1
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Haas S. Pilonidal reality calls for action. Br J Surg 2024; 111:znae054. [PMID: 38518113 PMCID: PMC10959429 DOI: 10.1093/bjs/znae054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Affiliation(s)
- Susanne Haas
- Department of Surgery, Randers Regional Hospital, Randers NØ, Denmark
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2
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Bierbaum V, Bobeth C, Roessler M, Gerken M, Tol KKV, Reissfelder C, Fürst A, Günster C, Dröge P, Ruhnke T, Klinkhammer-Schalke M, Schmitt J, Schoffer O. Treatment in certified cancer centers is related to better survival in patients with colon and rectal cancer: evidence from a large German cohort study. World J Surg Oncol 2024; 22:11. [PMID: 38183134 PMCID: PMC10770882 DOI: 10.1186/s12957-023-03262-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 11/22/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Certified cancer centers aim to ensure high-quality care by establishing structural and procedural standards according to evidence-based guidelines. Despite the high clinical and health policy relevance, evidence from a nation-wide study for the effectiveness of care for colorectal cancer in certified centers vs. other hospitals in Germany is still missing. METHODS In a retrospective cohort study covering the years 2009-2017, we analyzed patient data using demographic information, diagnoses, and treatments from a nationwide statutory health insurance enriched with information on certification. We investigated whether patients with incident colon or rectal cancer did benefit from primary therapy in a certified cancer center. We used relative survival analysis taking into account mortality data of the German population and adjustment for patient and hospital characteristics via Cox regression with shared frailty for patients in hospitals with and without certification. RESULTS The cohorts for colon and rectal cancer consisted of 109,518 and 51,417 patients, respectively, treated in a total of 1052 hospitals. 37.2% of patients with colon and 42.9% of patients with rectal cancer were treated in a certified center. Patient age, sex, comorbidities, secondary malignoma, and distant metastases were similar across groups (certified/non-certified) for both colon and rectal cancer. Relative survival analysis showed significantly better survival of patients treated in a certified center, with 68.3% (non-certified hospitals 65.8%) 5-year survival for treatment of colon cancer in certified (p < 0.001) and 65.0% (58.8%) 5-year survival in case of rectal cancer (p < 0.001), respectively. Cox regression with adjustment for relevant covariates yielded a lower hazard of death for patients treated in certified centers for both colon (HR = 0.92, 95% CI = 0.89-0.95) and rectal cancer (HR = 0.92, 95% CI = 0.88-0.95). The results remained robust in a series of sensitivity analyses. CONCLUSIONS This large cohort study yields new important evidence that patients with colorectal cancer have a better chance of survival if treated in a certified cancer center. Certification thus provides one powerful means to improve the quality of care for colorectal cancer. To decrease the burden of disease, more patients should thus receive cancer care in a certified center.
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Affiliation(s)
- Veronika Bierbaum
- Zentrum für Evidenzbasierte Gesundheitsversorgung, Universitätsklinikum und Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany.
| | - Christoph Bobeth
- Zentrum für Evidenzbasierte Gesundheitsversorgung, Universitätsklinikum und Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Martin Roessler
- Zentrum für Evidenzbasierte Gesundheitsversorgung, Universitätsklinikum und Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Michael Gerken
- Arbeitsgemeinschaft Deutscher Tumorzentren e.V., Berlin, Germany
| | - Kees Kleihues-van Tol
- Tumorzentrum Regensburg, Zentrum für Qualitätssicherung und Versorgungsforschung an der Fakultät für Medizin der Universität Regensburg, Regensburg, Germany
| | - Christoph Reissfelder
- Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Heidelberg, Germany
| | - Alois Fürst
- Klinik für Allgemein-, Viszeral-, Thoraxchirurgie, Adipositasmedizin, Caritas-Krankenhaus St. Josef Regensburg, Regensburg, Germany
| | | | | | | | - Monika Klinkhammer-Schalke
- Arbeitsgemeinschaft Deutscher Tumorzentren e.V., Berlin, Germany
- Tumorzentrum Regensburg, Zentrum für Qualitätssicherung und Versorgungsforschung an der Fakultät für Medizin der Universität Regensburg, Regensburg, Germany
| | - Jochen Schmitt
- Zentrum für Evidenzbasierte Gesundheitsversorgung, Universitätsklinikum und Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Olaf Schoffer
- Zentrum für Evidenzbasierte Gesundheitsversorgung, Universitätsklinikum und Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
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3
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Kim DR, Yoon BH, Ki Park Y, Moon BG. Significance of surgical first assistant expertise for surgical site infection prevention: Propensity score matching analysis. Medicine (Baltimore) 2023; 102:e33518. [PMID: 37058026 PMCID: PMC10101257 DOI: 10.1097/md.0000000000033518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 03/22/2023] [Indexed: 04/15/2023] Open
Abstract
Surgical site infection (SSI) is one of the most common postoperative complications in patients undergoing major operations, such as spinal fusion surgery, and a major contributor to patient morbidity and mortality. SSI is considered the most preventable type of infection; however, the risk of SSI is multifactorial. This study aimed to determine the extent to which the expertise of the surgical first assistant (SFA) affected SSI rates. We retrospectively reviewed 528 patients at a single institution who underwent lumbar spine fusion surgery via the posterior approach performed by a single surgeon between January 2012 and May 2020. The SFAs participating in the surgeries were classified into 2 groups: a certified neurosurgery specialist and relatively less experienced neurosurgery resident trainees. To reduce potential selection bias and confounding factors, propensity score matching was performed between the 2 groups. In 170 of the 528 lumbar spine fusion surgeries, the SFA was a certified neurosurgery specialist. In the other 358 surgeries, the SFA was a resident trainee. Seventeen patients met the SSI criteria. The SSI rate was significantly different between the 2 groups (0.6% (1 patient) and 4.5% (16 patients) in the certified specialist and resident trainee groups, respectively; P = .02). After propensity score matching, 170 paired patients were selected. After adjusting for confounding factors, SFAs that were certified neurosurgery specialists were associated with a lower likelihood of SSI (adjusted OR 0.09; 95% CI, 0.01 to 0.79; P = .029) than SFAs that were neurosurgery residents. A higher level of SFA expertise was significantly associated with a lower overall SSI rate in lumbar spine fusion surgeries. It is difficult to predict the incidence of SSI; however, this finding suggests the importance of SFA expertise in preventing SSI.
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Affiliation(s)
- Deok Ryeong Kim
- Department of Neurosurgery, Uijeongbu Eulji Medical Center, Eulji University, Seoul, Korea
| | - Byul Hee Yoon
- Department of Neurosurgery, Uijeongbu Eulji Medical Center, Eulji University, Seoul, Korea
| | - Yung Ki Park
- Department of Neurosurgery, Uijeongbu Eulji Medical Center, Eulji University, Seoul, Korea
| | - Byung Gwan Moon
- Department of Neurosurgery, Uijeongbu Eulji Medical Center, Eulji University, Seoul, Korea
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4
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Arnarson Ö, Syk I, Butt ST. Who should operate patients presenting with emergent colon cancer? A comparison of short- and long-term outcome depending on surgical sub-specialization. World J Emerg Surg 2023; 18:3. [PMID: 36624451 PMCID: PMC9830814 DOI: 10.1186/s13017-023-00474-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/01/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Colorectal cancer presents as emergencies in 20% of the cases. Emergency resection is associated with high postoperative morbidity and mortality. The specialization of the operating team in the emergency settings differs from the elective setting, which may have an impact on outcome. The aim of this study was to evaluate short- and long-term outcomes following emergent colon cancer surgery depending on sub-specialization of the operating team. METHODS This is a retrospective population study based on data from the Swedish Colorectal Cancer Registry (SCRCR). In total, 656 patients undergoing emergent surgery for colon cancer between 2011 and 2016 were included. The cohort was divided in groups according to specialization of the operating team: (1) colorectal team (CRT); (2) emergency surgical team (EST); (3) general surgical team (GST). The impact of specialization on short- and long-term outcomes was analyzed. RESULTS No statistically significant difference in 5-year overall survival (CRT 48.3%; EST 45.7%; GST 42.5%; p = 0.60) or 3-year recurrence-free survival (CRT 80.7%; EST 84.1%; GST 77.7%21.1%; p = 0.44) was noted between the groups. Neither was any significant difference in 30-day mortality (4.4%; 8.1%; 5.5%, p = 0.20), 90-day mortality (8.8; 11.9; 7.9%, p = 0.37) or postoperative complication rate (35.5%, 35.9 30.7, p = 0.52) noted between the groups. Multivariate analysis adjusted for case-mix showed no difference in hazard ratios for long-term survival or postoperative complications. The rate of permanent stoma after 3 years was higher in the EST group compared to the CRT and GST groups (34.5% vs. 24.3% and 23.9%, respectively; p < 0.0.5). CONCLUSION Surgical sub-specialization did not significantly affect postoperative complication rate, nor short- or long-term survival after emergent operation for colon cancer. Patients operated by emergency surgical teams were more likely to have a permanent stoma after 3 years.
