gradient preceding it. The inter-observer agreement was poor-moderate (Intraclass Correlation Coefficient (ICC): 0.378, 95% CI 0.210-0.579). CONCLUSION This study showed that quantification of bowel perfusion is a feasible method to differentiate between different perfusion patterns. In addition, the poor-moderate inter-observer agreement of the subjective interpretation of the fluorescence signal between surgeons emphasizes the need for objective quantification.
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Affiliation(s)
- Robin A Faber
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Floris P Tange
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Hidde A Galema
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Thomas C Zwaan
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Fabian A Holman
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Pieter J Tanis
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Jacobus Burggraaf
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Centre of Human Drug Research, Zernikedreef 8, 2333 CL, Leiden, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Merlijn Hutteman
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Stijn Keereweer
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Alexander L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Joost R van der Vorst
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Denise E Hilling
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
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Ingwersen EW, van der Beek PJK, Dekker JWT, van Dieren S, Daams F. One Decade of Declining Use of Defunctioning Stomas After Rectal Cancer Surgery in the Netherlands: Are We on the Right Track? Dis Colon Rectum 2023; 66:1003-1011. [PMID: 36607894 DOI: 10.1097/dcr.0000000000002625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The beneficial effect of a defunctioning stoma in mitigating the consequences of anastomotic leakage after rectal cancer surgery is still debated. OBJECTIVE This study aims to reflect on a decade of rectal cancer surgery in terms of stoma construction and anastomotic leakage. DESIGN Retrospective observational study. SETTING This study used data from the Dutch Colorectal Audit from 2011 to 2020. PATIENTS Patients undergoing rectal cancer surgery with a primary anastomosis. MAIN OUTCOME MEASURES Primary outcome was anastomotic leakage. Secondary outcomes were minor complications, admission to intensive care, length of stay, readmission, and patient death. RESULTS A total of 13,263 patients were included in this study. A defunctioning stoma was constructed in 7106 patients (53.6%). Patients with a defunctioning stoma were less likely to develop anastomotic leakage (7.9% vs 13.0%), and if anastomotic leakage occurred, fewer patients needed surgical reintervention (37.7% vs 81.1%). An annual decrease in the construction of a defunctioning stoma was seen (69.8% in 2011 vs 51.8% in 2015 vs 29.7% in 2020), accompanied by a 5% increase in anastomotic leakage (9.1% in 2011 vs 14.1% in 2020). A defunctioning stoma was associated with a higher occurrence of minor complications, increased admissions to the intensive care unit, longer length of stay, and more readmissions within 90 days. LIMITATION This retrospective study is susceptible to confounders by indications, and there could be risk factors for anastomotic leakage and the use of a stoma that were not regarded. CONCLUSIONS The reduction in defunctioning stomas is paralleled with an increase in anastomotic leakage. However, patients with a defunctioning stoma also showed more minor complications, a prolonged length of stay, more intensive care admissions, and more readmissions. In our opinion, the trade-offs of selective use should be individually considered. See Video Abstract at http://links.lww.com/DCR/C137 . UNA DCADA DISMINUYENDO EL USO DE ESTOMAS DISFUNCIONANTES EN LOS CASOS DE CNCER DE RECTO EN HOLANDA ESTAMOS HACIENDO LO CORRECTO ANTECEDENTES:Aún se debate el efecto benéfico de la confección de un estoma disfuncionante para limitar las consecuencias de la fuga anastomótica en los casos de cirugía por cáncer de recto.OBJETIVO:Reflexiones sobre una década de cirugía por cáncer de recto en términos de confección de estomas y de fugas anastomóticas.DISEÑO:Estudio retrospectivo y observacional.AJUSTE:El presente estudio utilizó datos de la Auditoría Colorectal Holandesa entre 2011 y 2020.PACIENTES:Todos aquellos intervenidos por cáncer de recto con anastomosis primaria.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue evaluar la fuga anastomótica. Los resultados secundarios fueron las complicaciones menores, la permanencia en cuidados intensivos, la duración de la hospitalización, las rehospitalizaciones y las causas de muerte en los pacientes.RESULTADOS:Un total de 13.263 pacientes fueron incluidos en el presente estudio. Se confeccionó un estoma disfuncionante en 7.106 (53,6%) pacientes. Aquellos portadores de un estoma disfuncionante tenían menos probabilidades de desarrollar una fuga anastomótica (7,9 % frente a 13,0 %) y, si ocurría una fuga anastomótica, menos pacientes necesitaban reintervención quirúrgica (37,7 % frente a 81,1 %). Se observó una disminución anual en la confección de un estoma disfuncionante (69,8 % en 2011 frente a 51,8 % en 2015 frente a 29,7 % en 2020), acompañada de un aumento del 5 % en la fuga anastomótica (9,1 % en 2011 frente a 14,1 % en 2020). Un estoma disfuncionante se asoció con una mayor incidencia de complicaciones menores, permanencia en la unidad de cuidados intensivos, una estadía más prolongada y más rehospitalizaciones dentro de los 90 días.LIMITACIÓN:Estudio retrospectivo susceptible de factores de confusión según las indicaciones, donde podrían no haber sido considerados ciertos factores de riesgo con relación a la fuga anastomótica y a la confección de un estoma disfuncionante.CONCLUSIÓN:La reducción de estomas disfuncionantes es paralela con el aumento de la fuga anastomótica. Sin embargo, los pacientes con un estoma disfuncionante también mostraron más complicaciones menores, una estadía prolongada, más admisiones a cuidados intensivos y más rehospitalizaciones. En nuestra opinión, las ventajas y desventajas del uso selectivo de estomas disfuncionantes deben ser consideradas caso por caso. Consulte Video Resumen en https://links.lww.com/DCR/C137 . (Traducción-Dr. Xavier Delgadillo ).
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Affiliation(s)
- Erik W Ingwersen
- Department of Gastrointestinal Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Paulien J K van der Beek
- Department of Gastrointestinal Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jan Willem T Dekker
- Department of Gastrointestinal Surgery, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Susan van Dieren
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Gastrointestinal Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
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7
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Wells CI, Varghese C, Boyle LJ, McGuinness MJ, Keane C, O'Grady G, Gurney J, Koea J, Harmston C, Bissett IP. "Failure to Rescue" following Colorectal Cancer Resection: Variation and Improvements in a National Study of Postoperative Mortality. Ann Surg 2023; 278:87-95. [PMID: 35920564 DOI: 10.1097/sla.0000000000005650] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To examine variation in "failure to rescue" (FTR) as a driver of differences in mortality between centres and over time for patients undergoing colorectal cancer surgery. BACKGROUND Wide variation exists in postoperative mortality following colorectal cancer surgery. FTR has been identified as an important determinant of variation in postoperative outcomes. We hypothesized that differences in mortality both between hospitals and over time are driven by variation in FTR. METHODS A national population-based study of patients undergoing colorectal cancer resection from 2010 to 2019 in Aotearoa New Zealand was conducted. Rates of 90-day FTR, mortality, and complications were calculated overall, and for surgical and nonoperative complications. Twenty District Health Boards (DHBs) were ranked into quartiles using risk- and reliability-adjusted 90-day mortality rates. Variation between DHBs and trends over the 10-year period were examined. RESULTS Overall, 15,686 patients undergoing resection for colorectal adenocarcinoma were included. Increased postoperative mortality at high-mortality centers (OR 2.4, 95% CI 1.8-3.3) was driven by higher rates of FTR (OR 2.0, 95% CI 1.5-2.8), and postoperative complications (OR 1.4, 95% CI 1.3-1.6). These trends were consistent across operative and nonoperative complications. Over the 2010 to 2019 period, postoperative mortality halved (OR 0.5, 95% CI 0.4-0.6), associated with a greater improvement in FTR (OR 0.5, 95% CI 0.4-0.7) than complications (OR 0.8, 95% CI 0.8-0.9). Differences between centers and over time remained when only analyzing patients undergoing elective surgery. CONCLUSION Mortality following colorectal cancer resection has halved over the past decade, predominantly driven by improvements in "rescue" from complications. Differences in FTR also drive hospital-level variation in mortality, highlighting the central importance of "rescue" as a target for surgical quality improvement.
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Affiliation(s)
- Cameron I Wells
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Chris Varghese
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Luke J Boyle
- Department of Statistics, The University of Auckland, Auckland, New Zealand
| | | | - Celia Keane
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland District Health Board, Auckland, New Zealand
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Jason Gurney
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Jonathan Koea
- Department of General Surgery, Waitemata District Health Board, Takapuna, New Zealand
| | - Chris Harmston
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Northland District Health Board, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland District Health Board, Auckland, New Zealand
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8
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van der Hulst HC, van der Bol JM, Bastiaannet E, Portielje JEA, Dekker JWT. Surgical and non-surgical complications after colorectal cancer surgery in older patients; time-trends and age-specific differences. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:724-729. [PMID: 36635163 DOI: 10.1016/j.ejso.2022.11.095] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 11/05/2022] [Accepted: 11/15/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Trends of surgical and non-surgical complications among the old, older and oldest patients after colorectal cancer (CRC) surgery could help to identify the best target outcome to further improve postoperative outcome. MATERIALS AND METHODS All consecutive patients ≥70 years receiving curative elective CRC resection between 2011 and 2019 in The Netherlands were included. Baseline variables and postoperative complications were prospectively collected by the Dutch ColoRectal audit (DCRA). We assessed surgical and non-surgical complications over time and within age categories (70-74, 75-79 and ≥ 80 years) and determined the impact of age on the risk of both types of complications by using multivariate logistic regression analyses. RESULTS Overall, 38648 patients with a median age of 76 years were included. Between 2011 and 2019 the proportion of ASA score ≥3 and laparoscopic surgery increased. Non-surgical complications significantly improved between 2011 (21.8%) and 2019 (17.1%) and surgical complications remained constant (from 17.6% to 16.8%). Surgical complications were stable over time for each age group. Non-surgical complications improved in the oldest two age groups. Increasing age was only associated with non-surgical complications (75-79 years; OR 1.17 (95% CI 1.10-1.25), ≥80 years; OR 1.46 (95% CI 1.37-1.55) compared to 70-74 years), not with surgical complications. CONCLUSION The reduction of postoperative complications in the older CRC population was predominantly driven by a decrease in non-surgical complications. Moreover, increasing age was only associated with non-surgical complications and not with surgical complications. Future care developments should focus on non-surgical complications, especially in patients ≥75 years.
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Affiliation(s)
| | | | - Esther Bastiaannet
- Institute of Epidemiology, Biostatistics and Prevention, University of Zurich, Zurich, Switzerland
| | - Johanna E A Portielje
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
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9
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Swartjes H, van Lankveld DWP, van Erning FN, Verheul HMW, de Wilt JHW, Koëter T, Vissers PAJ. Locoregionally Recurrent Colon Cancer: How Far Have We Come? A Population-Based, Retrospective Cohort Study. Ann Surg Oncol 2023; 30:1726-1734. [PMID: 36261752 PMCID: PMC9908679 DOI: 10.1245/s10434-022-12689-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/06/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND The reported outcomes of locoregionally recurrent colon cancer (LRCC) are poor, but the literature about LRCC is scarce and aged. Recent population-based studies to provide current insight into LRCC are warranted. This study aimed to provide an overview of the incidence, risk factors, treatment, and overall survival (OS) of patients with LRCC after curative resection of stage I-III primary colon cancer. METHODS Data on disease recurrence were collected for all patients with a diagnosis of non-metastasized primary colon cancer in the Netherlands during the first 6 months of 2015. Patients who underwent surgical resection (N = 3544) were included in this study. The 3-year cumulative incidence, risk factors, treatment, and OS for patients with LRCC were determined. RESULTS The 3-year cumulative incidence of LRCC was 3.8%. Synchronous distant metastases (LRCC-M1) were diagnosed in 62.7% of the patients. The risk factors for LRCC were age of 70 years or older, pT4, pN1-2, and R1-2. Adjuvant chemotherapy was associated with a decreased risk of LRCC for high-risk stage II and stage III patients [hazard ratio (HR), 0.47; 95% confidence interval (CI) 0.31-0.93]. The median OS for the patients with LRCC was 13.1 months (95% CI 9.1-18.3 months). Curative-intent treatment was given to 22.4% of the LRCC patients, and the subsequent 3 years OS was 71% (95% CI 58-87%). The patients treated with palliative treatment and best supportive care showed 3-year OS rates of 15% (95% CI 7.0-31%) and 3.7% (95% CI 1.0-14%), respectively. CONCLUSIONS The cumulative incidence of LRCC was low, and adjuvant chemotherapy was associated with a decreased risk for LRCC among targeted patients. Curative-intent treatment was given to nearly 1 in 4 LRCC patients, and the OS for this group was high.
