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Bianco F, Romano G, Tsarkov P, Stanojevic G, Shroyer K, Giuratrabocchetta S, Bergamaschi R. Extralevator with vs nonextralevator abdominoperineal excision for rectal cancer: the RELAPe randomized controlled trial. Colorectal Dis 2017; 19:148-157. [PMID: 27369739 DOI: 10.1111/codi.13436] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 05/12/2016] [Indexed: 02/08/2023]
Abstract
AIM A randomized controlled trial was conducted to test the null hypothesis that there is no difference in circumferential resection margin (CRM) between extralevator abdominoperineal excision (ELAPE) and non-ELAPE for rectal cancer. METHOD This was a multicentre, randomized controlled trial registered as NCT01702116. Patients with rectal cancer involving the external anal sphincter were randomized to ELAPE or non-ELAPE following neoadjuvant chemoradiation. Randomization was performed according to Consolidated Standards of Reporting Trials (CONSORT) guidelines. The primary end-point was CRM (in mm), defined as the shortest distance between the tumour and the cut edge of the specimen. Pathologists and centralized pathology were blinded to the patients' study arm. Interrater reliability (IRR) was assessed using Kendall's coefficient. Intra-operative perforation (IOP) was any rectal defect determined at pathology. Complications were classified using the Clavien-Dindo classification. Participating surgeons were retrained and credentialed. A sample size calculation showed that 34 subjects would provide sufficient power to reject the null hypothesis. RESULTS Thirty-four patients underwent the allocated intervention. Seventeen patients treated with ELAPE were comparable with 17 patients treated with non-ELAPE regarding age, gender, body mass index (BMI), American Society of Anesthesiology (ASA) class and pre-existing comorbidities. CRM depth (7.14 ± 5.76 mm vs 2.98 ± 3.28 mm, P = 0.016) and involvement rates (5.8% vs 41.0%, P = 0.04) were significantly increased in patients treated with ELAPE. The IRR for CRM was 0.78. There were no significant differences in IOP (5.8% vs 11.7%, P = 0.77) and complication rates (29% vs 29%, P = 0.97). CONCLUSIONS ELAPE was associated with statistically improved CRM with no difference in IOP and complication rates compared with non-ELAPE for rectal cancer involving the external anal sphincter.
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Affiliation(s)
- F Bianco
- Division of Colorectal Surgery, State University of New York, Stony Brook, New York, USA.,Department of Colorectal Surgery, National Cancer Institute, Naples, Italy
| | - G Romano
- Department of Colorectal Surgery, National Cancer Institute, Naples, Italy
| | - P Tsarkov
- Department of Colorectal Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
| | - G Stanojevic
- Department of Colorectal Surgery, School University of Niš, Niš, Serbia
| | - K Shroyer
- Department of Pathology, State University of New York, Stony Brook, New York, USA
| | - S Giuratrabocchetta
- Division of Colorectal Surgery, State University of New York, Stony Brook, New York, USA
| | - R Bergamaschi
- Division of Colorectal Surgery, State University of New York, Stony Brook, New York, USA
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Comber H, Sharp L, Timmons A, Keane FBV. Quality of rectal cancer surgery and its relationship to surgeon and hospital caseload: a population-based study. Colorectal Dis 2012; 14:e692-700. [PMID: 22731759 DOI: 10.1111/j.1463-1318.2012.03145.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM A population-based audit of all rectal cancers diagnosed in Ireland in 2007 has shown an inconsistent relationship between surgeon and hospital caseload and a range of quality measures. Better outcome for rectal cancer has been associated with increasing surgeon and hospital caseload, but there is less evidence of how this may relate to quality of care. Our aim was to examine how measures of quality in rectal cancer surgery related to surgeon and hospital workload and to outcome. METHOD All colorectal surgeons in Ireland participated in an audit of rectal cancer based on an evidence-based instrument. Data were extracted from medical records by trained coders. Generalized linear mixed models were used to determine the relationship between surgeon or hospital caseload and measures of quality of care. RESULTS Five hundred and eighty-one (95%) of the 614 rectal cancers diagnosed in Ireland in 2007 were audited; 49 hospitals and 86 surgeons participated. Ten (28%) hospitals treated fewer than five cases and seven fewer than three. A positive relationship between caseload and quality was seen for a few measures, more frequently for hospital than surgeon caseload. The relationship between caseload and quality of care was inconsistent, suggesting these measures do not represent a single dimension of quality. One-year survival was negatively associated with hospital caseload. There was no statistically significant relationship between survival and measures of quality of care. DISCUSSION Quality of care was inconsistently influenced by surgeon and hospital caseload. Caseload may affect only one aspect of surgical management, such as the quality of preoperative workup, and is not necessarily related to the quality of other hospital care. Simple measures of outcome, such as survival, cannot represent the complexity of this relationship.