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Affiliation(s)
- Örvar Arnarson
- Department of Surgery, Skane University Hospital Malmo, Lund University, Lund, Sweden.
| | - Ingvar Syk
- grid.4514.40000 0001 0930 2361Department of Surgery, Skane University Hospital Malmo, Lund University, Lund, Sweden
| | - Salma Tunå Butt
- grid.4514.40000 0001 0930 2361Department of Surgery, Skane University Hospital Malmo, Lund University, Lund, Sweden
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5
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Sturgess GR, Garner JP, Slater R. Abdominoperineal Resection in the United Kingdom: a Case against Centralisation. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03614-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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6
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Fahy MR, Hayes C, Kelly ME, Winter DC. Updated systematic review of the approach to pelvic exenteration for locally advanced primary rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2284-2291. [PMID: 35031157 DOI: 10.1016/j.ejso.2021.12.471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/23/2021] [Accepted: 12/29/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To review the evidence regarding surgical advances in the management of primary locally advanced rectal cancer. BACKGROUND The management of rectal cancer has evolved significantly in recent decades, with improved (neo)adjuvant treatment strategies and enhanced perioperative protocols. Centralization of care for complex, advanced cases has enabled surgeons in these units to undertake more ambitious surgical procedures. METHODS A Pubmed, Ovid, Embase and Cochrane database search was conducted according to the predetermined search strategy. The review protocol was prospectively registered with PROSPERO (CRD42021245582). RESULTS 14 studies were identified which reported on the outcomes of 3,188 patients who underwent pelvic exenteration (PE) for primary rectal cancer. 50% of patients had neoadjuvant radiotherapy. 24.2% underwent flap reconstruction, 9.4% required a bony resection and 34 patients underwent a major vascular excision. 73.9% achieved R0 resection, with 33.1% experiencing a major complication. Median length of hospital stay ranged from 13 to 19 days. 1.6% of patients died within 30 days of their operation. Five-year overall survival (OS) rates ranged 29%-78%. LIMITATIONS The studies included in our review were mostly single-centre observational studies published prior to the introduction of modern neoadjuvant treatment regimens. It was not possible to perform a meta-analysis on the basis that most were non-randomized, non-comparative studies. CONCLUSIONS Pelvic exenteration offers patients with locally advanced rectal cancer the chance of long-term survival with acceptable levels of morbidity. Increased experience facilitates more radical procedures, with the introduction of new platforms and/or reconstructive options.
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Affiliation(s)
- Matthew R Fahy
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland.
| | - Cathal Hayes
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
| | - Michael E Kelly
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
| | - Desmond C Winter
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
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7
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Rimini M, Casadei-Gardini A, Brandi G, Leone F, Fornaro L, Pella N, Silvestris N, Montagnani F, Lonardi S, Lai E, Galizia E, Santini D, Palloni A, Filippi R, Masi G, Aprile G, Aglietta M, Frega G, Fenocchio E, Vivaldi C, Satolli MA, Salani F, Scartozzi M, Faloppi L, Pellino A, Sperti E, Burgio V, Ratti F, Aldrighetti L, Cascinu S, Cucchetti A. Risk-adjusted analysis of survival variability among hospitals treating biliary malignancy. J Chemother 2022; 34:543-549. [PMID: 35156913 DOI: 10.1080/1120009x.2022.2036557] [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: 10/19/2022]
Abstract
Biliary tract cancer's (BTC) treatment main stone for advanced stages is constituted by chemotherapy. Surgical centralization and physicians' confidence in the use of new technologies and molecular analysis turned out to be of interest and potentially influencing survival. After applying a random-effect model, the relationship between each clinical variable on the main outcome was investigated through multilevel mixed-effects logistic regression. The risk-standardized outcomes were calculated for each centre involved. In the unadjusted cohort the median survival was 8.6 months (95%C.I.: 7.8-9.3) with a 9-month survival rate of 48.3% (95%C.I.: 45.0-51.5). A substantial heterogeneity across hospitals was found (I2: 70.3%). In multilevel mixed effect logistic regression, male, being treated for gallbladder cancer, higher ECOG, increased NLR, CEA and Ca 19.9 and low value of haemoglobin showed to increase the odds for 9-month mortality. The model estimated that the residual variance observed in 9-month mortality was attributable for the 2.6% to the treating hospital. Through a multilevel mixed effect model, average risk-standardized mortality within 9 months was 50.1%. As noticeable, all hospital's risk-standardized mortality falls within 95%C.I., thus all participating centres provided similar outcomes when adjusted for patient case-mix. Heterogenicity between hospital did not affect the outcome in term of overall survival.