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Affiliation(s)
- Hidde Swartjes
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Daan W P van Lankveld
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Felice N van Erning
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Henk M W Verheul
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tijmen Koëter
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Pauline A J Vissers
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
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10
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Gilbert A, Homer V, Brock K, Korsgen S, Geh I, Hill J, Gill T, Hainsworth P, Tutton M, Khan J, Robinson J, Steward M, Cunningham C, Kaur M, Magill L, Russell A, Quirke P, West NP, Sebag-Montefiore D, Bach SP. Quality-of-life outcomes in older patients with early-stage rectal cancer receiving organ-preserving treatment with hypofractionated short-course radiotherapy followed by transanal endoscopic microsurgery (TREC): non-randomised registry of patients unsuitable for total mesorectal excision. THE LANCET. HEALTHY LONGEVITY 2022; 3:e825-e838. [PMID: 36403589 PMCID: PMC9722406 DOI: 10.1016/s2666-7568(22)00239-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Older patients with early-stage rectal cancer are under-represented in clinical trials and, therefore, little high-quality data are available to guide treatment in this patient population. The TREC trial was a randomised, open-label feasibility study conducted at 21 centres across the UK that compared organ preservation through short-course radiotherapy (SCRT; 25 Gy in five fractions) plus transanal endoscopic microsurgery (TEM) with standard total mesorectal excision in adults with stage T1-2 rectal adenocarcinoma (maximum diameter ≤30 mm) and no lymph node involvement or metastasis. TREC incorporated a non-randomised registry offering organ preservation to patients who were considered unsuitable for total mesorectal excision by the local colorectal cancer multidisciplinary team. Organ preservation was achieved in 56 (92%) of 61 non-randomised registry patients with local recurrence-free survival of 91% (95% CI 84-99) at 3 years. Here, we report acute and long-term patient-reported outcomes from this non-randomised registry group. METHODS Patients considered by the local colorectal cancer multidisciplinary team to be at high risk of complications from total mesorectal excision on the basis of frailty, comorbidities, and older age were included in a non-randomised registry to receive organ-preserving treatment. These patients were invited to complete questionnaires on patient-reported outcomes (the European Organisation for Research and Treatment of Cancer Quality of Life [EORTC-QLQ] questionnaire core module [QLQ-C30] and colorectal cancer module [QLQ-CR29], the Colorectal Functional Outcome [COREFO] questionnaire, and EuroQol-5 Dimensions-3 Level [EQ-5D-3L]) at baseline and at months 3, 6, 12, 24, and 36 postoperatively. To aid interpretation, data from patients in the non-randomised registry were compared with data from those patients in the TREC trial who had been randomly assigned to organ-preserving therapy, and an additional reference cohort of aged-matched controls from the UK general population. This study is registered with the ISRCTN registry, ISRCTN14422743, and is closed. FINDINGS Between July 21, 2011, and July 15, 2015, 88 patients were enrolled onto the TREC study to undergo organ preservation, of whom 27 (31%) were randomly allocated to organ-preserving therapy and 61 (69%) were added to the non-randomised registry for organ-preserving therapy. Non-randomised patients were older than randomised patients (median age 74 years [IQR 67-80] vs 65 years [61-71]). Organ-preserving treatment was well tolerated among patients in the non-randomised registry, with mild worsening of fatigue; quality of life; physical, social, and role functioning; and bowel function 3 months postoperatively compared with baseline values. By 6-12 months, most scores had returned to baseline values, and were indistinguishable from data from the reference cohort. Only mild symptoms of faecal incontinence and urgency, equivalent to less than one episode per week, persisted at 36 months among patients in both groups. INTERPRETATION The SCRT and TEM organ-preservation approach was well tolerated in older and frailer patients, showed good rates of organ preservation, and was associated with low rates of acute and long-term toxicity, with minimal effects on quality of life and functional status. Our findings support the adoption of this approach for patients considered to be at high risk from radical surgery. FUNDING Cancer Research UK.
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Affiliation(s)
- Alexandra Gilbert
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK.
| | - Victoria Homer
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Kristian Brock
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Stephan Korsgen
- Department of Colorectal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Geh
- Department of Radiation Oncology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James Hill
- Department of Colorectal Surgery, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Talvinder Gill
- Department of Colorectal Surgery, North Tees and Hartlepool NHS Foundation Trust, Durham, UK
| | - Paul Hainsworth
- Department of Colorectal Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Matthew Tutton
- Department of Colorectal Surgery, East Suffolk and North Essex NHS Foundation Trust, Colchester, UK
| | - Jim Khan
- Department of Colorectal Surgery, Portsmouth Hospital NHS Trust, Portsmouth, UK
| | - Jonathan Robinson
- Department of Colorectal Surgery, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Mark Steward
- Department of Colorectal Surgery, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Christopher Cunningham
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Manjinder Kaur
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Laura Magill
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Ann Russell
- National Cancer Research Institute, London, UK
| | - Philip Quirke
- Division of Pathology and Data Analytics, School of Medicine, University of Leeds, Leeds, UK
| | - Nicholas P West
- Division of Pathology and Data Analytics, School of Medicine, University of Leeds, Leeds, UK
| | | | - Simon P Bach
- Department of Colorectal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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11
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Hol JC, Burghgraef TA, Rutgers MLW, Crolla RMPH, van Geloven NAW, Leijtens JWA, Polat F, Pronk A, Smits AB, Tuynman JB, Verdaasdonk EGG, Consten ECJ, Hompes R, Sietses C. Comparison of three-year oncological results after restorative low anterior resection, non-restorative low anterior resection and abdominoperineal resection for rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 49:730-737. [PMID: 36460530 DOI: 10.1016/j.ejso.2022.11.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/31/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Oncological outcome might be influenced by the type of resection in total mesorectal excision (TME) for rectal cancer. The aim was to see if non-restorative LAR would have worse oncological outcome. A comparison was made between non-restorative low anterior resection (NRLAR), restorative low anterior resection (RLAR) and abdominoperineal resection (APR). MATERIALS AND METHODS This retrospective cohort included data from patients undergoing TME for rectal cancer between 2015 and 2017 in eleven Dutch hospitals. A comparison was made for each different type of procedure (APR, NRLAR or RLAR). Primary outcome was 3-year overall survival (OS). Secondary outcomes included 3-year disease-free survival (DFS) and 3-year local recurrence (LR) rate. RESULTS Of 998 patients 363 underwent APR, 132 NRLAR and 503 RLAR. Three-year OS was worse after NRLAR (78.2%) compared to APR (86.3%) and RLAR (92.2%, p < 0.001). This was confirmed in a multivariable Cox regression analysis (HR 1.85 (1.07, 3.19), p = 0.03). The 3-year DFS was also worse after NRLAR (60.3%), compared to APR (70.5%) and RLAR (80.1%, p < 0.001), HR 2.05 (1.42, 2.97), p < 0.001. The LR rate was 14.6% after NRLAR, 5.2% after APR and 4.8% after RLAR (p = 0.005), HR 3.22 (1.61, 6.47), p < 0.001. CONCLUSION NRLAR might be associated with worse 3-year OS, DFS and LR rate compared to RLAR and APR.
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Affiliation(s)
- Jeroen C Hol
- Department of Surgery, Amsterdam University Medical Center, Location VU Medical Centre, Amsterdam, the Netherlands; Department of Surgery, Hospital Gelderse Vallei, Ede, the Netherlands.
| | - Thijs A Burghgraef
- Department of Surgery, Meander Medical Centre, Amersfoort, the Netherlands; Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Marieke L W Rutgers
- Department of Surgery, Amsterdam University Medical Center, Location Academic Medical Centre, Amsterdam, the Netherlands
| | | | | | | | - Fatih Polat
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Apollo Pronk
- Department of Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - Anke B Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam University Medical Center, Location VU Medical Centre, Amsterdam, the Netherlands
| | | | - Esther C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, the Netherlands; Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Center, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Colin Sietses
- Department of Surgery, Hospital Gelderse Vallei, Ede, the Netherlands
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12
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Fahim M, Couwenberg A, Verweij ME, Dijksman LM, Verkooijen HM, Smits AB. SPONGE-assisted versus Trendelenburg position surgery in laparoscopic sigmoid and rectal cancer surgery (SPONGE trial): randomized clinical trial. Br J Surg 2022; 109:1081-1086. [DOI: 10.1093/bjs/znac249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/27/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022]
Abstract
Abstract
Background
In minimally invasive surgery of the sigmoid colon and rectum a retractor sponge has been introduced as an alternative to the Trendelenburg position. This randomized clinical trial (RCT) compared postoperative duration of hospital stay and perioperative outcomes in patients with sigmoid or rectal cancer undergoing sponge-assisted versus Trendelenburg position surgery.
Methods
The SPONGE trial is a single-centre RCT nested within the Dutch nationwide prospective observational cohort of patients with colorectal cancer, and follows the Trials within Cohorts (TwiCs) design. Patients with sigmoid or rectal cancer undergoing elective laparoscopic or robotic surgery were randomized to either sponge-assisted or Trendelenburg surgery on a 1:1 basis using block randomization. Duration of postoperative hospital stay was the primary outcome and was compared using the Mann–Whitney U test. Secondary endpoints included the proportion of complications, readmissions, or mortality versus the χ2 test in intention-to-treat and per-protocol analyses. This trial was not blinded for patients in the intervention arm or physicians.
Results
Between November 2015 and June 2021, 82 patients were randomized to sponge-assisted surgery and 81 to Trendelenburg surgery. After post-randomization exclusion, 150 patients remained for analyses (75 patients per arm). There was no statistically significant difference in median duration of hospital stay (5 days versus 4 days, respectively; P = 0.06), 30-day postoperative complications (30 per cent versus 31 per cent; P = 1.00), readmission rate (8 per cent versus 15 per cent; P = 0.30), or mortality (0 per cent versus 1 per cent, P = 1.00). The per-protocol analysis showed similar results. No adverse device events were seen.
Conclusion
Sponge-assisted laparoscopic/robotic surgery does not reduce the duration of hospital stay, or perioperative morbidity or mortality.
Trial registration
NCT02574013 (http://www.clinicaltrials.gov)
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Affiliation(s)
- Milad Fahim
- Department of Value-Based Healthcare, St. Antonius Hospital , Nieuwegein , The Netherlands
- Department of Surgery, St. Antonius Hospital , Nieuwegein , The Netherlands
| | - Alice Couwenberg
- Department of Radiation Oncology, The Netherlands Cancer Institute , Amsterdam , The Netherlands
| | - Maaike E Verweij
- Division of Imaging and Oncology, University Medical Center Utrecht , Utrecht , The Netherlands
| | - Lea M Dijksman
- Department of Value-Based Healthcare, St. Antonius Hospital , Nieuwegein , The Netherlands
| | - Helena M Verkooijen
- Division of Imaging and Oncology, University Medical Center Utrecht , Utrecht , The Netherlands
| | - Anke B Smits
- Department of Surgery, St. Antonius Hospital , Nieuwegein , The Netherlands
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13
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Diehl TM, Soto E, Laryea JA, Zafar SN. Surgery as a Global Health Need. Clin Colon Rectal Surg 2022; 35:362-370. [PMID: 36111078 PMCID: PMC9470290 DOI: 10.1055/s-0042-1746185] [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: 11/03/2022]
Abstract
Surgical care is now recognized as a fundamental component of universal health coverage. Unfortunately, most of the world is still without access to safe and timely surgical care, including 9 out of 10 people living in low- and middle-income countries (LMICs). Additionally, even in LMICs with sustainable surgical programs, surgical outcomes continue to lag behind those in high-income countries. In this article, we will provide a brief history and introduction to global surgery, an overview of the existing literature on global surgical outcomes, and a discussion surrounding the challenges to building surgical capacity and improving surgical outcomes in LMICs. In addition, we will discuss the existing frameworks for building surgical care into national universal healthcare plans and initiatives striving improve surgical outcomes in LMICs.
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Affiliation(s)
- Thomas M. Diehl
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Ernie Soto
- Department of Surgery, University of Arkansas for Medical Sciences Medical Center, Little Rock, Arkansas
| | - Jonathan A. Laryea
- Department of Surgery, University of Arkansas for Medical Sciences Medical Center, Little Rock, Arkansas
| | - Syed Nabeel Zafar
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
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14
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Elfrink AKE, Alberga AJ, van Berge Henegouwen MI, Scheurs WH, van der Geest LGM, Verhagen HJM, Dekker JWT, Grünhagen DJ, Wouters MWJM, Klaase JM. Outcomes After Major Surgical Procedures in Octogenarians: A Nationwide Cohort Study. World J Surg 2022; 46:2399-2408. [PMID: 35927369 PMCID: PMC9436861 DOI: 10.1007/s00268-022-06642-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 11/25/2022]
Abstract
Introduction Aging of the worldwide population has been observed, and postoperative outcomes could be worse in elderly patients. This nationwide study assessed trends in number of surgical resections in octogenarians regarding various major surgical procedures and associated postoperative outcomes. Methods All patients who underwent surgery between 2014 and 2018 were included from Dutch nationwide quality registries regarding esophageal, stomach, pancreas, colorectal liver metastases, colorectal cancer, lung cancer and abdominal aortic aneurysms (AAA). For each quality registry, the number of patients who were 80 years or older (octogenarians) was calculated per year. Postoperative outcomes were length of stay (LOS), 30 day major morbidity and 30 day mortality between octogenarians and younger patients. Results No increase in absolute number and proportion of octogenarians that underwent surgery was observed. Median LOS was higher in octogenarians who underwent surgery for colorectal cancer, colorectal liver metastases, lung cancer, pancreatic disease and esophageal cancer. 30 day major morbidity was higher in octogenarians who underwent surgery for colon cancer, esophageal cancer and elective AAA-repair. 30 day mortality was higher in octogenarians who underwent surgery for colorectal cancer, lung cancer, stomach cancer, pancreatic disease, esophageal cancer and elective AAA-repair. Median LOS decreased between 2014 and 2018 in octogenarians who underwent surgery for stomach cancer and colorectal cancer. 30 day major morbidity decreased between 2014 and 2018 in octogenarians who underwent surgery for colon cancer. No trends were observed in octogenarians regarding 30 day mortality between 2014 and 2018. Conclusion No increase over time in absolute number and proportion of octogenarians that underwent major surgery was observed in the Netherlands. Postoperative outcomes were worse in octogenarians. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-022-06642-6.
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Affiliation(s)
- Arthur K E Elfrink
- Scientific Bureau, Dutch Institute for Clinical Auditing, 2333 AA, Leiden, The Netherlands.