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Affiliation(s)
- H Comber
- National Cancer Registry, Cork, Ireland Royal College of Surgeons in Ireland, Dublin, Ireland.
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Kellokumpu I, Vironen J, Kairaluoma M, Jantunen I, Kautiainen H, Nuorva K. Quality of surgical care, local recurrence, and survival in patients with low- and midrectal cancers following multimodal therapy. Int J Colorectal Dis 2012; 27:111-20. [PMID: 22038306 DOI: 10.1007/s00384-011-1322-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2011] [Indexed: 02/04/2023]
Abstract
PURPOSE To assess the quality of surgical care and outcome following multimodal treatment for low- and midrectal cancers, focusing on differences between low anterior and abdominoperineal resections. METHODS From 1999 to 2007, 179 patients underwent low anterior resection (LAR), abdominoperineal resection (APR), or proctocolectomy for low- or midrectal cancers. Preoperative (chemo)radiotherapy was given according to local guidelines and adjuvant postoperative chemotherapy in stage III disease. Outcome together with clinical and histopathological data were analyzed in relation to the type of surgery performed. RESULTS The postoperative mortality was 2.2%; morbidity, 39.6%; reoperation rate, 8.4%; and readmission rate, 16.0%. Involved circumferential resection margin (CRM ≤ 1 mm) rate was 4.5% (APR 9.1% vs. LAR 2.6%, p = 0.046). Intraoperative bowel perforation occurred in 5.5% of APRs. Anastomotic leak rate was 15.3%. The 5-year overall survival of the 179 patients was 68.5 %; disease-specific survival, 82.2%; and local recurrence rate, 6.3%. The overall, disease-specific, and disease-free survival rates in the 162 patients treated for cure were 73.1%, 84.6%, and 78.3%, and local recurrence rate was 4.4% with no significant differences between LAR and APR. CRM was the only independent predictor of local recurrence and CRM, tumor stage, and level independent predictors of disease-free survival. CONCLUSIONS Quality of surgical care was in line with the current international standards. CRM was an independent predictor for local recurrence and CRM, tumor stage, and level independent prognostic factors for disease-free survival. Neither the type of surgery (LAR vs. APR) nor the surgical approach (laparoscopic vs. open) influenced the oncologic outcome.
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Affiliation(s)
- Ilmo Kellokumpu
- Department of Surgery, Central Hospital of Central Finland, Jyväskylä, Finland.
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Augestad KM, Lindsetmo RO, Stulberg J, Reynolds H, Senagore A, Champagne B, Heriot AG, Leblanc F, Delaney CP. International preoperative rectal cancer management: staging, neoadjuvant treatment, and impact of multidisciplinary teams. World J Surg 2010; 34:2689-700. [PMID: 20703471 PMCID: PMC2949570 DOI: 10.1007/s00268-010-0738-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Little is known regarding variations in preoperative treatment and practice for rectal cancer (RC) on an international level, yet practice variation may result in differences in recurrence and survival rates. METHODS One hundred seventy-three international colorectal centers were invited to participate in a survey of preoperative management of rectal cancer. RESULTS One hundred twenty-three (71%) responded, with a majority of respondents from North America, Europe, and Asia. Ninety-three percent have more than 5 years' experience with rectal cancer surgery. Fifty-five percent use CT scan, 35% MRI, 29% ERUS, 12% digital rectal examination and 1% PET scan in all RC cases. Seventy-four percent consider threatened circumferential margin (CRM) an indication for neoadjuvant treatment. Ninety-two percent prefer 5-FU-based long-course neoadjuvant chemoradiation therapy (CRT). A significant difference in practice exists between the US and non-US surgeons: poor histological differentiation as an indication for CRT (25% vs. 7.0%, p = 0.008), CRT for stage II and III rectal cancer (92% vs. 43%, p = 0.0001), MRI for all RC patients (20% vs. 42%, p = 0.03), and ERUS for all RC patients (43% vs. 21%, p = 0.01). Multidisciplinary team meetings significantly influence decisions for MRI (RR = 3.62), neoadjuvant treatment (threatened CRM, RR = 5.67, stage II + III RR = 2.98), quality of pathology report (RR = 4.85), and sphincter-saving surgery (RR = 3.81). CONCLUSIONS There was little consensus on staging, neoadjuvant treatment, and preoperative management of rectal cancer. Regular multidisciplinary team meetings influence decisions about neoadjuvant treatment and staging methods.