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Affiliation(s)
- Margherita Rimini
- Department of Oncology, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy
| | - Andrea Casadei-Gardini
- Department of Oncology, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy.,Department of Oncology, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Brandi
- Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Francesco Leone
- Division of Medical Oncology, ASL BI, Nuovo Ospedale degli Infermi, Ponderano, BI, Italy
| | - Lorenzo Fornaro
- U.O. Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, IT, Italy
| | | | - Nicola Silvestris
- Department of Molecular Medicine, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Oncology, IRCCS Istituto Tumori "Giovanni Paolo II" of Bari, Bari, Italy
| | - Francesco Montagnani
- Division of Medical Oncology, ASL BI, Nuovo Ospedale degli Infermi, Ponderano, BI, Italy
| | - Sara Lonardi
- Oncology Unit 3, Department of Oncology, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Eleonora Lai
- Medical Oncology, University Hospital and University of Cagliari, Cagliari, Italy
| | - Eva Galizia
- Macerata General Hospital, Medical Oncology Unit, Macerata, Italy
| | - Daniele Santini
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Andrea Palloni
- Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Roberto Filippi
- Division of Medical Oncology, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, TO, Italy.,Department of Oncology, University of Turin, Torino, Italy.,Centro Oncologico Ematologico Subalpino, Azienda Universitaria Ospedaliera Città della Salute e della Scienza di Torino, Torino, Italy
| | - Gianluca Masi
- U.O. Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, IT, Italy
| | | | - Massimo Aglietta
- Division of Medical Oncology, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, TO, Italy.,Department of Oncology, University of Turin, Torino, Italy
| | - Giorgio Frega
- Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Elisabetta Fenocchio
- Multidisciplinary Outpatient Oncology Clinic, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, TO, Italy
| | - Caterina Vivaldi
- U.O. Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, IT, Italy
| | - Maria Antonietta Satolli
- Department of Oncology, University of Turin, Torino, Italy.,Centro Oncologico Ematologico Subalpino, Azienda Universitaria Ospedaliera Città della Salute e della Scienza di Torino, Torino, Italy
| | - Francesca Salani
- U.O. Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, IT, Italy
| | - Mario Scartozzi
- Medical Oncology, University Hospital and University of Cagliari, Cagliari, Italy
| | - Luca Faloppi
- Macerata General Hospital, Medical Oncology Unit, Macerata, Italy
| | - Antonio Pellino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.,Oncology Unit 1, Department of Oncology, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Elisa Sperti
- Division of Medical Oncology, Ordine Mauriziano Hospital, Torino, Italy
| | - Valentina Burgio
- Department of Oncology, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy
| | | | | | - Stefano Cascinu
- Department of Oncology, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy.,Department of Oncology, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,Oncology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
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8
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Taylor JC, Iversen LH, Burke D, Finan PJ, Howell S, Pedersen L, Iles MM, Morris EJA, Quirke P. Influence of age on surgical treatment and postoperative outcomes of patients with colorectal cancer in Denmark and Yorkshire, England. Colorectal Dis 2021; 23:3152-3161. [PMID: 34523211 DOI: 10.1111/codi.15910] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 12/16/2022]
Abstract
AIM Denmark and Yorkshire are demographically similar and both have undergone changes in their management of colorectal cancer to improve outcomes. The differential provision of surgical treatment, especially in the older age groups, may contribute to the magnitude of improved survival rates. This study aimed to identify differences in the management of colorectal cancer surgery and postoperative outcomes according to patient age between Denmark and Yorkshire. METHOD This was a retrospective population-based study of colorectal cancer patients diagnosed in Denmark and Yorkshire between 2005 and 2016. Proportions of patients undergoing major surgical resection, postoperative mortality and relative survival were compared between Denmark and Yorkshire across several age groups (18-59, 60-69, 70-79 and ≥80 years) and over time. RESULTS The use of major surgical resection was higher in Denmark than in Yorkshire, especially for patients aged ≥80 years (70.5% versus 50.5% for colon cancer, 49.3% versus 38.1% for rectal cancer). Thirty-day postoperative mortality for Danish patients aged ≥80 years was significantly higher than that for Yorkshire patients with colonic cancer [OR (95% CI) = 1.22 (1.07, 1.38)] but not for rectal cancer or for 1-year postoperative mortality. Relative survival significantly increased in all patients aged ≥80 years except for Yorkshire patients with colonic cancer. CONCLUSION This study suggests that there are major differences between the management of elderly patients with colorectal cancer between the two populations. Improved selection for surgery and better peri- and postoperative care in these patients appears to improve long-term outcomes, but may come at the cost of a higher 30-day mortality.
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Affiliation(s)
- John C Taylor
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Lene H Iversen
- Department of Surgery, Aarhus University Hospital, and Danish Colorectal Cancer Group, Aarhus, Denmark
| | - Dermot Burke
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Paul J Finan
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Simon Howell
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Mark M Iles
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Eva J A Morris
- Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK
| | - Philip Quirke
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
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9
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Park H, Kim HI, Choe JH, Chung MK, Son YI, Hahn SY, Hwang NY, Woo SY, Kim SW, Chung JH, Kim TH, Kim JS. Surgeon Volume and Long-Term Oncologic Outcomes in Patients with Medullary Thyroid Carcinoma. Ann Surg Oncol 2021; 28:8863-8871. [PMID: 34240294 DOI: 10.1245/s10434-021-10383-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgery is the most important curative treatment for medullary thyroid carcinoma (MTC). The relationship between surgeon volume (the number of surgeries performed) and short-term surgical outcomes, such as increased postoperative complication or costs, is well established. This study evaluated whether surgeon volume influenced long-term oncologic outcomes. METHODS We retrospectively reviewed 246 patients diagnosed with MTC after initial thyroid surgery from 1995 to 2019. After exclusion, 194 patients were eligible for inclusion in the study. Surgeons were categorized as low/intermediate volume (fewer than 100 operations per year) or high volume (at least 100 operations per year). RESULTS Of the 194 included patients, 60 (30.9%) developed disease recurrence, and 9 (4.6%) died of MTC during the median follow-up of 92.5 months. Having a low/intermediate-volume surgeon was associated with high disease recurrence (log-rank test, p < 0.001). After adjustment for age, sex, tumor type (sporadic versus hereditary), primary tumor size, presence of central lymph node metastasis (LNM), presence of lateral LNM, extrathyroidal extension, and positive resection margin, surgeon volume was a significant factor for disease recurrence (hazard ratio 2.28, p = 0.004); however, cancer-specific survival was not affected by surgeon volume (hazard ratio 4.16, p = 0.115). CONCLUSIONS Surgeon volume is associated with long-term oncologic outcome. MTC patients will be able to make the best decisions for their treatment based on the results of this study.
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Affiliation(s)
- Hyunju Park
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye In Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jun-Ho Choe
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Man Ki Chung
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Ik Son
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Yeon Hahn
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Na-Young Hwang
- Statistics and Data Center, Samsung Medical Center, Seoul, Korea
| | - Sook-Young Woo
- Statistics and Data Center, Samsung Medical Center, Seoul, Korea
| | - Sun Wook Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hoon Chung
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Hyuk Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Jee Soo Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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10
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Association of certification, improved quality and better oncological outcomes for rectal cancer in a specialized colorectal unit. Int J Colorectal Dis 2021; 36:517-533. [PMID: 33165684 DOI: 10.1007/s00384-020-03792-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Centralization of cancer care is expected to yield superior results. In Germany, the national strategy is based on a voluntary certification process. The effect of centre certification is difficult to prove because quality data are rarely available prior to certification. This observational study aims to assess outcomes for rectal cancer patients before and after implementation of a certified cancer centre. PATIENTS AND METHODS All consecutive patients treated for rectal cancer in our certified centre from 2009 to 2017 were retrieved from a prospective database. The dataset was analyzed according to a predefined set of 19 quality indicators comprising 36 quality goals. The results were compared to an identical cohort of patients, treated from 2000 to 2008 just before centre implementation. RESULTS In total, 1059 patients were included, 481 in the 2009-2017 interval and 578 in the 2000-2008 interval. From 2009 to 2017, 25 of 36 quality goals were achieved (vs. 19/36). The proportion of anastomotic leaks in low anastomoses was improved (13.5% vs. 22.1%, p = 0.018), as was the local 5-year recurrence rate for stage (y)pIII rectal cancers (7.7% vs. 17.8%, p = 0.085), and quality of mesorectal excision (0.3% incomplete resections vs. 5.5%, p = 0.002). Furthermore, a decrease of abdominoperineal excisions was noted (47.1% vs. 60.0%, p = 0.037). For the 2009-2017 interval, local 5-year recurrence rate in stages (y)p0-III was 4.6% and 5-year overall survival was 80.2%. CONCLUSIONS Certification as specialized centre and regular audits were associated with an improvement of various quality parameters. The formal certification process has the potential to enhance quality of care for rectal cancer patients.
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Crouse DL, Boudreau J, Leonard PSJ, Pawluk K, McDonald JT. Provider caseload volume and short-term outcomes following colorectal surgeries in New Brunswick: a provincial-level cohort study. Can J Surg 2020. [PMID: 33107818 DOI: 10.1503/cjs.012319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND American studies have shown that higher provider and hospital volumes are associated with reduced risk of mortality following colorectal surgical interventions. Evidence from Canada is limited, and to our knowledge only a single study has considered outcomes other than death. We describe associations between provider surgical volume and all-cause mortality and postoperative complications following colorectal surgical interventions in New Brunswick. METHODS We used hospital discharge abstracts linked to vital statistics, the provincial cancer registry and patient registry data. We considered all admissions for colorectal surgeries from 2007 through 2013. We used logistic regression to identify odds of dying and odds of complications (from any of anastomosis leak, unplanned colostomy, intra-abdominal sepsis or pneumonia) within 30 days of discharge from hospital according to provider volume (i.e., total interventions performed over the preceding 2 years) adjusted for personal, contextual, provider and hospital characteristics. RESULTS Overall, 9170 interventions were performed by 125 providers across 18 hospitals. We found decreased odds of experiencing a complication following colorectal surgery per increment of 10 interventions performed per year (odds ratio 0.94, 95% confidence interval 0.91-0.96). We found no associations with mortality. Associations remained consistent across models restricted to cancer patients or to interventions performed by general surgeons and across models that also considered overall hospital volumes. CONCLUSION Our results suggest that increased caseloads are associated with reduced odds of complications, but not with all-cause mortality, following colorectal surgery in New Brunswick. We also found no evidence of volume having differential effects on outcomes from colon and rectal procedures.