- Department of Hepatobiliary Surgery and Liver Transplantation, Universitair Medisch Centrum Groningen, Groningen, The Netherlands.
| | - Anna J Alberga
- Scientific Bureau, Dutch Institute for Clinical Auditing, 2333 AA, Leiden, The Netherlands
- Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Locatie AMC, Cancer Center Amsterdam, Universiteit Van Amsterdam, Amsterdam, The Netherlands
| | | | | | | | | | - Dirk J Grünhagen
- Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Michel W J M Wouters
- Scientific Bureau, Dutch Institute for Clinical Auditing, 2333 AA, Leiden, The Netherlands
- Department of Surgery, Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Joost M Klaase
- Department of Hepatobiliary Surgery and Liver Transplantation, Universitair Medisch Centrum Groningen, Groningen, The Netherlands
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15
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Impact of Age on Multimodality Treatment and Survival in Locally Advanced Rectal Cancer Patients. Cancers (Basel) 2022; 14:cancers14112741. [PMID: 35681721 PMCID: PMC9179565 DOI: 10.3390/cancers14112741] [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: 05/01/2022] [Revised: 05/29/2022] [Accepted: 05/30/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Optimal treatment for locally advanced rectal cancer is neoadjuvant (chemo)radiation followed by radical surgery. This is challenging in the aging population because of frequently concomitant comorbidity. We analyzed whether age below and above 70 years is associated with differences in treatment strategy and outcome in this population-based study. Methods: Data between 2008 and 2016 were extracted from the Netherlands Cancer Registry with follow-up until 2021. Differences in therapy, referral and outcome were analyzed using χ2 tests, multivariable logistic regression and relative survival analysis. Results: In total, 6524 locally advanced rectal cancer patients were included. A greater proportion of patients <70 years underwent resection compared to older patients (89% vs. 71%). Patients ≥70 years were more likely treated with neoadjuvant radiotherapy (OR 3.4, 95% CI 2.61−4.52), than with chemoradiation (OR 0.3, 95% CI 0.23−0.37) and less often referred to higher volume hospitals for resection (OR 0.7, 95% CI 0.51−0.87). Five-year relative survival after resection following neoadjuvant therapy was comparable and higher for both patients <70 years and ≥70 years (82% and 77%) than after resection only. Resection only was associated with worse survival in the elderly compared to younger patients (56% vs. 75%). Conclusion: Elderly patients with locally advanced rectal cancer received less intensive treatment and were less often referred to higher volume hospitals for surgery. Relative survival was good and comparable after optimal treatment in both age groups. Effort is necessary to improve guideline adherence, and multimodal strategies should be tailored to age, comorbidity and performance status.
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Argillander T, van der Hulst H, van der Zaag-Loonen H, van Duijvendijk P, Dekker J, van der Bol J, Bastiaannet E, Verkuyl J, Neijenhuis P, Hamaker M, Schiphorst A, Aukema T, Burghgraef T, Sonneveld D, Schuijtemaker J, van der Meij W, van den Bos F, Portielje J, Souwer E, van Munster B. Predictive value of selected geriatric parameters for postoperative outcomes in older patients with rectal cancer – A multicenter cohort study. J Geriatr Oncol 2022; 13:796-802. [DOI: 10.1016/j.jgo.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 03/23/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
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Warps AK, Saraste D, Westerterp M, Detering R, Sjövall A, Martling A, Dekker JWT, Tollenaar RAEM, Matthiessen P, Tanis PJ. National differences in implementation of minimally invasive surgery for colorectal cancer and the influence on short-term outcomes. Surg Endosc 2022; 36:5986-6001. [PMID: 35258664 PMCID: PMC9283170 DOI: 10.1007/s00464-021-08974-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 12/31/2021] [Indexed: 12/24/2022]
Abstract
Background The timing and degree of implementation of minimally invasive surgery (MIS) for colorectal cancer vary among countries. Insights in national differences regarding implementation of new surgical techniques and the effect on postoperative outcomes are important for quality assurance, can show potential areas for country-specific improvement, and might be illustrative and supportive for similar implementation programs in other countries. Therefore, this study aimed to evaluate differences in patient selection, applied techniques, and results of minimal invasive surgery for colorectal cancer between the Netherlands and Sweden. Methods Patients who underwent elective minimally invasive surgery for T1-3 colon or rectal cancer (2012–2018) registered in the Dutch ColoRectal Audit or Swedish ColoRectal Cancer Registry were included. Time trends in the application of MIS were determined. Outcomes were compared for time periods with a similar level of MIS implementation (Netherlands 2012–2013 versus Sweden 2017–2018). Multilevel analyses were performed to identify factors associated with adverse short-term outcomes. Results A total of 46,095 Dutch and 8,819 Swedish patients undergoing MIS for colorectal cancer were included. In Sweden, MIS implementation was approximately 5 years later than in the Netherlands, with more robotic surgery and lower volumes per hospital. Although conversion rates were higher in Sweden, oncological and surgical outcomes were comparable. MIS in the Netherlands for the years 2012–2013 resulted in a higher reoperation rate for colon cancer and a higher readmission rate but lower non-surgical complication rates for rectal cancer if compared with MIS in Sweden during 2017–2018. Conclusion This study showed that the implementation of MIS for colorectal cancer occurred later in Sweden than the Netherlands, with comparable outcomes despite lower volumes. Our study demonstrates that new surgical techniques can be implemented at a national level in a controlled and safe way, with thorough quality assurance. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08974-1.
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Affiliation(s)
- A K Warps
- Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, Netherlands.,Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333 AA, Leiden, Netherlands
| | - D Saraste
- Department of Surgery, Södersjukhuset, 118 83, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Insitutet, 171 76, Stockholm, Sweden
| | - M Westerterp
- Department of Surgery, Haagland Medisch Centrum, Lijnbaan 32, 2512 VA, Den Haag, Netherlands
| | - R Detering
- Department of Surgery, Amsterdam University Medical Centres, Meibergdreef 9, 1105 AZ, Amsterdam, Netherlands
| | - A Sjövall
- Department of Molecular Medicine and Surgery, Karolinska Insitutet, 171 76, Stockholm, Sweden.,Department of Surgery, Karolinska University Hospital, Anna Steckséns gata 53, 171 64, Solna, Sweden
| | - A Martling
- Department of Molecular Medicine and Surgery, Karolinska Insitutet, 171 76, Stockholm, Sweden.,Department of Surgery, Karolinska University Hospital, Anna Steckséns gata 53, 171 64, Solna, Sweden
| | - J W T Dekker
- Department of Surgery, Reinier de Graaf Groep, Reinier de Graafweg 5, 2625 AD, Delft, Netherlands
| | - R A E M Tollenaar
- Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, Netherlands.,Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333 AA, Leiden, Netherlands
| | - P Matthiessen
- Department of Surgery, Örebro University Hospital, von Rosens väg 1, 70185, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health Sciences, Örebro University, 70182, Örebro, Sweden
| | - P J Tanis
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam University Medical Centres, University of Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, Netherlands.
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Massa I, Ghignone F, Ugolini G, Ercolani G, Montroni I, Capelli P, Garulli G, Catena F, Lucchi A, Ansaloni L, Gentili N, Danesi V, Montella MT, Altini M. Emilia-Romagna Surgical Colorectal Cancer Audit (ESCA): a value-based healthcare retro-prospective study to measure and improve the quality of surgical care in colorectal cancer. Int J Colorectal Dis 2022; 37:1727-1738. [PMID: 35779080 PMCID: PMC9262771 DOI: 10.1007/s00384-022-04203-w] [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: 06/15/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgery is the main treatment for non-metastatic colorectal cancer. Despite huge improvements in perioperative care, colorectal surgery is still associated with a significant burden of postoperative complications and ultimately costs for healthcare organizations. Systematic clinical auditing activity has already proven to be effective in measuring and improving clinical outcomes, and for this reason, we decided to evaluate its impact in a large area of northern Italy. METHODS The Emilia-Romagna Surgical Colorectal Audit (ESCA) is an observational, multicentric, retro-prospective study, carried out by 7 hospitals located in the Emilia-Romagna region. All consecutive patients undergoing surgery for colorectal cancer during a 54-month study period will be enrolled. Data regarding baseline conditions, preoperative diagnostic work-up, surgery and postoperative course will be collected in a dedicated case report form. Primary outcomes regard postoperative complications and mortality. Secondary outcomes include each center's adherence to the auditing (enrolment rate) and evaluation of the systematic feedback activity on key performance indicators for the entire perioperative process. CONCLUSION This protocol describes the methodology of the Emilia-Romagna Surgical Colorectal Audit. The study will provide real-world clinical data essential for benchmarking and feedback activity, to positively impact outcomes and ultimately to improve the entire healthcare process of patients undergoing colorectal cancer surgery. CLINICAL TRIAL REGISTRATION The study ESCA is registered on the clinicaltrials.gov platform (Identifier: NCT03982641).
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Affiliation(s)
- Ilaria Massa
- Outcome Research, Healthcare Administration, IRCCS Istituto Romagnolo per lo studio dei tumori (IRST) “ Dino Amadori”, Meldola, Italy
| | - Federico Ghignone
- U.O. Chirurgia Generale, Hospital “Santa Maria delle Croci”, AUSL, Ravenna, Romagna Italy
| | - Giampaolo Ugolini
- U.O. Chirurgia Generale, Hospital “Santa Maria delle Croci”, AUSL, Ravenna, Romagna Italy
| | - Giorgio Ercolani
- U.O. Chirurgia Generale e Terapie Oncologiche avanzate, Hospital “GB. Morgagni-L.Pierantoni”, AUSL, Forli, Romagna Italy
| | - Isacco Montroni
- U.O Chirurgia Generale, Hospital “degli Infermi”, AUSL, Faenza, Romagna Italy
| | - Patrizio Capelli
- Department of Surgery, Hospital “G. Da Saliceto”, Piacenza, AUSL, Piacenza, Italy
| | - Gianluca Garulli
- U.O. Chirurgia Generale, Hospital “Infermi”, AUSL, Rimini, Romagna Italy
| | - Fausto Catena
- General, Emergency and Trauma Surgery Dept., Bufalini Hospital, AUSL, Cesena, Romagna Italy
| | - Andrea Lucchi
- U.O. Chirurgia Generale, Hospital “Ceccarini”, AUSL, Riccione, Romagna Italy
| | - Luca Ansaloni
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Nicola Gentili
- Outcome Research, Healthcare Administration, IRCCS Istituto Romagnolo per lo studio dei tumori (IRST) “ Dino Amadori”, Meldola, Italy
| | - Valentina Danesi
- Outcome Research, Healthcare Administration, IRCCS Istituto Romagnolo per lo studio dei tumori (IRST) “ Dino Amadori”, Meldola, Italy
| | - Maria Teresa Montella
- Outcome Research, Healthcare Administration, IRCCS Istituto Romagnolo per lo studio dei tumori (IRST) “ Dino Amadori”, Meldola, Italy
| | - Mattia Altini
- Healthcare Administration, AUSL of Romagna, Ravenna, Italy
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Arron MNN, Greijdanus NG, ten Broek RPG, Dekker JWT, van Workum F, van Goor H, Tanis PJ, de Wilt JHW. Trends in risk factors of anastomotic leakage after colorectal cancer surgery (2011-2019): A Dutch population-based study. Colorectal Dis 2021; 23:3251-3261. [PMID: 34536987 PMCID: PMC9293104 DOI: 10.1111/codi.15911] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/27/2021] [Accepted: 09/07/2021] [Indexed: 01/04/2023]
Abstract
AIM Anastomotic leakage (AL) after colon cancer (CC) and rectal cancer (RC) surgery often requires reintervention. Prevalence and morbidity may change over time with evolutions in treatment strategies and changes in patient characteristics. This nationwide study aimed to evaluate changes in the incidence, risk factors and mortality from AL during the past nine years. METHODS Data of CC and RC resections with primary anastomosis were extracted from the Dutch Colorectal Audit (2011-2019). AL was registered if requiring reintervention. Three consecutive cohorts were compared using logistic regression analysis. RESULTS Incidence of AL after CC surgery decreased from 6.6% in 2011-2013 to 4.8% in 2017-2019 and increased from 8.6% to 11.9% after RC surgery. In 2011-2013, male sex, ASA ≥3, (y)pT3-4, neoadjuvant therapy, emergency surgery and multivisceral resection were identified as risk factors for AL after CC surgery. In 2017-2019, only male sex and ASA ≥3 were risk factors for AL. For RC patients, male sex and neoadjuvant therapy were a risk factor for AL in 2011-2013. In 2017-2019, transanal approach was also a risk factor for AL. Postoperative mortality rate after AL was 12% (CC) and 2% (RC) in 2017-2019, without significant changes over time. CONCLUSION Contradictory trends in incidence and mortality for AL were observed among CC and RC surgery with changing risk factors over the past 9 years. High mortality after AL is only observed after CC surgery and remains unchanged. Continued efforts should be made to improve early detection and treatment of AL for these patients.