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Affiliation(s)
- Knut M. Augestad
- Division of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047 USA
- Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway
- Department of Telemedicine and Health Service Research, University Hospital of North Norway, Tromsø, Norway
| | - Rolv-Ole Lindsetmo
- Division of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047 USA
- Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway
- Institute of Clinical Medicine, Tromsø University, Tromsø, Norway
| | - Jonah Stulberg
- Division of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047 USA
- Department of Biostatistics and Epidemiology, Case Western Reserve University School of Medicine, Cleveland, OH 44106 USA
| | - Harry Reynolds
- Division of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047 USA
| | - Anthony Senagore
- Spectrum Health Care, Department of Surgery, Michigan State University, Grand Rapids, MI 49503 USA
| | - Brad Champagne
- Division of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047 USA
| | - Alexander G. Heriot
- Division of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Fabien Leblanc
- Department of Digestive Surgery, University Hospitals of Bordeaux, Bordeaux, France
| | - Conor P. Delaney
- Division of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047 USA
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Augestad KM, Lindsetmo RO, Stulberg J, Reynolds H, Senagore A, Champagne B, Heriot AG, Leblanc F, Delaney CP. International preoperative rectal cancer management: staging, neoadjuvant treatment, and impact of multidisciplinary teams. World J Surg 2010; 34:2689-2700. [PMID: 20703471 DOI: 10.1007/s00268-010-0738-3] [citation(s)] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
BACKGROUND Little is known regarding variations in preoperative treatment and practice for rectal cancer (RC) on an international level, yet practice variation may result in differences in recurrence and survival rates. METHODS One hundred seventy-three international colorectal centers were invited to participate in a survey of preoperative management of rectal cancer. RESULTS One hundred twenty-three (71%) responded, with a majority of respondents from North America, Europe, and Asia. Ninety-three percent have more than 5 years' experience with rectal cancer surgery. Fifty-five percent use CT scan, 35% MRI, 29% ERUS, 12% digital rectal examination and 1% PET scan in all RC cases. Seventy-four percent consider threatened circumferential margin (CRM) an indication for neoadjuvant treatment. Ninety-two percent prefer 5-FU-based long-course neoadjuvant chemoradiation therapy (CRT). A significant difference in practice exists between the US and non-US surgeons: poor histological differentiation as an indication for CRT (25% vs. 7.0%, p = 0.008), CRT for stage II and III rectal cancer (92% vs. 43%, p = 0.0001), MRI for all RC patients (20% vs. 42%, p = 0.03), and ERUS for all RC patients (43% vs. 21%, p = 0.01). Multidisciplinary team meetings significantly influence decisions for MRI (RR = 3.62), neoadjuvant treatment (threatened CRM, RR = 5.67, stage II + III RR = 2.98), quality of pathology report (RR = 4.85), and sphincter-saving surgery (RR = 3.81). CONCLUSIONS There was little consensus on staging, neoadjuvant treatment, and preoperative management of rectal cancer. Regular multidisciplinary team meetings influence decisions about neoadjuvant treatment and staging methods.
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Affiliation(s)
- Knut M Augestad
- Division of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047, USA
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