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Affiliation(s)
- Dan L Crouse
- From the Department of Sociology, University of New Brunswick, Fredericton, N.B. (Crouse); the New Brunswick Institute for Research, Data and Training, University of New Brunswick, Fredericton, N.B. (Crouse, Boudreau, Leonard, McDonald); the Department of Economics, University of New Brunswick, Fredericton, N.B. (Leonard, McDonald); and the Faculty of Medicine, Dalhousie University, Halifax, N.S. (Pawluk)
| | - Jonathan Boudreau
- From the Department of Sociology, University of New Brunswick, Fredericton, N.B. (Crouse); the New Brunswick Institute for Research, Data and Training, University of New Brunswick, Fredericton, N.B. (Crouse, Boudreau, Leonard, McDonald); the Department of Economics, University of New Brunswick, Fredericton, N.B. (Leonard, McDonald); and the Faculty of Medicine, Dalhousie University, Halifax, N.S. (Pawluk)
| | - Philip S J Leonard
- From the Department of Sociology, University of New Brunswick, Fredericton, N.B. (Crouse); the New Brunswick Institute for Research, Data and Training, University of New Brunswick, Fredericton, N.B. (Crouse, Boudreau, Leonard, McDonald); the Department of Economics, University of New Brunswick, Fredericton, N.B. (Leonard, McDonald); and the Faculty of Medicine, Dalhousie University, Halifax, N.S. (Pawluk)
| | - Keith Pawluk
- From the Department of Sociology, University of New Brunswick, Fredericton, N.B. (Crouse); the New Brunswick Institute for Research, Data and Training, University of New Brunswick, Fredericton, N.B. (Crouse, Boudreau, Leonard, McDonald); the Department of Economics, University of New Brunswick, Fredericton, N.B. (Leonard, McDonald); and the Faculty of Medicine, Dalhousie University, Halifax, N.S. (Pawluk)
| | - James T McDonald
- From the Department of Sociology, University of New Brunswick, Fredericton, N.B. (Crouse); the New Brunswick Institute for Research, Data and Training, University of New Brunswick, Fredericton, N.B. (Crouse, Boudreau, Leonard, McDonald); the Department of Economics, University of New Brunswick, Fredericton, N.B. (Leonard, McDonald); and the Faculty of Medicine, Dalhousie University, Halifax, N.S. (Pawluk)
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The Impact of Hospital Volume and Charlson Score on Postoperative Mortality of Proctectomy for Rectal Cancer. Ann Surg 2018; 268:854-860. [DOI: 10.1097/sla.0000000000002898] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Versteeg S, Ho V, Siesling S, Varkevisser M. Centralisation of cancer surgery and the impact on patients’ travel burden. Health Policy 2018; 122:1028-1034. [DOI: 10.1016/j.healthpol.2018.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/11/2018] [Accepted: 07/01/2018] [Indexed: 11/28/2022]
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Relationship between hospital volume and short-term outcomes: a nationwide population-based study including 75,280 rectal cancer surgical procedures. Oncotarget 2018; 9:17149-17159. [PMID: 29682212 PMCID: PMC5908313 DOI: 10.18632/oncotarget.24699] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 02/28/2018] [Indexed: 01/02/2023] Open
Abstract
There is growing interest on the potential relationship between hospital volume (HV) and outcomes as it might justify the centralization of care for rectal cancer surgery. From the National Italian Hospital Discharge Dataset, data on 75,280 rectal cancer patients who underwent elective major surgery between 2002 and 2014 were retrieved and analyzed. HV was grouped into tertiles: low-volume performed 1-12, while high-volume hospitals performed 33+ procedures/year. The impact of HV on in-hospital mortality, abdominoperineal resection (APR), 30-day readmission, and length of stay (LOS) was assessed. Risk factors were calculated using multivariate logistic regression. The proportion of procedures performed in low-volume hospitals decreased by 6.7 percent (p<0.001). The rate of in-hospital mortality, APR and 30-day readmission was 1.3%, 16.3%, and 7.2%, respectively, and the median LOS was 13 days. The adjusted risk of in-hospital mortality (OR = 1.49, 95% CI = 1.25-1.78), APR (OR 1.10, 95%CI 1.02-1.19), 30-day readmission (OR 1.49, 95%CI 1.38-1.61), and prolonged LOS (OR 2.29, 95%CI 2.05-2.55) were greater for low-volume hospitals than for high-volume hospitals. This study shows an independent impact of HV procedures on all short-term outcome measures, justifying a policy of centralization for rectal cancer surgery, a process which is underway.
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Benchmarking rectal cancer care: institutional compliance with a longitudinal checklist. J Surg Res 2018; 225:142-147. [PMID: 29605024 DOI: 10.1016/j.jss.2018.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/28/2017] [Accepted: 01/04/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND In 2012, the American Society of Colon and Rectal Surgeons published the Rectal Cancer Surgery Checklist, a consensus document listing 25 essential elements of care for all patients undergoing radical surgery for rectal cancer. The authors herein examine checklist adherence in a mature, multisurgeon specialty academic practice. MATERIALS AND METHODS A retrospective medical record review of patients undergoing elective radical resection for rectal adenocarcinoma over a 23-mo period was conducted. Checklists were completed post hoc for each patient, and these results were tabulated to determine levels of compliance. Subgroup analyses by compliance and experience levels of the treating surgeon were performed. RESULTS A total of 161 patients underwent resection, demonstrating a median completion rate of 84% per patient. Poor compliance was noted consistently in documenting baseline sexual function (0%), multidisciplinary discussion of treatment plans (16.8%), pelvic nerve identification (8.7%) and leak testing (52.9%), and radial margin status reporting (57.5%). Junior surgeons achieved higher rates of compliance and were more likely to restage after neoadjuvant therapy (67.9% versus 29.4%, P < 0.001), discuss patients at tumor board (31.3% versus 13.2%, P = 0.014), and document leak testing (86.7% versus 47.2%, P = 0.005) compared with senior surgeons. CONCLUSIONS Checklist compliance within a high-volume, specialty academic practice remains varied. Only surgeon experience level was significantly associated with high checklist compliance. Junior surgeons achieved greater compliance with certain items, particularly those that reinforce decision-making. Further efforts to standardize rectal cancer care should focus on checklist implementation, targeted surgeon outreach, and assessment of checklist compliance correlation to clinical outcomes.
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Kim HI, Kim TH, Choe JH, Kim JH, Kim JS, Kim YN, Kim H, Kim SW, Chung JH. Surgeon volume and prognosis of patients with advanced papillary thyroid cancer and lateral nodal metastasis. Br J Surg 2018; 105:270-278. [DOI: 10.1002/bjs.10655] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 01/25/2017] [Accepted: 06/23/2017] [Indexed: 01/03/2023]
Abstract
Abstract
Background
Surgery is the most important treatment modality for papillary thyroid cancer (PTC). However, the relationship between surgeon volume and long-term oncological outcomes has not been explored.
Methods
Patients diagnosed with N1b PTC after initial thyroid surgery between 1 July 1994 and 31 December 2011 were eligible for inclusion in the study. Surgeons were categorized into high (at least 100 operations per year) and low (fewer than 100 operations per year) volume groups. Kaplan–Meier survival analysis according to surgeon volume was performed, and Cox proportional hazard modelling was used to estimate hazard ratios (HRs) with 95 per cent confidence intervals according to patient, tumour and surgeon factors.