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Affiliation(s)
- Melissa N. N. Arron
- Radboud Institute for Health SciencesDepartment of SurgeryRadboud University Medical CentreNijmegenThe Netherlands
| | - Nynke G. Greijdanus
- Radboud Institute for Health SciencesDepartment of SurgeryRadboud University Medical CentreNijmegenThe Netherlands
| | - Richard P. G. ten Broek
- Radboud Institute for Health SciencesDepartment of SurgeryRadboud University Medical CentreNijmegenThe Netherlands
| | | | - Frans van Workum
- Department of SurgeryCanisius‐Wilhelmina HospitalNijmegenThe Netherlands
| | - Harry van Goor
- Radboud Institute for Health SciencesDepartment of SurgeryRadboud University Medical CentreNijmegenThe Netherlands
| | - Pieter J. Tanis
- Amsterdam UMCDepartment of SurgeryCancer Centre AmsterdamUniversity of AmsterdamAmsterdamThe Netherlands
| | - Johannes H. W. de Wilt
- Radboud Institute for Health SciencesDepartment of SurgeryRadboud University Medical CentreNijmegenThe Netherlands
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Rutgers ML, Detering R, Roodbeen SX, Crolla RM, Dekker JWT, Tuynman JB, Sietses C, Bemelman WA, Tanis PJ, Hompes R. Influence of Minimally Invasive Resection Technique on Sphincter Preservation and Short-term Outcome in Low Rectal Cancer in the Netherlands. Dis Colon Rectum 2021; 64:1488-1500. [PMID: 33990499 DOI: 10.1097/dcr.0000000000001906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transanal and robotic-assisted total mesorectal excision are techniques that can potentially overcome challenges encountered with a pure laparoscopic approach in patients with rectal cancer. OBJECTIVE The aim of this study was to evaluate the proportion and predictive factors of restorative procedures and subsequent short-term outcomes of 3 minimally invasive techniques to treat low rectal cancer. DESIGN This is a nationwide observational comparative registry study. SETTINGS Patients with rectal cancer were selected from the mandatory Dutch ColoRectal Audit. PATIENTS Patients with low rectal cancer (≤5 cm) who underwent curative minimally invasive total mesorectal excision between 2015 and 2018 were included. MAIN OUTCOME MEASURES The primary outcomes measured were the proportion of restorative procedure, positive circumferential resection margin, and postoperative complications. RESULTS A total of 3466 patients were included for analysis, of which 33% underwent a restorative procedure. Resections were performed laparoscopically in 2845 patients, transanally in 448 patients, and were robot-assisted in 173 patients, with a proportion of restorative procedures of 28%, 66%, and 40%. The transanal approach was independently associated with a restorative procedure (OR, 4.11; 95% CI, 3.21-5.26; p < 0.001). Independent risk factors for a nonrestorative procedure, irrespective of the surgical technique, were age >75 years, ASA physical status ≥3, BMI >30, history of abdominal surgery, clinical T4-stage, mesorectal fascia ≤1 mm, neoadjuvant therapy, and having a procedure in 2015 to 2016 versus 2017 to 2018. The circumferential resection margin involvement was similar for all 3 groups (5.4%, 5.1%, and 5.1%). Short-term postoperative complications were less favorable for the newer techniques than for the laparoscopic approach. LIMITATIONS This study was limited because of the registry's variables and different group sizes. CONCLUSION Patients with low rectal cancer in the Netherlands are more likely to receive a restorative procedure with a transanal approach, compared with a laparoscopic or robotic procedure. Short-term oncological outcomes are comparable between the 3 minimally invasive techniques. See Video Abstract at http://links.lww.com/DCR/B608. INFLUENCIA DE LA TCNICA DE RESECCIN MINIMAMENTE INVASIVA CON PRESERVACIN DE ESFNTERES EN LA RESOLUCIN A CORTO PLAZO EN CANCER DE TERCIO INFERIOR DE RECTO EN LOS PASES BAJOS ANTECEDENTES:La excisión mesorrectal transanal y asistida por robot son técnicas que potencialmente pueden superar algunos obstáculos que podemos encontrar en un abordaje exclusivamente laparoscópico en pacientes con cáncer de recto.OBJECTIVOS:El objetivo de este estudio es evaluar la proporción y los factores de predicción positivos de los procedimientos restauradores y los resultados subsecuentes a corto plazo de tres técnicas mínimamente invasivas para tratar el cáncer de tercio inferior de recto.DISEÑO:Es un estudio comparativo observacional del registro nacional.ESCENARIO:Pacientes con cáncer de recto seleccionados del Registro Oficial de la Auditoría Holandesa Colo-rectal.PACIENTGES:Pacientes con cáncer de tercio inferior de recto (≤5 centimetros) sometidos a excision mesorrectal total mínimamente invasiva curativa.PRINCIPALES PARAMETROS DE EFECTIVIDAD:Proporción de procedimientos restauradores, margen de resección circunferencial positivo y complicaciones postoperatorias.RESULTADOS:Se incluyeron un total de 3,466 pacientes para análisis, de los cuales 33% fueron sometidos a procedimiento restaurador. Las resecciones fueron laparoscópica en 2,845 pacientes, transanal en 448 y asistidas por robot en 173, con una proporción de procedimientos restauradores en 28%, 66% y 40% respectivamente. El abordaje transanal se correlacionó en forma independiente con el procedimiento restaurador (OR 4.11; 95% CI 4.11; 95% CI 3.21-5.26; p<0.001). Los factores de riesgo independientes para un procedimiento no restaurador, sin tomar en cuenta la técnica quirúrgica fueron: edad >75, American Society of Anesthesiologist ≥3, índice de masa corporal >30, antecedente de cirugía abdominal, Estadio clínico T4, fascia mesorrectal ≤1 millimetro, terapia neoadyuvante y haber sido sometido al procedimiento en 2015-2016 y no en 2017-2018. El margen circunferencial de resección involucrado fue similar para los tres grupos (5.4%, 5.1% y 5.1%). Las complicaciones postquirúrgicas a corto plazo fueron menos favorables para las técnicas nuevas comparadas con el abordaje laparoscópico.LIMTANTES:El estudio tiene la limitación de las variables dependientes del registro y la diferencia entre el número de pacientes en cada grupo.CONCLUSION:Los pacientes con cáncer de tercio inferior de recto en Holanda se tratan con mayor frecuencia mediante un procedimiento restaurador transanal en comparación con los abordajes laparoscópico o robótico. Los resultados favorables desde el punto de vista oncológico a corto plazo son comparables entre las tres técnicas de invasión mínima. Consulte Video Resumenhttp://links.lww.com/DCR/B608.
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Affiliation(s)
- Marieke L Rutgers
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Robin Detering
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Sapho X Roodbeen
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | | | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam University Medical Centers, Free University Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Colin Sietses
- Department of Surgery, Gelderse Vallei Hospital, Ede, the Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
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Long-term stoma-related reinterventions after anterior resection for rectal cancer with or without anastomosis: population data from the Dutch snapshot study. Tech Coloproctol 2021; 26:99-108. [PMID: 34837140 DOI: 10.1007/s10151-021-02543-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The aim of this study was to analyze the stoma-related reinterventions, complications and readmissions after an anterior resection for rectal cancer, based on a cross-sectional nationwide cohort study with 3-year follow-up. METHODS Rectal cancer patients who underwent a resection with either a functional anastomosis, a defunctioned anastomosis, or Hartmann's procedure (HP) with an end colostomy in 2011 in 71 Dutch hospitals were included. The primary outcome was number of stoma-related reinterventions. RESULTS Of the 2095 patients with rectal cancer, 1400 patients received an anterior resection and were included in this study; 257 received an initially functional anastomosis, 741 a defunctioned anastomosis, and 402 patients a HP. Of the 1400 included patients, 62% were males, 38% were females and the mean age was 67 years (SD 11.1). Following a primary functional anastomosis, 48 (19%) patients received a secondary stoma. Stoma-related complications occurred in six (2%) patients, requiring reintervention in one (0.4%) case. In the defunctioned anastomosis group, stoma-related complications were present in 92 (12%) patients, and required reintervention in 23 (3%) patients, in 10 (1%) of these more than 1 year after initial resection. Stoma-related complications occurred in 92 (23%) patients after a HP, and required reintervention in 39 (10%) patients in 17 (4%) of cases more than 1 year after initial resection. The permanent stoma rate was 11% and 20%, in the functional anastomosis and the defuctioned anastomosis group, respectively. The end colostomy in the HP group was reversed in 4% of cases. CONCLUSIONS Construction of a stoma after resection for rectal cancer with preservation of the sphincter is accompanied with long-term stoma-related morbidity. Stoma complications are more frequent after a HP. Even after 1 year, a significant number of reinterventions are required.
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Voeten DM, Busweiler LAD, van der Werf LR, Wijnhoven BPL, Verhoeven RHA, van Sandick JW, van Hillegersberg R, van Berge Henegouwen MI. Outcomes of Esophagogastric Cancer Surgery During Eight Years of Surgical Auditing by the Dutch Upper Gastrointestinal Cancer Audit (DUCA). Ann Surg 2021; 274:866-873. [PMID: 34334633 DOI: 10.1097/sla.0000000000005116] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate changes in treatment and outcomes of esophagogastric cancer surgery after introduction of the DUCA. In addition, the presence of risk-averse behavior was assessed. SUMMARY OF BACKGROUND DATA Clinical auditing is seen as an important quality improvement tool; however, its long-term efficacy remains largely unknown. In addition, critics claim that enhancements result from risk-averse behavior rather than positive effects of auditing. METHODS DUCA data were used from registration start (1-1-2011) until 31-12-2018. Trends in patient, tumor, hospital and treatment characteristics were univariably assessed. Trends in short-term outcomes were investigated using multilevel multivariable logistic regression. Presence of risk aversion was described by the corrected proportion of patients undergoing surgery, using data from the Netherlands Cancer Registry. To evaluate the impact of centralization on time trends identified, the association between hospital volume and outcomes was investigated. RESULTS This study included 6172 patients with esophageal and 3,690 with gastric cancer who underwent surgery. Pathological outcomes (lymph node yield, radicality) improved and futile surgery decreased over the years. In-hospital/30-day mortality decreased for esophagectomy (4.2% to 2.5%) and for gastrectomy (7.1% to 4.3%). Reinterventions, (minor) complications and readmissions increased. Risk aversion appeared absent. Between 2011-2018, annual median hospital volumes increased from 38 to 53 for esophagectomy and from 14 to 29 for gastrectomy. Higher hospital volumes were associated with several improved outcomes measures. CONCLUSIONS During 8 years of auditing, outcomes improved, with no signs of risk-averse behavior. These improvements occurred in parallel with centralization. Feedback on postoperative complications remains the focus of the DUCA.
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Affiliation(s)
- Daan M Voeten
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands
| | - Linde A D Busweiler
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Gelre Hospital, Apeldoorn, the Netherlands
| | - Leonie R van der Werf
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Gelre Hospital, Apeldoorn, the Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rob H A Verhoeven
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Johanna W van Sandick
- Department of Surgical Oncology, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
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van der Kruijssen DEW, Elias SG, Vink GR, van Rooijen KL, 't Lam-Boer J, Mol L, Punt CJA, de Wilt JHW, Koopman M. Sixty-Day Mortality of Patients With Metastatic Colorectal Cancer Randomized to Systemic Treatment vs Primary Tumor Resection Followed by Systemic Treatment: The CAIRO4 Phase 3 Randomized Clinical Trial. JAMA Surg 2021; 156:1093-1101. [PMID: 34613339 DOI: 10.1001/jamasurg.2021.4992] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance The role of primary tumor resection (PTR) in synchronous patients with metastatic colorectal cancer (mCRC) who had unresectable metastases and few or absent symptoms of their primary tumor is unclear. Studying subgroups with low postoperative mortality may identify patients who potentially benefit from PTR. Objective To determine the difference in 60-day mortality between patients randomized to systemic treatment only vs PTR followed by systemic treatment, and to explore risk factors associated with 60-day mortality. Design, Setting, and Participants CAIRO4 is a randomized phase 3 trial initiated in 2012 in which patients with mCRC were randomized to systemic treatment only or PTR followed by systemic treatment with palliative intent. This multicenter study was conducted by the Danish and Dutch Colorectal Cancer Group in general and academic hospitals in Denmark and the Netherlands. Patients included between August 2012 and December 2019 with histologically proven colorectal cancer, unresectable metastases, and a primary tumor with few or absent symptoms were eligible. Interventions Systemic treatment, consisting of fluoropyrimidine-based chemotherapy with bevacizumab vs PTR followed by fluoropyrimidine-based chemotherapy with bevacizumab. Main Outcomes and Measures The aim of the current analysis was to compare 60-day mortality rates in both treatment arms. A secondary aim was the identification of risk factors for 60-day mortality in the treatment arms. These aims were not predefined in the study protocol. Results A total of 196 patients were included in the intention-to-treat analysis (112 [57%] men; median [IQR] age, 65 [59-70] years). Sixty-day mortality was 3% (95% CI, 1%-9%) in the systemic treatment arm and 11% (95% CI, 6%-19%) in the PTR arm (P = .03). In a per-protocol analysis, 60-day mortality was 2% (95% CI, 1%-7%) vs 10% (95% CI, 5%-18%; P = .048). Patients with elevated serum levels of lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, and/or neutrophils who were randomized to PTR had a significantly higher 60-day mortality than patients without these characteristics. Conclusions and Relevance Patients with mCRC who were randomized to PTR followed by systemic treatment had a higher 60-day mortality than patients randomized to systemic treatment. Especially patients randomized to the PTR arm with elevated serum levels of lactate dehydrogenase, neutrophils, aspartate aminotransferase, and/or alanine aminotransferase were at high risk of postoperative mortality. Final study results on overall survival have to be awaited. Trial Registration ClinicalTrials.gov Identifier: NCT01606098.