Results
A total of 1103 patients with a median follow-up of 81 (i.q.r. 62–108) months were included in the study. During follow-up, 200 patients (18·1 per cent) developed structural recurrence. A high surgeon volume was associated with low structural recurrence (P = 0·006). After adjustment for age, sex and conventional risk factors for recurrence (histology, tumour size, gross extrathyroidal extension, margin status, more than 5 positive lymph nodes, radioactive iodine therapy), the adjusted HR for structural recurrence for low-volume surgeons was 1·46 (95 per cent c.i. 1·08 to 1·96), compared with high-volume surgeons. Distant metastasis (P = 0·242) and disease-specific mortality (P = 0·288) were not affected by surgeon volume.
Conclusion
Surgeon volume is associated with structural recurrence, but not distant metastasis or cancer-specific death in patients with N1b PTC. Surgeon volume is important in initial surgery for advanced PTC with extensive nodal metastasis in order to ensure curative outcome and reduce treatment-related morbidity.
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Affiliation(s)
- H I Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - T H Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - J-H Choe
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - J-H Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - J S Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Y N Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - H Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - S W Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - J H Chung
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
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Bundgaard NS, Bendtsen VO, Ingeholm P, Seidelin UH, Jensen KH. Intraoperative Tumor Perforation is Associated with Decreased 5-Year Survival in Colon Cancer: A Nationwide Database Study. Scand J Surg 2017; 106:202-210. [PMID: 28737074 DOI: 10.1177/1457496916683091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND It is a widely held belief that intraoperative tumor perforation in colon cancer impairs survival and causes local recurrence, although the prognostic importance remains unclear. AIM The aim of this study was to assess the effect of unintended intraoperative tumor perforation on postoperative mortality and long-term survival. MATERIAL AND METHODS This national cohort study was based on data from a prospectively maintained nationwide colorectal cancer database. We included 16,517 colon cancer patients who were resected with curative intent from 2001 to 2012. RESULTS Intraoperative tumor perforation produced a significantly impaired 5-year survival of 40% compared to 64% in non-perforated colon cancer. Intraoperative tumor perforation was an independent risk factor for death, hazard ratio 1.63 (95% confidence interval: 1.4-1.94), with a significantly increased 90-day postoperative mortality of 17% compared to 7% in non-perforated tumors, p < 0.001. We showed that tumor fixation, emergency operations, and laparotomies were associated with an increased risk of intraoperative tumor perforation. CONCLUSION This nationwide study demonstrates that intraoperative tumor perforation in colon cancer is associated with statistically significant reduced long-term survival and increased postoperative mortality.
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Affiliation(s)
- N S Bundgaard
- 1 Department of Surgery, Bispebjerg Hospital, København, Denmark
| | - V O Bendtsen
- 2 Department of Surgery, Slagelse Hospital, Slagelse, Denmark
| | - P Ingeholm
- 3 Department of Pathology, Herlev Hospital, Herlev, Denmark
| | - U H Seidelin
- 4 Danish Cancer Society Research Center, København, Denmark
| | - K H Jensen
- 2 Department of Surgery, Slagelse Hospital, Slagelse, Denmark
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Impact of hospital volume on quality indicators for rectal cancer surgery in British Columbia, Canada. Am J Surg 2017; 213:388-394. [DOI: 10.1016/j.amjsurg.2016.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/05/2016] [Accepted: 07/12/2016] [Indexed: 12/19/2022]
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Maurer CA, Dietrich D, Schilling MK, Metzger U, Laffer U, Buchmann P, Lerf B, Villiger P, Melcher G, Klaiber C, Bilat C, Brauchli P, Terracciano L, Kessler K. Prospective multicenter registration study of colorectal cancer: significant variations in radicality and oncosurgical quality-Swiss Group for Clinical Cancer Research Protocol SAKK 40/00. Int J Colorectal Dis 2017; 32:57-74. [PMID: 27714521 DOI: 10.1007/s00384-016-2667-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aimed to investigate in a multicenter cohort study the radicality of colorectal cancer resections, to assess the oncosurgical quality of colorectal specimens, and to compare the performance between centers. METHODS One German and nine Swiss hospitals agreed to prospectively register all patients with primary colorectal cancer resected between September 2001 and June 2005. The median number of eligible patients with one primary tumor included per center was 95 (range 12-204). RESULTS The following variations of median values or percentages between centers were found: length of bowel specimen 20-39 cm (25.8 cm), maximum height of mesocolon 6.5-12.5 cm (9.0 cm), number of examined lymph nodes 9-24 (16), distance to nearer bowel resection margin in colon cancer 4.8-12 cm (7 cm), and in rectal cancer 2-3 cm (2.5 cm), central ligation of major artery 40-97 % (71 %), blood loss 200-500 ml (300 ml), need for perioperative blood transfusion 5-40 % (19 %), tumor opened during mobilization 0-11 % (5 %), T4-tumors not en-bloc resected 0-33 % (4 %), inadvertent perforation of mesocolon/mesorectum 0-8 % (4 %), no-touch isolation technique 36-86 % (67 %), abdominoperineal resection for rectal cancer 0-30 % (17 %), rectal cancer specimen with circumferential margin ≤1 mm 0-19 % (10 %), in-hospital mortality 0-6 % (2 %), anastomotic leak or intra-abdominal abscess 0-17 % (7 %), re-operation 0-17 % (8 %). CONCLUSION In colorectal cancer, surgery considerable variations between different centers were found with regard to radicality and oncosurgical quality, suggesting a potential for targeted improvement of surgical technique.
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Affiliation(s)
- Christoph A Maurer
- Departments of Surgery of Hospital of Liestal, Liestal, Switzerland.
- Hirslanden Group, Clinic Beau-Site, Schänzlihalde 11, 3000, Bern, Switzerland.
| | - Daniel Dietrich
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
| | | | - Urs Metzger
- Triemli Hospital of Zürich, Zürich, Switzerland
| | | | | | | | | | | | | | | | - Peter Brauchli
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
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Nielsen MB, Rasmussen PC, Tanderup K, Nielsen SK, Fokdal L, Laurberg S, Lindegaard JC. Clinical outcome of interstitial pulsed dose rate brachytherapy in multimodality treatment of locally advanced primary or recurrent rectal and sigmoid cancer with high risk of incomplete microscopic resection. Acta Oncol 2016; 55:1408-1413. [PMID: 27537776 DOI: 10.1080/0284186x.2016.1213416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the role of interstitial pulsed dose rate brachytherapy (PDR-BT) in multimodality treatment of locally advanced primary or recurrent rectal and sigmoid cancer with high risk of microscopic incomplete resection (R1). METHODS AND MATERIAL A total of 73 consecutive patients (recurrent/primary: 40/33) were treated with PDR-BT between 2001 and 2010. Patients received preoperative external beam radiotherapy (EBRT) and concomitant chemotherapy. Following resection of the tumor and the involved pelvic organs, a median of four (3-8) catheters were sutured to the tumor bed with a distance of approximately 1 cm between the catheters. A target respecting the catheters with a margin of 5 mm was contoured on computed tomography (CT) and three-dimensional (3D) dose planning with a planning aim for BT of D90 > 30 Gy, (0.6 Gy/pulse, 1 pulse/h) was performed. Previously irradiated patients (27%) underwent surgery that was directly followed by PDR-BT. Postoperative EBRT was then applied to the tumor bed 3-5 weeks after PDR-BT. RESULTS A total of 23 patients (31%) received a radical resection (R0) and 45 patients (62%) received an R1 resection. Five patients (7%) received a macroscopic incomplete resection (R2). The five-year overall survival was 33%. Local control at five years was 67% for patients who received a R0 resection and 32% for patients who received an R1 resection. The five-year actuarial risk of a grade 3-4 BT-related complication was 5%. CONCLUSIONS Meaningful disease control and survival can be obtained at an acceptable rate of late morbidity in selected patients with locally advanced primary and recurrent rectal or sigmoid cancer using (chemo) RT, extensive surgery and PDR-BT when a high risk of an R1 resection is expected.
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Affiliation(s)
| | | | - Kari Tanderup
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
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Morche J, Mathes T, Pieper D. Relationship between surgeon volume and outcomes: a systematic review of systematic reviews. Syst Rev 2016; 5:204. [PMID: 27899141 PMCID: PMC5129247 DOI: 10.1186/s13643-016-0376-4] [Citation(s) in RCA: 227] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 11/08/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The surgeon volume-outcome relationship has been discussed for many years and its existence or nonexistence is of importance for various reasons. A lot of empirical work has been published on it. We aimed to summarize systematic reviews in order to present current evidence. METHODS Medline, Embase, Cochrane database of systematic reviews (CDSR), and health technology assessment websites were searched up to October 2015 for systematic reviews on the surgeon volume-outcome relationship. Reviews were critically appraised, and results were extracted and synthesized by type of surgical procedure/condition. RESULTS Thirty-two reviews reporting on 15 surgical procedures/conditions were included. Methodological quality of included systematic reviews assessed with the assessment of multiple systematic reviews (AMSTAR) was generally moderate to high albeit included literature partly neglected considering methodological issues specific to volume-outcome relationship. Most reviews tend to support the presence of a surgeon volume-outcome relationship. This is most clear-cut in colorectal cancer, bariatric surgery, and breast cancer where reviews of high quality show large effects. CONCLUSIONS When taking into account its limitations, this overview can serve as an informational basis for decision makers. Our results seem to support a positive volume-outcome relationship for most procedures/conditions. However, forthcoming reviews should pay more attention to methodology specific to volume-outcome relationship. Due to the lack of information, any numerical recommendations for minimum volume thresholds are not possible. Further research is needed for this issue.
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Affiliation(s)
- Johannes Morche
- Institute of Health Economics and Clinical Epidemiology, The University Hospital of Cologne (AöR), Gleueler Str. 176-178, 50935, Cologne, Germany
| | - Tim Mathes
- Faculty of Health, School of Medicine, Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany.
| | - Dawid Pieper
- Faculty of Health, School of Medicine, Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany
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Pomazkin VI. [Long-term results of obstructing colonic cancer]. Khirurgiia (Mosk) 2016:51-56. [PMID: 27723696 DOI: 10.17116/hirurgia2016951-56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM to compare long-term results after 2 types of stage management of obstructing colonic cancer. MATERIAL AND METHODS Main group included 105 patients after staged treatment with decompressive colostomy followed by radical surgery at the second stage. Control group consisted of 115 patients after obstructive colonic resection with colostomy as radical intervention at the first stage; the second stage included reconstructive intervention colostomy removal. RESULTS Local recurrences were observed in 5.1% and 13.7% in the main and control groups respectively. Distant metastases occurred in 7.1% and 13.7% in both groups respectively. 5-year overall survival was 69.4% and 50.9% in the main and control groups respectively. Recurrence-free sirvival was 65.3% and 48.1% in both groups. CONCLUSION Decompressive colostomy and delayed radical surgery with intestinal integrity restoration improve long-term outcomes compared with emergency radical interventions.
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Affiliation(s)
- V I Pomazkin
- Sverdlovsk Regional Hospital for War Veterans, Ekaterinburg, Russia
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Veen T, Stormark K, Nedrebø BS, Berg M, Søreide JA, Kørner H, Søreide K. Long-Term Follow-Up and Survivorship After Completing Systematic Surveillance in Stage I-III Colorectal Cancer: Who Is Still at Risk? J Gastrointest Cancer 2016; 46:259-66. [PMID: 25917794 PMCID: PMC4519589 DOI: 10.1007/s12029-015-9723-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE In patients with a high life expectancy at the time of surgery for colorectal cancer (CRC), the long-term outcome may be influenced by factors other than their cancer. We aimed to investigate the long-term outcome and cause of death beyond a 5-year surveillance programme. METHODS We evaluated the overall survival (OS) and cancer-specific survival (CSS) of a population-based cohort of stage I-III CRC patients <75 years old who completed a systematic surveillance programme. RESULTS In total, 161 patients <75 years old, 111 (69 %) of whom were node negative (pN0), were included. The median follow-up time was 12.1 years. The OS was 54 % at 15 years and differed significantly between the pN0 and pN+ patients (65 vs. 30 %; P < 0.001); CSS (72 %) also differed between the pN0 and pN+ patients (85 vs. 44 %; P < 0.001). For the 5-year survivors (n = 119), 14 (12 %) died of CRC during additional long-term follow-up (7 each for pN0 and pN+), and 6 patients (5 %; all pN0) died of other cancers. Patients aged <65 years exhibited better long-term survival (81 %), but most of the deaths were due to CRC (10/12 deaths). Only two of the 14 cancer-related deaths involved microsatellite instable (MSI) CRC. Females exhibited better OS and CSS beyond 5 years of surveillance. CONCLUSIONS The long-term survival beyond 5-year survivorship for stage I-III CRC is very good. Nonetheless, cancer-related deaths are encountered in one-third of patients and occur most frequently in patients who are <65 years old at disease onset-pointing to a still persistent risk several years after surgery.
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Affiliation(s)
- T. Veen
- />Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068 Stavanger, Norway
| | - K. Stormark
- />Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068 Stavanger, Norway
| | - B. S. Nedrebø
- />Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068 Stavanger, Norway
| | - M. Berg
- />Centre for Organelle Research, Faculty of Science and Technology, University of Stavanger, 4036 Stavanger, Norway
| | - J. A. Søreide
- />Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068 Stavanger, Norway
- />Department of Clinical Medicine, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway
| | - H. Kørner
- />Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068 Stavanger, Norway
- />Department of Clinical Medicine, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway
| | - Kjetil Søreide
- />Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068 Stavanger, Norway
- />Department of Clinical Medicine, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway
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Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Kelly KN, Hensley BJ, Rickles AS, Noyes K, Fleming FJ, Monson JR. High volume improves outcomes: The argument for centralization of rectal cancer surgery. Surgery 2016; 159:736-48. [DOI: 10.1016/j.surg.2015.09.021] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/04/2015] [Accepted: 09/23/2015] [Indexed: 11/28/2022]
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Influence of Individual Surgeon Volume on Oncological Outcome of Colorectal Cancer Surgery. Int J Surg Oncol 2015; 2015:464570. [PMID: 26425367 PMCID: PMC4573626 DOI: 10.1155/2015/464570] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 08/10/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Surgery performed by a high-volume surgeon improves short-term outcomes. However, not much is known about long-term effects. Therefore we performed the current study to evaluate the impact of high-volume colorectal surgeons on survival. METHODS We conducted a retrospective analysis of our prospectively collected colorectal cancer database between 2004 and 2011. Patients were divided into two groups: operated on by a high-volume surgeon (>25 cases/year) or by a low-volume surgeon (<25 cases/year). Perioperative data were collected as well as follow-up, recurrence rates, and survival data. RESULTS 774 patients underwent resection for colorectal malignancies. Thirteen low-volume surgeons operated on 453 patients and 4 high-volume surgeons operated on 321 patients. Groups showed an equal distribution for preoperative characteristics, except a higher ASA-classification in the low-volume group. A high-volume surgeon proved to be an independent prognostic factor for disease-free survival in the multivariate analysis (P = 0.04). Although overall survival did show a significant difference in the univariate analysis (P < 0.001) it failed to reach statistical significance in the multivariate analysis (P = 0.09). CONCLUSIONS In our study, a higher number of colorectal cases performed per surgeon were associated with longer disease-free survival. Implementing high-volume surgery results in improved long-term outcome following colorectal cancer.