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Affiliation(s)
- Dave E W van der Kruijssen
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sjoerd G Elias
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Geraldine R Vink
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Karlijn L van Rooijen
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jorine 't Lam-Boer
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Linda Mol
- Clinical Research Department, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Cornelis J A Punt
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Koëter T, de Nes LCF, Wasowicz DK, Zimmerman DDE, Verhoeven RHA, Elferink MA, de Wilt JHW. Hospital variation in sphincter-preservation rates in rectal cancer treatment: results of a population-based study in the Netherlands. BJS Open 2021; 5:6325344. [PMID: 34291288 PMCID: PMC8295312 DOI: 10.1093/bjsopen/zrab065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/28/2021] [Indexed: 01/18/2023] Open
Abstract
Background This study aimed to examine the sphincter-preservation rate variations in rectal cancer surgery. The influence of hospital volume on sphincter-preservation rates and short-term outcomes (anastomotic leakage (AL), positive circumferential resection margin (CRM), 30- and 90-day mortality rates) were also analysed. Methods Non-metastasized rectal cancer patients treated between 2009 and 2016 were selected from the Netherlands Cancer Registry. Surgical procedures were divided into sphincter-preserving surgery and an end colostomy group. Multivariable logistic regression models were generated to estimate the probability of undergoing sphincter-preserving surgery according to the hospital of surgery and tumour height (low, 5 cm or less, mid, more than 5 cm to 10 cm, and high, more than 10 cm). The influence of annual hospital volume (less than 20, 20–39, more than 40 resections) on sphincter-preservation rate and short-term outcomes was also examined. Results A total of 20 959 patients were included (11 611 sphincter preservation and 8079 end colostomy) and the observed median sphincter-preservation rate in low, mid and high rectal cancer was 29.3, 75.6 and 87.9 per cent respectively. After case-mix adjustment, hospital of surgery was a significant factor for patients’ likelihood for sphincter preservation in all three subgroups (P < 0.001). In mid rectal cancer, borderline higher rates of sphincter preservation were associated with low-volume hospitals (odds ratio 1.20, 95 per cent c.i. 1.01 to 1.43). No significant association between annual hospital volume and sphincter-preservation rate in low and high rectal cancer nor short-term outcomes (AL, positive CRM rate and 30- and 90-day mortality rates) was identified. Conclusion This population-based study showed a significant hospital variation in sphincter-preservation rates in rectal surgery. The annual hospital volume, however, was not associated with sphincter-preservation rates in low, and high rectal cancer nor with other short-term outcomes.
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Affiliation(s)
- T Koëter
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - L C F de Nes
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Surgery, Maasziekenhuis Pantein, Boxmeer, The Netherlands
| | - D K Wasowicz
- Department of Surgery, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - D D E Zimmerman
- Department of Surgery, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - R H A Verhoeven
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - M A Elferink
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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Warps AK, Detering R, Tollenaar RAEM, Tanis PJ, Dekker JWT. Textbook outcome after rectal cancer surgery as a composite measure for quality of care: A population-based study. Eur J Surg Oncol 2021; 47:2821-2829. [PMID: 34120807 DOI: 10.1016/j.ejso.2021.05.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/09/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Textbook outcome is a composite measure of combined outcome indicators, which has been suggested to be of additional value over single outcome parameters in clinical auditing of surgical treatment. This study aimed to assess textbook outcome after rectal cancer surgery as short-term marker for quality of care. MATERIALS AND METHODS Patients who underwent elective rectal cancer surgery between 2012 and 2019 and registered in the Dutch ColoRectal Audit were included. Textbook outcome was achieved when the following criteria were met: 30-day and primary hospital admission survival, no reintervention, tumour-free margins, no postoperative complications, a hospital stay of less than 14 days and no readmission. Hospital variation was evaluated in case-mix corrected funnel-plots. A multilevel logistic regression analysis was performed to identify associated factors with textbook outcome. RESULTS The study population consisted of 20,521 patients who underwent primary rectal cancer surgery, of whom 56.3% achieved textbook outcome. Postoperative complications were the main contributor to not achieving textbook outcome. Case-mix corrected funnel plots demonstrated that underperforming hospitals in 2012-2015 were no underperformers in 2016-2019 anymore. Female sex, laparoscopic surgery, and rectal resection without defunctioning stoma creation were positively associated with textbook outcome. CONCLUSION Textbook outcome after rectal cancer resection is mainly driven by postoperative complications. Although textbook outcome showed some discriminating value for identifying underperforming hospitals, it does not fit the plan-do-check-act cycle of clinical auditing. In our opinion, textbook outcome has little added value to the current outcome indicators for rectal cancer surgery.
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Affiliation(s)
- A K Warps
- Leiden University Medical Centre, Department of Surgery, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333 AA, Leiden, the Netherlands
| | - R Detering
- Amsterdam University Medical Centres, Department of Surgery, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - R A E M Tollenaar
- Leiden University Medical Centre, Department of Surgery, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333 AA, Leiden, the Netherlands
| | - P J Tanis
- Amsterdam University Medical Centres, Department of Surgery, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - J W T Dekker
- Reinier de Graaf Groep, Department of Surgery, Reinier de Graafweg 5, 2625 AD, Delft, the Netherlands.
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van der Hulst HC, Bastiaannet E, Portielje JEA, van der Bol JM, Dekker JWT. Can physical prehabilitation prevent complications after colorectal cancer surgery in frail older patients? Eur J Surg Oncol 2021; 47:2830-2840. [PMID: 34127328 DOI: 10.1016/j.ejso.2021.05.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/26/2021] [Accepted: 05/28/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Frail patients with colorectal cancer (CRC) are at increased risk of complications after surgery. Prehabilitation seems promising to improve this outcome and therefore we evaluated the effect of physical prehabilitation on postoperative complications in a retrospective cohort of frail CRC patients. METHODS The study consisted of all consecutive non-metastatic CRC patients ≥70 years who had elective surgery from 2014 to 2019 in a teaching hospital in the Netherlands, where a physical prehabilitation program was implemented from 2014 on. We performed both an intention-to-treat and per protocol analysis to evaluate postoperative complications in the physical prehabilitation (PhP) and non-prehabilitation (NP) group. RESULTS Eventually, 334 elective patients were included. The 124 (37.1%) patients in the PhP-group presented with higher age, higher comorbidity scores and walking-aid use compared to the NP-group. Medical complications occurred in 26.6% of the PhP-group and in 20.5% of the NP-group (p = 0.20) and surgical complications in 19.4% and 14.3% (p = 0.22) respectively. In all frailty subgroups, the medical complications were lower in the PhP-group compared to the NP-group (35.9% vs. 45.5% for patients with ≥2 comorbidities, 36.2% vs. 39.1% for ASA score ≥ III, 29.2% vs. 45.8% for walking-aid use). Differences were not significant. CONCLUSIONS In this study, patients selected for physical prehabilitation had a worse frailty profile and therefore a higher a priori risk of postoperative complications. However, the postoperative complication rate was not increased compared to patients who were less frail at baseline and without prehabilitation. Hence, physical prehabilitation may prevent postoperative complications in frail CRC patients ≥70 years.
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Affiliation(s)
- Heleen C van der Hulst
- Department of Surgery, Reinier De Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, the Netherlands.
| | - Esther Bastiaannet
- Department of Medical Oncology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Johanna E A Portielje
- Department of Medical Oncology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Jessica M van der Bol
- Department of Geriatric Medicine, Reinier De Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, the Netherlands
| | - Jan Willem T Dekker
- Department of Surgery, Reinier De Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, the Netherlands
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Risk of metachronous peritoneal metastases in patients with pT4a versus pT4b colon cancer: An international multicentre cohort study. Eur J Surg Oncol 2021; 47:2405-2413. [PMID: 34030920 DOI: 10.1016/j.ejso.2021.05.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/25/2021] [Accepted: 05/06/2021] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION With evolving treatment strategies aiming at prevention or early detection of metachronous peritoneal metastases (PM), identification of high-risk colon cancer patients becomes increasingly important. This study aimed to evaluate differences between pT4a (peritoneal penetration) and pT4b (invasion of other organs/structures) subcategories regarding risk of PM and other oncological outcomes. MATERIALS AND METHODS From eight databases deriving from four countries, patients who underwent curative intent treatment for pT4N0-2M0 primary colon cancer were included. Primary outcome was the 5-year metachronous PM rate assessed by Kaplan-Meier analysis. Independent predictors for metachronous PM were identified by Cox regression analysis. Secondary endpoints included 5-year local and distant recurrence rates, and 5-year disease free and overall survival (DFS, OS). RESULTS In total, 665 patients with pT4a and 187 patients with pT4b colon cancer were included. Median follow-up was 38 months (IQR 23-60). Five-year PM rate was 24.7% and 12.2% for pT4a and pT4b categories, respectively (p = 0.005). Independent predictors for metachronous PM were female sex, right-sided colon cancer, peritumoral abscess, pT4a, pN2, R1 resection, signet ring cell histology and postoperative surgical site infections. Five-year local recurrence rate was 14% in both pT4a and pT4b cancer (p = 0.138). Corresponding five-year distant metastases rates were 35% and 28% (p = 0.138). Five-year DFS and OS were 54% vs. 62% (p = 0.095) and 63% vs. 68% (p = 0.148) for pT4a vs. pT4b categories, respectively. CONCLUSION Patients with pT4a colon cancer have a higher risk of metachronous PM than pT4b patients. This observation has important implications for early detection and future adjuvant treatment strategies.
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Roodbeen SX, Blok RD, Borstlap WA, Bemelman WA, Hompes R, Tanis PJ. Does oncological outcome differ between restorative and nonrestorative low anterior resection in patients with primary rectal cancer? Colorectal Dis 2021; 23:843-852. [PMID: 33245846 PMCID: PMC8247354 DOI: 10.1111/codi.15464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/29/2020] [Accepted: 11/01/2020] [Indexed: 12/29/2022]
Abstract
AIM Nonrestorative low anterior resection (n-rLAR) (also known as low Hartmann's) is performed for rectal cancer when a poor functional outcome is anticipated or there have been problems when constructing the anastomosis. Compared with restorative LAR (rLAR), little oncological outcome data are available for n-rLAR. The aim of this study was to compare oncological outcomes between rLAR and n-rLAR for primary rectal cancer. METHOD This was a nationwide cross-sectional comparative study including all elective sphincter-saving LAR procedures for nonmetastatic primary rectal cancer performed in 2011 in 71 Dutch hospitals. Oncological outcomes of patients undergoing rLAR and n-rLAR were collected in 2015; the data were evaluated using Kaplan-Meier survival analysis and the results compared using log-rank testing. Uni- and multivariable Cox regression analysis was used to evaluate the association between the type of LAR and oncological outcome measures. RESULTS A total of 1197 patients were analysed, of whom 892 (75%) underwent rLAR and 305 (25%) underwent n-rLAR. The 3-year local recurrence (LR) rate was 3% after rLAR and 8% after n-rLAR (P < 0.001). The 3-year disease-free survival and overall survival rates were 77% (rLAR) vs 62% (n-rLAR) (P < 0.001) and 90% (rLAR) vs 75% (n-rLAR) (P < 0.001), respectively. In multivariable Cox analysis, n-rLAR was independently associated with a higher risk of LR (OR = 2.95) and worse overall survival (OR = 1.72). CONCLUSION This nationwide study revealed that n-rLAR for rectal cancer was associated with poorer oncological outcome than r-LAR. This is probably a noncausal relationship, and might reflect technical difficulties during low pelvic dissection in a subset of those patients, with oncological implications.
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Affiliation(s)
- Sapho X. Roodbeen
- Department of SurgeryAmsterdam UMCCancer Center AmsterdamUniversity of AmsterdamAmsterdamthe Netherlands
| | - Robin D. Blok
- Department of SurgeryAmsterdam UMCCancer Center AmsterdamUniversity of AmsterdamAmsterdamthe Netherlands,LEXORCenter for Experimental and Molecular MedicineOncode InstituteCancer Center AmsterdamAmsterdam UMC (AMC)University of AmsterdamAmsterdamthe Netherlands
| | - Wernard A. Borstlap
- Department of SurgeryAmsterdam UMCCancer Center AmsterdamUniversity of AmsterdamAmsterdamthe Netherlands
| | - Willem A. Bemelman
- Department of SurgeryAmsterdam UMCCancer Center AmsterdamUniversity of AmsterdamAmsterdamthe Netherlands
| | - Roel Hompes
- Department of SurgeryAmsterdam UMCCancer Center AmsterdamUniversity of AmsterdamAmsterdamthe Netherlands
| | - Pieter J. Tanis
- Department of SurgeryAmsterdam UMCCancer Center AmsterdamUniversity of AmsterdamAmsterdamthe Netherlands
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van den Bosch T, Warps ALK, de Nerée tot Babberich MPM, Stamm C, Geerts BF, Vermeulen L, Wouters MWJM, Dekker JWT, Tollenaar RAEM, Tanis PJ, Miedema DM. Predictors of 30-Day Mortality Among Dutch Patients Undergoing Colorectal Cancer Surgery, 2011-2016. JAMA Netw Open 2021; 4:e217737. [PMID: 33900400 PMCID: PMC8076964 DOI: 10.1001/jamanetworkopen.2021.7737] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Quality improvement programs for colorectal cancer surgery have been introduced with benchmarking based on quality indicators, such as mortality. Detailed (pre)operative characteristics may offer relevant information for proper case-mix correction. OBJECTIVE To investigate the added value of machine learning to predict quality indicators for colorectal cancer surgery and identify previously unrecognized predictors of 30-day mortality based on a large, nationwide colorectal cancer registry that collected extensive data on comorbidities. DESIGN, SETTING, AND PARTICIPANTS All patients who underwent resection for primary colorectal cancer registered in the Dutch ColoRectal Audit between January 1, 2011, and December 31, 2016, were included. Multiple machine learning models (multivariable logistic regression, elastic net regression, support vector machine, random forest, and gradient boosting) were made to predict quality indicators. Model performance was compared with conventionally used scores. Risk factors were identified by logistic regression analyses and Shapley additive explanations (ie, SHAP values). Statistical analysis was performed between March 1 and September 30, 2020. MAIN OUTCOMES AND MEASURES The primary outcome of this cohort study was 30-day mortality. Prediction models were trained on a training set by performing 5-fold cross-validation, and outcomes were measured by the area under the receiver operating characteristic curve on the test set. Machine learning was further used to identify risk factors, measured by odds ratios and SHAP values. RESULTS This cohort study included 62 501 records, most patients were male (35 116 [56.2%]), were aged 61 to 80 years (41 560 [66.5%]), and had an American Society of Anesthesiology score of II (35 679 [57.1%]). A 30-day mortality rate of 2.7% (n = 1693) was found. The area under the curve of the best machine learning model for 30-day mortality (0.82; 95% CI, 0.79-0.85) was significantly higher than the American Society of Anesthesiology score (0.74; 95% CI, 0.71-0.77; P < .001), Charlson Comorbidity Index (0.66; 95% CI, 0.63-0.70; P < .001), and preoperative score to predict postoperative mortality (0.73; 95% CI, 0.70-0.77; P < .001). Hypertension, myocardial infarction, chronic obstructive pulmonary disease, and asthma were comorbidities with a high risk for increased mortality. Machine learning identified specific risk factors for a complicated course, intensive care unit admission, prolonged hospital stay, and readmission. Laparoscopic surgery was associated with a decreased risk for all adverse outcomes. CONCLUSIONS AND RELEVANCE This study found that machine learning methods outperformed conventional scores to predict 30-day mortality after colorectal cancer surgery, identified specific patient groups at risk for adverse outcomes, and provided directions to optimize benchmarking in clinical audits.