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Lash TL, Riis AH, Ostenfeld EB, Erichsen R, Vyberg M, Thorlacius-Ussing O. A validated algorithm to ascertain colorectal cancer recurrence using registry resources in Denmark. Int J Cancer 2014; 136:2210-5. [DOI: 10.1002/ijc.29267] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 09/25/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Timothy L. Lash
- Department of Epidemiology; Rollins School of Public Health; Atlanta GA
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
| | - Anders H. Riis
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
| | - Eva B. Ostenfeld
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
- Department of Gastrointestinal Surgery; Aalborg University Hospital; Aalborg Denmark
| | - Rune Erichsen
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
| | - Mogens Vyberg
- Institute for Pathology; Aalborg University Hospital; Aalborg Denmark
| | - Ole Thorlacius-Ussing
- Department of Gastrointestinal Surgery; Aalborg University Hospital; Aalborg Denmark
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Leonard D, Penninckx F, Kartheuser A, Laenen A, Van Eycken E. Effect of hospital volume on quality of care and outcome after rectal cancer surgery. Br J Surg 2014; 101:1475-82. [PMID: 25142810 DOI: 10.1002/bjs.9624] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 06/05/2014] [Accepted: 06/30/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND Research on the relationship between hospital volume and quality of care in the treatment of rectal cancer is limited. METHODS Process and outcome indicators were assessed in patients with rectal adenocarcinoma who underwent total mesorectal excision, registered on a voluntary basis in the PROCARE clinical database. Volume was derived from an administrative database and analysed as a continuous variable. Sphincter preservation, 30-day mortality and survival rates were cross-checked against population-based data. RESULTS A total of 1469 patients registered in PROCARE between 2006 and 2011 were included in this study. A volume effect was observed regarding neoadjuvant therapy for stage II-III disease, reporting of the circumferential resection margin, R0 resection rate, sphincter preservation rate, and number of nodes examined after chemoradiotherapy. The global estimate of quality of care was highly variable, but surgery was the single domain in which quality correlated with volume. No volume effect was observed for recurrence and overall survival rates. In the population-based data set (5869 patients), volume was associated with 30-day mortality adjusted for age (odds ratio 0·99, 95 per cent confidence interval (c.i.) 0·98 to 1·00; P = 0·014) and adjusted overall survival (HR 0·99 (95 per cent c.i. 0·99 to 1·00) per additional procedure; P = 0·001), but not with the sphincter preservation rate. Because of incomplete and biased registration on a voluntary basis, results from a clinical database could not be extrapolated to the population. CONCLUSION Some volume effects were observed, but their effect size was limited.
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Affiliation(s)
- D Leonard
- Colorectal Surgery Unit, Cliniques universitaires Saint-Luc, Brussels, Belgium
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Piccoli M, Agresta F, Trapani V, Nigro C, Pende V, Campanile FC, Vettoretto N, Belluco E, Bianchi PP, Cavaliere D, Ferulano G, La Torre F, Lirici MM, Rea R, Ricco G, Orsenigo E, Barlera S, Lettieri E, Romano GM, Ferulano G, Giuseppe F, La Torre F, Filippo LT, Lirici MM, Maria LM, Rea R, Roberto R, Ricco G, Gianni R, Orsenigo E, Elena O, Barlera S, Simona B, Lettieri E, Emanuele L, Romano GM, Maria RG. Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference. Int J Colorectal Dis 2014; 29:863-75. [PMID: 24820678 DOI: 10.1007/s00384-014-1887-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome. METHOD An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM). RESULTS AND CONCLUSION The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.
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Patel SS, Senagore AJ. General surgeons vs. colorectal surgeons: Who should be doing what to whom? SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2013.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Pelletier JS, Degara C, Porter G, Ghosh S, Schiller D. Retrospective review of rectal cancer surgery in northern Alberta. Can J Surg 2013; 56:E51-8. [PMID: 23883504 DOI: 10.1503/cjs.006612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Previous studies, including research published more than 10 years ago in Northern Alberta, have demonstrated improved outcomes with increased surgical volume and subspecialisation in the treatment of rectal cancer. We sought to examine contemporary rectal cancer care in the same region to determine whether practice patterns have changed and whether outcomes have improved. METHODS We reviewed the charts of all patients with rectal adenocarcinoma diagnosed between 1998 and 2003 who had a potentially curative resection. The main outcomes examined were 5-year local recurrence (LR) and disease-specific survival (DSS). Surgeons were classified into 3 groups according to training and volume, and we compared outcome measures among them. We also compared our results to those of the previous study from our region. RESULTS We included 433 cases in the study. Subspecialty-trained colorectal surgeons performed 35% of all surgeries in our study compared to 16% in the previous study. The overall 5-year LR rate and DSS in our study were improved compared to the previous study. On multivariate analysis, the only factor associated with increased 5-year LR was presence of obstruction, and the factors associated with decreased 5-year DSS were high-volume noncolorectal surgeons, presence of obstruction and increased stage. CONCLUSION Over the past 10 years, the long-term outcomes of treatment for rectal cancer have improved. We found that surgical subspecialization was associated with improved DSS but not LR. Increased surgical volume was not associated with LR or DSS.
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Chen ZW, Neufeld H, Copete MA, Garratt J, Gilks CB, Torlakovic EE. Academic and nonacademic laboratories perform equally on CIQC immunohistochemistry proficiency testing. Am J Clin Pathol 2013; 140:55-60. [PMID: 23765534 DOI: 10.1309/ajcphbl59mwbvyrd] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES To test whether academic centers (ACs) are more successful than nonacademic centers (NACs) in immunohistochemistry (IHC) external quality assessment challenges in the Canadian Immunohistochemistry Quality Control (CIQC) program. METHODS Results of 9 CIQC challenges for breast cancer marker (BM) and various non-breast cancer marker (NBM) tests were examined. Success rates were compared between AC/NAC laboratories and those located in small or large cities. Performance was also correlated with annual IHC case volumes. RESULTS There was no statistically significant difference in performance in any of the comparisons. However, overall performance on BM was significantly better (P < .0001, t test) than on NBM tests regardless of AC/NAC nature or city size. The mean failure rate on NBM was approximately twice that of BM tests. CONCLUSION Our results suggest that recent emphasis on breast hormone IHC quality assurance has led to improved test quality.
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Affiliation(s)
- Zhongchuan Will Chen
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Heather Neufeld
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Maria A. Copete
- Department of Oral Pathology, College of Dentistry, University of Saskatchewan, Saskatoon, Canada
| | - John Garratt
- Department of Pathology, Lions Gate Hospital, Vancouver, Canada
| | - C. Blake Gilks
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Emina E. Torlakovic
- Department of Laboratory Hematology, University Health Network, University of Toronto, Toronto, Canada
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Riboe DG, Dogan TS, Brodersen J. Potential biases in colorectal cancer screening using faecal occult blood test. J Eval Clin Pract 2013; 19:311-6. [PMID: 22332801 DOI: 10.1111/j.1365-2753.2012.01824.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is one of the most common types of cancer in European countries and associated with a high mortality rate. A 16% relative risk reduction (RRR) of mortality was found in a meta-analysis based on four randomized controlled trials (RCT) on CRC screening. The aim of this paper was to scrutinize these trials for potential biases and assess their influence on the screening trials. METHODS The four RCTs were reviewed based on the principles of 'Critical Appraisal of the Medical Literature'. Principal investigators of the four RCTs were contacted to clarify uncertainties in their study. Data were collected from The Danish Data Archives. Authors of the Cochrane review were contacted. RESULTS Six biases were identified, of which five favour screening. Three of the biases identified were specific to CRC screening: type of diagnostic method, place of surgery and diagnostic delay. CONCLUSION The 16% RRR in CRC mortality found in the updated Cochrane review's meta-analysis is overestimated.
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Affiliation(s)
- Dea Grip Riboe
- Research Unit and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
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Pieper D, Mathes T, Neugebauer E, Eikermann M. State of evidence on the relationship between high-volume hospitals and outcomes in surgery: a systematic review of systematic reviews. J Am Coll Surg 2013; 216:1015-1025.e18. [PMID: 23528183 DOI: 10.1016/j.jamcollsurg.2012.12.049] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 12/20/2012] [Accepted: 12/20/2012] [Indexed: 01/19/2023]
Affiliation(s)
- Dawid Pieper
- Institute for Research in Operative Medicine, Faculty of Health, School of Medicine, Witten/Herdecke University, Cologne, Germany.