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Affiliation(s)
- Tom van den Bosch
- Laboratory for Experimental Oncology and Radiobiology, Center for Experimental and Molecular Medicine, Cancer Center Amsterdam and Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Oncode Institute, Utrecht, the Netherlands
| | - Anne-Loes K. Warps
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Dutch Institute for Clinical Auditing, Leiden, the Netherlands
| | | | | | | | - Louis Vermeulen
- Laboratory for Experimental Oncology and Radiobiology, Center for Experimental and Molecular Medicine, Cancer Center Amsterdam and Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Oncode Institute, Utrecht, the Netherlands
| | - Michel W. J. M. Wouters
- Dutch Institute for Clinical Auditing, Leiden, the Netherlands
- Department of Surgical Oncology, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Reinier de Graaf Groep, Delft, the Netherlands
| | - Jan-Willem T. Dekker
- Dutch Institute for Clinical Auditing, Leiden, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Reinier de Graaf Groep, Delft, the Netherlands
| | - Rob A. E. M. Tollenaar
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Dutch Institute for Clinical Auditing, Leiden, the Netherlands
| | - Pieter J. Tanis
- Amsterdam University Medical Centers, Department of Surgery, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Daniël M. Miedema
- Laboratory for Experimental Oncology and Radiobiology, Center for Experimental and Molecular Medicine, Cancer Center Amsterdam and Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Oncode Institute, Utrecht, the Netherlands
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Hendricks A, Diers J, Baum P, Weibel S, Kastner C, Müller S, Lock JF, Köhler F, Meybohm P, Kranke P, Germer CT, Wiegering A. Systematic review and meta-analysis on volume-outcome relationship of abdominal surgical procedures in Germany. Int J Surg 2021; 86:24-31. [PMID: 33429078 DOI: 10.1016/j.ijsu.2020.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/11/2020] [Accepted: 12/28/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the past, for a number of abdominal surgical interventions a correlation between treatment volume of a hospital and the patient's outcome was shown in national and international studies. METHODS Based on a systematic literature search we analyzed the absolute and risk-adjusted in-house lethality as well as the rate of complications and the failure to rescue after abdominal surgery in Germany. The hospitals were grouped in quintiles according to the volume of treatment. RESULTS 11 studies including more than 2 million patients were identified and surgeries for the treatment of 9 disease conditions were studied. The meta-analysis shows a significantly lower absolute and risk-adjusted in-house mortality for surgery in hospitals with high treatment volumes compared to low volume hospitals. In the context of subgroup analysis, this effect is demonstrated especially for complex surgical procedures. The failure to rescue in patients suffering from sepsis is significantly lower in high volume centers compared to low volume centers. CONCLUSION This systematic review and meta-analysis shows on more than 2 million patients that there is a volume-outcome relationship for the surgical treatment of abdominal diseases in Germany across various organ systems, which is particularly true for complex interventions.
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Affiliation(s)
- Anne Hendricks
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Philip Baum
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany; Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126, Heidelberg, Germany
| | - Stephanie Weibel
- Clinic and Policlinic for Anesthesiology Surgery, University Hospital Würzburg, Germany
| | - Carolin Kastner
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Sophie Müller
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Johan Friso Lock
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Franziska Köhler
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Patrik Meybohm
- Clinic and Policlinic for Anesthesiology Surgery, University Hospital Würzburg, Germany
| | - Peter Kranke
- Clinic and Policlinic for Anesthesiology Surgery, University Hospital Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany; Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany; Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Germany; Department of Biochemistry and Molecular Biology University of Würzburg Würzburg, Germany.
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Warps AK, Detering R, Dekker JWT, Tollenaar RAEM, Tanis PJ. A 10-Year Evaluation of Short-Term Outcomes After Synchronous Colorectal Cancer Surgery: a Dutch Population-Based Study. J Gastrointest Surg 2021; 25:2637-2648. [PMID: 34031855 PMCID: PMC8523499 DOI: 10.1007/s11605-021-05036-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 05/03/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Synchronous colorectal cancer (CRC) has been associated with higher postoperative morbidity and mortality rates compared to solitary CRC. The influence of improved CRC care and introduction of screening on these outcomes remains unknown. This study aimed to evaluate time trends in incidence, population characteristics, and short-term outcomes of synchronous CRC patients at the population level over a 10-year time period. METHODS Data of all patients that underwent resection for primary CRC were extracted from the Dutch ColoRectal Audit (2010-2019). Analyses were stratified for solitary and synchronous colon and rectal cancer. Multilevel logistic regression analyses were used to determine factors associated with pathological and surgical outcomes. RESULTS Among 100,474 patients, 3.1% underwent surgery for synchronous CRC. A screening-related decrease for surgically treated left-sided solitary and synchronous colon cancer and a temporary increase for exclusively right-sided colon cancer were observed. Synchronous CRC patients had higher rates of complicated postoperative course, failure to rescue, and mortality. Bilateral synchronous colon cancer was more often treated with subtotal colectomy (25.4%) and demonstrated higher rates of surgical complications, reinterventions, prolonged hospital stay, and mortality than other synchronous tumor locations. DISCUSSION National bowel screening resulted in contradictory effects on surgical resections for synchronous CRCs depending on sidedness. Bilateral synchronous colon cancer required more often extended resection resulting in significantly worse outcomes than other synchronous tumor locations. Identification of low volume, high complex CRC subpopulations is relevant for individualized care and has implications for case-mix correction and benchmarking in clinical auditing.
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Affiliation(s)
- A. K. Warps
- grid.10419.3d0000000089452978Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands ,grid.511517.6Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands
| | - R. Detering
- grid.7177.60000000084992262Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - J. W. T. Dekker
- grid.415868.60000 0004 0624 5690Department of Surgery, Reinier de Graaf Groep, Reinier de Graafweg 5, 2625 AD Delft, The Netherlands
| | - R. A. E. M. Tollenaar
- grid.10419.3d0000000089452978Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands ,grid.511517.6Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands
| | - P. J. Tanis
- grid.7177.60000000084992262Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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Qaderi SM, Galjart B, Verhoef C, Slooter GD, Koopman M, Verhoeven RHA, de Wilt JHW, van Erning FN. Disease recurrence after colorectal cancer surgery in the modern era: a population-based study. Int J Colorectal Dis 2021; 36:2399-2410. [PMID: 33813606 PMCID: PMC8505312 DOI: 10.1007/s00384-021-03914-w] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE This population-based study determined the cumulative incidence (CI) of local, regional, and distant recurrences, examined metastatic patterns, and identified risk factors for recurrence after curative treatment for CRC. METHODS All patients undergoing resection for pathological stage I-III CRC between January 2015 and July 2015 and registered in the Netherlands Cancer Registry were selected (N = 5412). Additional patient record review and data collection on recurrences was conducted by trained administrators in 2019. Three-year CI of recurrence was calculated according to sublocation (right-sided: RCC, left-sided: LCC and rectal cancer: RC) and stage. Cox competing risk regression analyses were used to identify risk factors for recurrence. RESULTS The 3-year CI of recurrence for stage I, II, and III RCC and LCC was 0.03 vs. 0.03, 0.12 vs. 0.16, and 0.31 vs. 0.24, respectively. The 3-year CI of recurrence for stage I, II, and III RC was 0.08, 0.24, and 0.38. Distant metastases were found in 14, 12, and 16% of patients with RCC, LCC, and RC. Multiple site metastases were found often in patients with RCC, LCC, and RC (42 vs. 32 vs. 28%). Risk factors for recurrence in stage I-II CRC were age 65-74 years, pT4 tumor size, and poor tumor differentiation whereas in stage III CRC, these were ASA III, pT4 tumor size, N2, and poor tumor differentiation. CONCLUSIONS Recurrence rates in recently treated patients with CRC were lower than reported in the literature and the metastatic pattern and recurrence risks varied between anatomical sublocations.
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Affiliation(s)
- Seyed M. Qaderi
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands ,Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Boris Galjart
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Gerrit D. Slooter
- Department of Surgical Oncology, Máxima Medical Center, Eindhoven, The Netherlands
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Robert H. A. Verhoeven
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands ,Department of Research & Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - Johannes H. W. de Wilt
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Felice N. van Erning
- Department of Research & Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
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Burghgraef TA, Zweep AL, Sikkenk DJ, van der Pas MHGM, Verheijen PM, Consten ECJ. In vivo sentinel lymph node identification using fluorescent tracer imaging in colon cancer: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2020; 158:103149. [PMID: 33450679 DOI: 10.1016/j.critrevonc.2020.103149] [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: 04/25/2020] [Revised: 10/31/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The use of fluorescence might improve the performance of the sentinel lymph node procedure in patients with colon cancer. This systematic review was conducted to gain insight in the performance and applicability of the sentinel lymph node procedure using fluorescence. METHOD A systematic literature search was performed. Databases were searched for prospective studies concerning sentinel node identification using fluorescence in colon cancer. Detection rate, accuracy rate and sensitivity of the sentinel lymph node procedure were calculated for early stage (T1-T2) and more invasive (T3-T4) tumours. RESULTS Analyses of five included studies showed for respectively T3-T4 and T1-T2 tumours a detection rate of 90 % and 91 %, an accuracy rate of 77 % and 98 %, and a sensitivity of 30 % and 80 %. CONCLUSION The sentinel lymph node procedure using fluorescence in early stage (T1-T2) colon cancer seems to be promising. Larger cohorts are necessary to confirm these results.
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Affiliation(s)
- T A Burghgraef
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands; Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands.
| | - A L Zweep
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - D J Sikkenk
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands; Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
| | | | - P M Verheijen
- Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
| | - E C J Consten
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands; Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
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Paszat LF, Sutradhar R, Luo J, Baxter NN, Tinmouth J, Rabeneck L. Morbidity and mortality after major large bowel resection of non-malignant polyp among participants in a population-based screening program. J Med Screen 2020; 28:261-267. [PMID: 33153368 PMCID: PMC8366188 DOI: 10.1177/0969141320967960] [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] [Indexed: 12/02/2022]
Abstract
Background and aims Colonoscopy following positive fecal occult blood screening may detect non-malignant polyps deemed to require major large bowel resection. We aimed to estimate the major inpatient morbidity and mortality associated with major resection of non-malignant polyps detected at colonoscopy following positive guaiac fecal occult blood screening in Ontario's population-based colorectal screening program. Methods We identified those without a diagnosis of colorectal cancer in the Ontario Cancer Registry ≤24 months following the date of colonoscopy prompted by positive fecal occult blood screening between 2008 and 2017, who underwent a major large bowel resection ≤24 months after the colonoscopy, with a diagnosis code for non-malignant polyp, in the absence of a code for any other large bowel diagnosis. We extracted records of major inpatient complications and readmissions ≤30 days following resection. We computed mortality within 90 days following resection. Results For those undergoing colonoscopy ≤6 months following positive guaiac fecal occult blood screening, 420/127,872 (0.03%) underwent major large bowel resection for a non-malignant polyp. In 50/420 (11.9%), the resection included one or more rectosigmoid or rectal polyps, with or without a colonic polyp. There were one or more major inpatient complications or readmissions within 30 days in 117/420 (27.9%). Death occurred within 90 days in 6/420 (1.4%). Conclusions Serious inpatient complications and readmissions following major large bowel resection for non-malignant colorectal polyps are common, but mortality ≤90 days following resection is low. These outcomes should be considered as unintended adverse consequences of population-based colorectal screening programs.
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Affiliation(s)
- Lawrence F Paszat
- Institute for Health Care Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Rinku Sutradhar
- Institute for Health Care Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jin Luo
- Cancer Program, Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Nancy N Baxter
- Institute for Health Care Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jill Tinmouth
- Institute for Health Care Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Linda Rabeneck
- Institute for Health Care Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Diers J, Baum P, Matthes H, Germer CT, Wiegering A. Mortality and complication management after surgery for colorectal cancer depending on the DKG minimum amounts for hospital volume. Eur J Surg Oncol 2020; 47:850-857. [PMID: 33020007 DOI: 10.1016/j.ejso.2020.09.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/16/2020] [Accepted: 09/21/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The German Cancer Society ("Deutsche Krebsgesellschaft"; DKG) certifies on a volunteer base colorectal cancer centers based on, among other things, minimum operative amounts (at least 30 oncological colon cancer resections and 20 oncological rectal cancer resections per year). In this work, nationwide hospital mortality and death after documented complications ('Failure to Rescue' = FtR) were evaluated depending on the fulfillment of the minimum amounts. METHODS This is a retrospective analysis of the nationwide hospital billing data (DRG data, 2012-2017). Categorization is based on the DKG minimum quantities (fully, partially or not fulfilled). RESULTS Of 287,227 patients analyzed, 56.5% were operated in centers that met the DKG minimum amounts. The overall hospital mortality rate was 5.0%. In centers which met the minimum quantities, it was significantly lower (4.3%) than in hospitals which partially (5.7%) or not (6.2%) met the minimum quantities. The risk-adjusted hospital mortality rate for patients in hospitals who meet the minimum amount was 20% lower (OR 0.80; 95% CI [0.74-0.87], p < 0.001). For complications, both surgical and non-surgical, there was an unadjusted and adjusted lower FtR in hospitals that met the minimum amounts (e.g. anastomotic leak: 11.2% vs. 15.6%, p < 0.001; pulmonary artery embolism 21.3% vs. 28.2%, p = 0.001). CONCLUSION There is a 1/3 lower mortality and FtR rate after surgery for a colon or rectal cancer in centers fulfilling the DKG minimum amounts. The presented data implicate that there is an urgent need for a nationwide centralization program.
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Affiliation(s)
- Johannes Diers
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 2, 97080, Wuerzburg, Germany; Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - Philip Baum
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 2, 97080, Wuerzburg, Germany; Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Harald Matthes
- Institute for Social Medicine, Epidemiology and Health Economics of the Charité - Universitätsmedizin Berlin, Germany; Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 2, 97080, Wuerzburg, Germany; Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Center, Josef-Schneiderstr. 6, 97080, Wuerzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 2, 97080, Wuerzburg, Germany; Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Center, Josef-Schneiderstr. 6, 97080, Wuerzburg, Germany; Department of Biochemistry and Molecular Biology, University of Wuerzburg, Germany.
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Paszat LF, Sutradhar R, Corn E, Luo J, Baxter NN, Tinmouth J, Rabeneck L. Morbidity and mortality following major large bowel resection for colorectal cancer detected by a population-based screening program. J Med Screen 2020; 28:252-260. [PMID: 32954965 DOI: 10.1177/0969141320957361] [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] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS In 2008, Ontario initiated a population-based colorectal screening program using guaiac fecal occult blood testing. This work was undertaken to fill a major gap in knowledge by estimating serious post-operative complications and mortality following major large bowel resection of colorectal cancer detected by a population-based screening program. METHODS We identified persons with a first positive fecal occult blood result between 2008 and 2016, at the age of 50-74 years, who underwent a colonoscopy within 6 months, and proceeded to major large bowel resection for colon cancer within 6 months or rectosigmoid/rectal cancer within 12 months, and identified an unscreened cohort of resected cases diagnosed during the same years at the age of 50-74 years. We identified serious postoperative complications and readmissions ≤30 days following resection, and postoperative mortality ≤30 days, and between 31 and 90 days among the screen-detected and the unscreened cohorts. RESULTS Serious post-operative complications or readmissions within 30 days were observed among 1476/4999 (29.5%) cases in the screen-detected cohort, and among 3060/8848 (34.6%) unscreened cases. Mortality within 30 days was 43/4999 (0.9%) among the screen-detected cohort, and 208/8848 (2.4%) among the unscreened cohort. Among 30 day survivors, mortality between 31 and 90 days was 28/4956 (0.6%) and 111/8640 (1.3%), respectively. CONCLUSION Serious post-operative complications, readmissions, and mortality may be more common following major large bowel resection for colorectal cancer between the ages of 50 and 74 among unscreened compared to screen-detected cases.
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Affiliation(s)
- Lawrence F Paszat
- Institute for Healthcare Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Rinku Sutradhar
- Institute for Healthcare Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Elyse Corn
- Cancer Programme, ICES, Toronto, Ontario, Canada
| | - Jin Luo
- Cancer Programme, ICES, Toronto, Ontario, Canada
| | - Nancy N Baxter
- Institute for Healthcare Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jill Tinmouth
- Institute for Healthcare Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Linda Rabeneck
- Institute for Healthcare Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Matthes N, Diers J, Schlegel N, Hankir M, Haubitz I, Germer CT, Wiegering A. Validation of MTL30 as a quality indicator for colorectal surgery. PLoS One 2020; 15:e0238473. [PMID: 32857807 PMCID: PMC7454590 DOI: 10.1371/journal.pone.0238473] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/16/2020] [Indexed: 01/01/2023] Open
Abstract
Background Valid indicators are required to measure surgical quality. These ideally should be sensitive and selective while being easy to understand and adjust. We propose here the MTL30 quality indicator which takes into account 30-day mortality, transfer within 30 days, and a length of stay of 30 days as composite markers of an uneventful operative/postoperative course. Methods Patients documented in the StuDoQ|Colon and StuDoQ|Rectal carcinoma register of the German Society for General and Visceral Surgery (DGAV) were analyzed with regard to the effects of patient and tumor-related risk factors as well as postoperative complications on the MTL30. Results In univariate analysis, the MTL30 correlated significantly with patient and tumor-related risk factors such as ASA score (p<0.001), age (p<0.001), or UICC stage (p<0.001). There was a high sensitivity for the postoperative occurrence of complications such as re-operations (p<0.001) or subsequent bleeding (p<0.001), as well as a significant correlation with the CDC classification (p<0.001). In multivariate analysis, patient-related risk factors and postoperative complications significantly increased the odds ratio for a positive MTL30. A negative MTL30 showed a high specify for an uneventful operative and postoperative course. Conclusion The MTL30 is a valid indicator of colorectal surgical quality.
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Affiliation(s)
- Niels Matthes
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Johannes Diers
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Nicolas Schlegel
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Mohammed Hankir
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Imme Haubitz
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
- Comprehensive Cancer Center Mainfranken, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
- Comprehensive Cancer Center Mainfranken, University Hospital Wuerzburg, Wuerzburg, Germany
- Department of Biochemistry and Molecular Biology, Theodor Boveri Institute, University of Wuerzburg, Wuerzburg, Germany
- * E-mail:
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Postoperative administration of non-steroidal anti-inflammatory drugs in colorectal cancer surgery does not increase anastomotic leak rate; A systematic review and meta-analysis. Eur J Surg Oncol 2020; 46:2167-2173. [PMID: 32792221 DOI: 10.1016/j.ejso.2020.07.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/15/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Evidence on the effect of non-steroidal anti-inflammatory drugs (NSAIDs) on anastomotic leak (AL) rate after colorectal surgery is conflicting. Effects of NSAIDs might depend on the underlying disease. This meta-analysis aimed to review the effect of NSAIDs on AL rate in a homogeneous colorectal cancer patient population. METHODS A systematic literature search using MEDLINE and EMBASE database was performed for studies with AL as primary outcome comparing NSAID use in the early postoperative phase with no NSAID administration in colorectal cancer patients undergoing surgical resection. RESULTS Nine studies including 10,868 patients met the inclusion criteria. The majority, 7689 patients (70.7%) underwent low anterior resection and 3050 patients (28.1%) underwent colonic resection. The pooled incidence of AL was 8.6% (95%CI 7.0-10.0). Overall AL rate after colorectal cancer surgery was not increased in patients using NSAIDs for postoperative analgesia compared to non-users (p = 0.34, RR 1.23; 95%CI 0.81-1.86). This effect remained non-significant after stratification for low anterior resections (p = 0.07). Stratification for colonic resections could not be performed because AL results for this subgroup were not reported separately. Neither non-selective NSAID use nor COX-2 selective NSAID use caused an increased AL rate (p = 0.19, p = 0.26). The results were robust throughout sensitivity analyses. CONCLUSION Use of NSAIDs in cohorts with patients undergoing surgical resection for colorectal cancer does not increase overall AL rate. Since results were robust throughout several subgroup and sensitivity analyses, prescription of NSAIDs after colorectal cancer surgery seems safe.
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de Neree Tot Babberich MPM, Ledeboer M, van Leerdam ME, Spaander MCW, van Esch AAJ, Ouwendijk RJ, van der Schaar PJ, van der Beek S, Lacle MM, Seegers PA, Wouters MWJM, Fockens P, Dekker E. Dutch Gastrointestinal Endoscopy Audit: automated extraction of colonoscopy data for quality assessment and improvement. Gastrointest Endosc 2020; 92:154-162.e1. [PMID: 32057727 DOI: 10.1016/j.gie.2020.01.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 01/28/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The importance of having quality assessment, assurance, and improvement tools in health care is increasingly recognized. However, the additional associated administration burden progressively interferes with the structural implementation and adoption of such tools, especially when it concerns high-volume procedures such as colonoscopies. The development of the Dutch Gastrointestinal Endoscopy Audit (DGEA), a registry with automated extraction of colonoscopy quality data, and its first results are described. METHODS In close cooperation with commercial endoscopy reporting systems and a national histopathology database, healthcare professionals performing colonoscopies initiated a quality registry that extracts data from its core hospital resource or histology database without manual interference of the healthcare providers. Data extracted consisted of patient age, gender, indication of the colonoscopy, American Society of Anesthesiologists score, Boston Bowel Preparation Score, and cecal intubation; for the colonoscopy after a positive fecal immunochemical test in the colorectal cancer screening program, other data were polyp detection rate, which was available for all 48 hospitals or endoscopy centers, and adenoma detection rate, which was available for 26 hospitals or endoscopy centers. RESULTS Between January 1, 2016 and March 31, 2019, 48 hospitals or endoscopy centers voluntarily participated in the DGEA, and 275,017 unique patients with 313,511 colonoscopies were registered. Overall missing values were limited to <1%. CONCLUSIONS The results of this study demonstrate that it is feasible to deploy a quality registry collecting uniform data without additional administration burden for healthcare professionals.
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Affiliation(s)
| | - Michiel Ledeboer
- Department of Gastroenterology & Hepatology, Deventer Hospital, Deventer, the Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology & Hepatology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Aura A J van Esch
- Department of Gastroenterology & Hepatology, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Rob J Ouwendijk
- Department of Gastroenterology & Hepatology, Bravis Hospital, Roosendaal, the Netherlands
| | - Peter J van der Schaar
- Department of Gastroenterology & Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Sander van der Beek
- Department of Internal Medicine, Rivierenland Hospital, Tiel, the Netherlands
| | - Miangela M Lacle
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Michel W J M Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Evelien Dekker
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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Bakker WJ, van Hessen CV, Clevers GJ, Verleisdonk EJMM, Burgmans JPJ. Value and patient appreciation of follow-up after endoscopic totally extraperitoneal (TEP) inguinal hernia repair. Hernia 2020; 24:1033-1040. [PMID: 32447533 DOI: 10.1007/s10029-020-02220-8] [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: 02/19/2020] [Accepted: 05/11/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE There is some consensus on inguinal hernia surgery follow-up in research settings. However, consensus on regular follow-up is lacking. Therefore, patients and surgeons are unnecessarily burdened and not cost-efficient. Moreover, the purpose of follow-up is barely questioned. This study aims to evaluate follow-up after inguinal hernia repair and determine patient satisfaction. METHODS This prospective cohort study was executed in a high-volume specialized hernia clinic. All totally extraperitoneal (TEP) repair patients between July and October 2016 were included. Telephone follow-up was performed at 1 day, 6 weeks and 1 year postoperatively. One year postoperatively it was assessed whether patients visited other healthcare organizations, had remaining inguinal complaints, a Post-INguinal-repair-Questionnaire by telephone (PINQ-PHONE) was executed, and appreciation with follow-up was determined. RESULTS Respectively, 6 weeks and 1 year postoperatively, 138 (79.3%) and 130 (74.7%) of 174 included patients were reached. One year postoperatively 15 patients (11.5%) had remaining inguinal complaints, of which only four patients (3.1%) had not already reported their symptoms. Nineteen patients (14.6%) presented with self-reported complaints between 6 weeks and 1 year, and no patients went to other hospitals. Respectively, 107 (82.3%), 61 (46.9%) and 117 (90.0%) patients considered follow-up useful at 6 weeks, 1 year and in general. One hundred nineteen patients (91.5%) preferred telephone follow-up to outpatient clinic appointments. CONCLUSION TEP patients value a telephone follow-up time-point, however, long-term follow-up is not considered useful. Patients report postoperative complaints themselves, therefore performing follow-up serves no clinical purpose. The purpose of follow-up is patient satisfaction and registration for quality objectives.
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Affiliation(s)
- W J Bakker
- Department of Surgery, Hernia Clinic, Diakonessenhuis, Room Secretariaat Heelkunde, Professor Lorentzlaan 76, Zeist, 3707 HL, Utrecht, The Netherlands.
| | - C V van Hessen
- Department of Surgery, Hernia Clinic, Diakonessenhuis, Room Secretariaat Heelkunde, Professor Lorentzlaan 76, Zeist, 3707 HL, Utrecht, The Netherlands
| | - G J Clevers
- Department of Surgery, Hernia Clinic, Diakonessenhuis, Room Secretariaat Heelkunde, Professor Lorentzlaan 76, Zeist, 3707 HL, Utrecht, The Netherlands
| | - E J M M Verleisdonk
- Department of Surgery, Hernia Clinic, Diakonessenhuis, Room Secretariaat Heelkunde, Professor Lorentzlaan 76, Zeist, 3707 HL, Utrecht, The Netherlands
| | - J P J Burgmans
- Department of Surgery, Hernia Clinic, Diakonessenhuis, Room Secretariaat Heelkunde, Professor Lorentzlaan 76, Zeist, 3707 HL, Utrecht, The Netherlands
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Detering R, Saraste D, de Neree tot Babberich MPM, Dekker JWT, Wouters MWJM, van Geloven AAW, Bemelman WA, Tanis PJ, Martling A, Westerterp M. International evaluation of circumferential resection margins after rectal cancer resection: insights from the Swedish and Dutch audits. Colorectal Dis 2020; 22:416-429. [PMID: 31696599 PMCID: PMC7187294 DOI: 10.1111/codi.14903] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 10/18/2019] [Indexed: 12/14/2022]
Abstract
AIM This study aimed to determine predictive factors for the circumferential resection margin (CRM) within two northern European countries with supposed similarity in providing rectal cancer care. METHOD Data for all patients undergoing rectal resection for clinical tumour node metastasis (TNM) stage I-III rectal cancer were extracted from the Swedish ColoRectal Cancer Registry and the Dutch ColoRectal Audit (2011-2015). Separate analyses were performed for cT1-3 and cT4 stage. Predictive factors for the CRM were determined using univariable and multivariable logistic regression analyses. RESULTS A total of 6444 Swedish and 12 089 Dutch patients were analysed. Over time the number of hospitals treating rectal cancer decreased from 52 to 42 in Sweden, and 82 to 79 in the Netherlands. In the Swedish population, proportions of cT4 stage (17% vs 8%), multivisceral resection (14% vs 7%) and abdominoperineal excision (APR) (37% vs 31%) were higher. The overall proportion of patients with a positive CRM (CRM+) was 7.8% in Sweden and 5.4% in the Netherlands. In both populations with cT1-3 stage disease, common independent risk factors for CRM+ were cT3, APR and multivisceral resection. No common risk factors for CRM+ in cT4 stage disease were found. An independent impact of hospital volume on CRM+ could be demonstrated for the cT1-3 Dutch population. CONCLUSION Within two northern European countries with implemented clinical auditing, rectal cancer care might potentially be improved by further optimizing the treatment of distal and locally advanced rectal cancer.
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Affiliation(s)
- R. Detering
- Department of SurgeryAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands,Scientific bureau of the Dutch Institute of Clinical AuditingLeidenThe Netherlands
| | - D. Saraste
- Department of Molecular Medicine and SurgeryKarolinska Institutet,StockholmSweden
| | - M. P. M. de Neree tot Babberich
- Scientific bureau of the Dutch Institute of Clinical AuditingLeidenThe Netherlands,Department of Gastroenterology and HepatologyAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - J. W. T. Dekker
- Department of SurgeryReinier de Graaf Hospital,DelftThe Netherlands
| | - M. W. J. M. Wouters
- Scientific bureau of the Dutch Institute of Clinical AuditingLeidenThe Netherlands,Department of Surgical OncologyNetherlands Cancer Institute–Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands
| | | | - W. A. Bemelman
- Department of SurgeryAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - P. J. Tanis
- Department of SurgeryAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - A. Martling
- Department of Molecular Medicine and SurgeryKarolinska Institutet,StockholmSweden
| | - M. Westerterp
- Department of Colorectal SurgeryHaaglanden Medical CenterThe HagueThe Netherlands
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Diers J, Wagner J, Baum P, Lichthardt S, Kastner C, Matthes N, Matthes H, Germer CT, Löb S, Wiegering A. Nationwide in-hospital mortality rate following rectal resection for rectal cancer according to annual hospital volume in Germany. BJS Open 2020; 4:310-319. [PMID: 32207577 PMCID: PMC7093786 DOI: 10.1002/bjs5.50254] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/15/2019] [Indexed: 12/11/2022] Open
Abstract
Background The impact of hospital volume after rectal cancer surgery is seldom investigated. This study aimed to analyse the impact of annual rectal cancer surgery cases per hospital on postoperative mortality and failure to rescue. Methods All patients diagnosed with rectal cancer and who had a rectal resection procedure code from 2012 to 2015 were identified from nationwide administrative hospital data. Hospitals were grouped into five quintiles according to caseload. The absolute number of patients, postoperative deaths and failure to rescue (defined as in‐hospital mortality after a documented postoperative complication) for severe postoperative complications were determined. Results Some 64 349 patients were identified. The overall in‐house mortality rate was 3·9 per cent. The crude in‐hospital mortality rate ranged from 5·3 per cent in very low‐volume hospitals to 2·6 per cent in very high‐volume centres, with a distinct trend between volume categories (P < 0·001). In multivariable logistic regression analysis using hospital volume as random effect, very high‐volume hospitals (53 interventions/year) had a risk‐adjusted odds ratio of 0·58 (95 per cent c.i. 0·47 to 0·73), compared with the baseline in‐house mortality rate in very low‐volume hospitals (6 interventions per year) (P < 0·001). The overall postoperative complication rate was comparable between different volume quintiles, but failure to rescue decreased significantly with increasing caseload (15·6 per cent after pulmonary embolism in the highest volume quintile versus 38 per cent in the lowest quintile; P = 0·010). Conclusion Patients who had rectal cancer surgery in high‐volume hospitals showed better outcomes and reduced failure to rescue rates for severe complications than those treated in low‐volume hospitals.
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Affiliation(s)
- J Diers
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany.,Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - J Wagner
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - P Baum
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - S Lichthardt
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - C Kastner
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - N Matthes
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany.,Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany
| | - H Matthes
- Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - C-T Germer
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany.,Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany
| | - S Löb
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - A Wiegering
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany.,Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany.,Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany
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Haak HE, Maas M, Lambregts DMJ, Beets-Tan RGH, Beets GL. Is watch and wait a safe and effective way to treat rectal cancer in older patients? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:358-362. [PMID: 31982206 DOI: 10.1016/j.ejso.2020.01.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/13/2019] [Accepted: 01/03/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The aim was assess the oncological and functional outcome of the watch-and-wait (W&W) approach in older patients with a clinical (near)complete response after neoadjuvant treatment for rectal cancer. MATERIAL AND METHODS Patients were included in a W&W-approach (2004-2019) when digital rectal examination, endoscopy and MRI showed a (near)clinical complete response. Patients underwent endoscopy and MRI every 3 months during the first year, and 6-monthly thereafter. Patients aged ≥75 and ≥ 2 years of follow-up (FU) were selected. Oncological outcomes were assessed with Kaplan-Meier curves. Functional outcome was assessed with colostomy-free rate, Vaizey incontinence score, low anterior resection syndrome-score and International Prostate Syndrome Score. RESULTS 43/304 (14%) of patients in a W&W-approach met the inclusion criteria. Median FU was 37 (24-109) months. 5/43(12%) developed a local regrowth. All were treated surgically, with one patient experiencing a pelvic failure. Distant metastases occurred in 3/43 patients and 4 patients died, 3 of whom not related to rectal cancer. The 3-year local regrowth-free rate was 88%, 3-year non-regrowth disease-free survival 91%, overall survival 97% and 3-year colostomy-free rate 93%. Overall, the bowel- and urinary dysfunction scores at 3, 12 and 24 months indicated good continence, no or minor LARS and moderate urinary problems. CONCLUSION W&W for older patients with a clinical (near) complete response appears to be a safe alternative to a total mesorectal excision (TME), with a very high pelvic control rate, and few rectal cancer related deaths. Most patients can avoid major surgery and a definitive colostomy, and have a reasonable anorectal and urinary function.
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Affiliation(s)
- Hester E Haak
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands; GROW School for Oncology and Developmental Biology - Maastricht University, Maastricht, the Netherlands.
| | - Monique Maas
- Department of Radiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
| | - Doenja M J Lambregts
- Department of Radiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands; GROW School for Oncology and Developmental Biology - Maastricht University, Maastricht, the Netherlands.
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands; GROW School for Oncology and Developmental Biology - Maastricht University, Maastricht, the Netherlands.
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45
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Detering R, de Neree Tot Babberich MPM, Bos ACRK, Dekker JWT, Wouters MWJM, Bemelman WA, Beets-Tan RGH, Marijnen CAM, Hompes R, Tanis PJ. Nationwide analysis of hospital variation in preoperative radiotherapy use for rectal cancer following guideline revision. Eur J Surg Oncol 2019; 46:486-494. [PMID: 31882252 DOI: 10.1016/j.ejso.2019.12.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/02/2019] [Accepted: 12/17/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The revised Dutch colorectal cancer guideline (2014), led to an overall decrease in preoperative radiotherapy (RT) use. This study evaluates hospital variation in RT use for resectable rectal cancer and the influence of guideline revision, including the nationwide impact of changing RT application on short term outcomes. METHODS Data of surgically resected rectal cancer patients registered in the Dutch ColoRectal Audit were extracted between 2011 and 2017. Patients were divided into groups based on time of guideline revision (<2014 and ≥ 2014). Primary outcome was guideline adherence at hospital level regarding RT application, stratified for three stage groups. Secondary outcomes included positive circumferential resection (CRM+) and 30-day complicated postoperative course. RESULTS The groups consisted of 7364 and 12,057 patients, respectively. In total, 6772 patients did not receive RT (17.6% (<2014) vs. 45.7% (≥2014), p < 0.001). The largest increase of surgery alone was observed for cT1-2N0 stage rectal cancer (35.1% vs. 91.8%, p < 0.001), with a substantial decrease in hospital variation (IQR 22.2-50.0% vs. IQR 87.6-98.0%). For cT1-3N1MRF- stage rectal cancer, a substantial amount of hospital variation in short course RT remained after guideline revision (IQR 26.8-54.1% vs. IQR 26.2-50.0%). A significant decrease in CRM+ (5.8% vs. 4.2%, p < 0.001) and complicated course (22.5% vs. 18.5%, p < 0.001) was observed. CONCLUSIONS Radiotherapy for early-stage rectal cancer was uniformly abandoned after guideline revision, while substantial hospital variation remained for intermediate risk resectable rectal cancer in the Netherlands. The substantial nationwide decrease in the use of RT for rectal cancer treatment did not negatively impact CRM involvement.
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Affiliation(s)
- Robin Detering
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands.
| | | | - Amanda C R K Bos
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
| | | | - Michel W J M Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiotherapy, Leiden University Medical Center, Leiden, the Netherlands; Department of Radiotherapy, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands
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46
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Brouwer NPM, Heil TC, Olde Rikkert MGM, Lemmens VEPP, Rutten HJT, de Wilt JHW, van Erning FN. The gap in postoperative outcome between older and younger patients with stage I-III colorectal cancer has been bridged; results from the Netherlands cancer registry. Eur J Cancer 2019; 116:1-9. [PMID: 31163335 DOI: 10.1016/j.ejca.2019.04.036] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 04/22/2019] [Accepted: 04/27/2019] [Indexed: 12/25/2022]
Abstract
AIM OF THE STUDY Previous studies have shown that older patients benefited less than younger patients from surgical treatment for colorectal cancer (CRC). However, CRC care has advanced over time, and it is time to assess whether the difference in postoperative mortality between older and younger CRC patients is still present. METHODS Patients with primary stage I-III CRC diagnosed between 2005 and 2016 were selected from the Netherlands Cancer Registry (N = 111,778). Trends in postoperative mortality and 1-year postoperative relative survival (RS) were analysed, stratified according to age (<75 versus ≥75 years) and tumour location (colon versus rectum). One-year postoperative RS was analysed to correct for background mortality in the older population. RESULTS Between 2005 and 2016, 30-day postoperative mortality showed a stronger decrease for older patients (from 10.0% to 4.0% for colon cancer [p < 0.001] and from 8.3% to 2.7% for rectal cancer [p < 0.001]) compared with younger patients (from 2.0% to 0.9% for colon cancer [p < 0.001] and from 1.4% to 0.7% for rectal cancer [p = 0.01]). Between 2005 and 2016, also 1-year RS increased more for older patients (from 84.8% to 94.6% for colon cancer and from 86.1% to 97.2% for rectal cancer) compared with younger patients (from 94.0% to 97.8% for colon cancer and from 96.3% to 98.8% for rectal cancer). CONCLUSION Between 2005 and 2016, differences in postoperative mortality between older and younger CRC patients decreased. One-year postoperative RS was almost equal for older and younger patients in 2015-2016. This information is crucial for shared decision-making on surgical treatment.
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Affiliation(s)
- Nelleke P M Brouwer
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands.
| | - Thea C Heil
- Department of Geriatrics, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands.
| | - Marcel G M Olde Rikkert
- Department of Geriatrics, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands.
| | - Valery E P P Lemmens
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Godebaldkwartier 419, 3511 DT, Utrecht, the Netherlands; Department of Public Health, Erasmus University Medical Center, Doctor Molewaterplein 30, 3015 GD, Rotterdam, the Netherlands.
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, the Netherlands; Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands.
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands.
| | - Felice N van Erning
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Godebaldkwartier 419, 3511 DT, Utrecht, the Netherlands.
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47
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Ghadban T, Reeh M, Bockhorn M, Grotelueschen R, Bachmann K, Grupp K, Uzunoglu FG, Izbicki JR, Perez DR. Decentralized colorectal cancer care in Germany over the last decade is associated with high in-hospital morbidity and mortality. Cancer Manag Res 2019; 11:2101-2107. [PMID: 30881134 PMCID: PMC6419594 DOI: 10.2147/cmar.s197865] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Purpose Despite several national initiatives, centralization of cancer care in Germany remains insufficient for most malignancies. Currently, there is a plethora of centers, including 290 voluntary certified and audited colorectal cancer (CRC) centers by the end of 2017, in the nation with many patients still being treated outside of such centers. This study aimed to assess morbidity and mortality rates of surgical procedures for primary colorectal CRC in Germany over the last decade through a comprehensive unbiased analysis. Patients and methods We performed an analysis of the national diagnosis-related group inpatient statistics from 2005 to 2015 including all German hospitals. All patients who underwent surgeries for primary CRC during the study period were included. Results A total of 351,028 cases were analyzed (61.6% colonic and 38.4% rectal resections). The mortality rate of colonic resections remained high during the study period (4.9% in 2005 vs 4.5% in 2015; P=0.57). Reduced perioperative mortality after rectal surgery was observed only after 2012 compared to previous years (3.8% in 2005 vs 3.0% in 2015; P<0.001), with no further improvement. In-hospital morbidity such as anastomotic leak, wound infections, hemorrhage, pneumonia, deep vein thrombosis, and lung embolism did not improve for either rectal or for colonic surgery, but in contrast, most outcomes deteriorated over time. Conclusion The present study challenges the current national health policies aiming to improve outcomes of surgical patients. CRC care in Germany remains decentralized with high in-hospital morbidity and mortality rates. New national strategies focusing on the implementation of centralization and high-quality CRC care are urgently needed.
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Affiliation(s)
- Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany,
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany,
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany,
| | - Rainer Grotelueschen
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany,
| | - Kai Bachmann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany,
| | - Katharina Grupp
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany,
| | - Faik G Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany,
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany,
| | - Daniel R Perez
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany,
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