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Hohenberger W, Merkel S, Hermanek P. Volume and outcome in rectal cancer surgery: the importance of quality management. Int J Colorectal Dis 2013; 28:197-206. [PMID: 23143162 DOI: 10.1007/s00384-012-1596-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE For many years, the impact of the surgeon volume on short- and long-term outcome after rectal carcinoma surgery is controversially discussed. Literature and own department data were reviewed in order to clarify the impact of surgeon volume in the current era of total mesorectal excision surgery, multimodal therapy, quality management, and centralization of cancer care. METHODS Uni- and multivariate analysis of data from 1,028 patients with solitary rectal carcinoma, treated between 1995 and 2010 at the Department of Surgery, University Hospital, Erlangen, Germany, was performed. Surgeons were subdivided according to the number of operations/year into high- (at least seven/year), medium- (three to six), and low- (less than three) volume surgeons. RESULTS Of 1,028 patients, 800 (77.8 %) were operated by five high-volume surgeons, 193 (18.8 %) by seven medium-volume surgeons, and 35 (3.4 %) by 12 low-volume surgeons. Surgeon volume was significantly associated with postoperative mortality and the rate of positive pathological circumferential resection margin. In risk-adjusted analysis, after primary surgery, surgeon volume had a significant impact on observed overall survival and disease-free survival, but not on locoregional recurrence. After neoadjuvant radiochemotherapy, only observed overall survival was significantly influenced by surgeon volume. CONCLUSIONS In surgical departments with special interest in rectal carcinoma, surgeon volume has some influence on short- and long-term outcome. Irrespective of this fact, specialization, experience, individual skill, hospital organization, and regular quality assurance are essential prognostic factors ensuring good results in rectal carcinoma surgery.
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Affiliation(s)
- Werner Hohenberger
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstr. 12, 91054, Erlangen, Germany.
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Sacerdote C, Baldi I, Bertetto O, Dicuonzo D, Farina E, Pagano E, Rosato R, Senore C, Merletti F, Ciccone G. Hospital factors and patient characteristics in the treatment of colorectal cancer: a population based study. BMC Public Health 2012; 12:775. [PMID: 22971126 PMCID: PMC3551723 DOI: 10.1186/1471-2458-12-775] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 09/05/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The present study focuses on the analysis of social, clinical and hospital characteristics that can lead to disparities in the management and outcome of care. To that end, indicators of the quality of initial treatment delivered to newly-diagnosed colorectal cancer patients in a North-Western Region of Italy, were investigated using administrative data. METHODS The cohort includes all incident colorectal cancer patients (N = 24,187) selected by a validated algorithm from the Piedmont Hospital Discharge Record system over an 8-year period (2000-2007).Three indicators of quality of care in this population-based cohort were evaluated: the proportion of preoperative radiotherapy (RT) and of abdominoperineal (AP) resection in rectal cancer patients, and the proportion of postoperative in-hospital mortality in colorectal cancer patients. RESULTS Among rectal cancers, older patients were less likely to have preoperative RT, and more likely to receive an AP resection compared to younger patients. The probability of undergoing preoperative RT and AP resection was reduced in females compared to males (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.64-0.93 and OR 0.78, 95%CI 0.69-0.89, respectively). However, there was a trend of increasing RT over time (p for trend <0.01). The probability of undergoing AP resection was increased in less-educated patients and in hospitals with a low caseload.A higher risk of postoperative in-hospital mortality was found among colorectal cancer patients who were older, male, (female versus male OR 0.71, 95%CI 0.60-0.84), unmarried (OR 1.32, 95%CI 1.09-1.59) or with unknown marital status. CONCLUSIONS The study provides evidence of the importance of social, clinical and hospital characteristics on the equity and quality of care in a Southern European country with an open-access public health care system.
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Affiliation(s)
- Carlotta Sacerdote
- Cancer Epidemiology Unit, San Giovanni Battista Hospital, CPO Piemonte and University of Turin, Via Santena 7, 10129, Torino, Italy.
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Nielsen MB, Rasmussen PC, Lindegaard JC, Laurberg S. A 10-year experience of total pelvic exenteration for primary advanced and locally recurrent rectal cancer based on a prospective database. Colorectal Dis 2012; 14:1076-83. [PMID: 22107085 DOI: 10.1111/j.1463-1318.2011.02893.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM The study was conducted in a dedicated centre treating the majority of Danish patients with intended curative total pelvic exenteration for primary advanced (PARC) or locally recurrent (LRRC) rectal cancer. We compared PARC and LRRC and analysed postoperative morbidity and mortality, and long-term outcome. METHOD There were 90 consecutive patients (PARC/LRRC 50/40) treated between January 2001 and October 2010, recorded on a prospectively maintained database. RESULTS The median age was 63 (32-75) years with a gender ratio of 7 women to 83 men. All patients were American Society of Anesthesiologists level I or II. Sacral resection was performed in five patients with PARC and 15 with LRRC (P=0.002). R0 resection was achieved in 33 (66%) patients with PARC and in 15 (38%) with LRRC, R1 resection in 17 (34%) with PARC and 20 (50%) with LRRC and R2 resection in five (13%) with LRRC. R0 resection was more frequent in PARC (P=0.007). Forty-four (49%) patients had no postoperative complications. Fifty-five major complications were registered. Two (2.2%) patients died within 30 days, and the total in-hospital mortality was 5.6%. The median follow-up was 12 (0.4-91) months. The 5-year survival was 46% for PARC and 17% for LRRC (P=0.16). CONCLUSION Pelvic exenteration is associated with considerable morbidity but low mortality in an experienced centre. Pelvic exenteration can improve long-term survival, especially for patients with PARC. However, pelvic exenteration is also justified for patients with LRRC.
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Affiliation(s)
- M B Nielsen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.
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Archampong D, Borowski D, Wille-Jørgensen P, Iversen LH. Workload and surgeon's specialty for outcome after colorectal cancer surgery. Cochrane Database Syst Rev 2012:CD005391. [PMID: 22419309 DOI: 10.1002/14651858.cd005391.pub3] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A large body of research has focused on investigating the effects of healthcare provider volume and specialization on patient outcomes including outcomes of colorectal cancer surgery. However there is conflicting evidence about the role of such healthcare provider characteristics in the management of colorectal cancer. OBJECTIVES To examine the available literature for the effects of hospital volume, surgeon caseload and specialization on the outcomes of colorectal, colon and rectal cancer surgery. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL), and LILACS using free text search words (as well as MESH-terms). We also searched Medline (January 1990-September 2011), Embase (January 1990-September 2011) and registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. SELECTION CRITERIA Non-randomised and observational studies that compared outcomes for colorectal cancer, colon cancer and rectal cancer surgery (overall 5-year survival, five year disease specific survival, operative mortality, 5-year local recurrence rate, anastomotic leak rate, permanent stoma rate and abdominoperineal excision of the rectum rate) between high volume/specialist hospitals and surgeons and low volume/specialist hospitals and surgeons. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data and assessed risk of bias in included studies. Results were pooled using the random effects model in unadjusted and case-mix adjusted meta-analyses. MAIN RESULTS Overall five year survival was significantly improved for patients with colorectal cancer treated in high-volume hospitals (HR=0.90, 95% CI 0.85 to 0.96), by high-volume surgeons (HR=0.88, 95% CI 0.83 to 0.93) and colorectal specialists (HR=0.81, 95% CI 0.71 to 0.94). Operative mortality was significantly better for high-volume surgeons (OR=0.77, 95% CI 0.66 to 0.91) and specialists (OR=0.74, 95% CI 0.60 to 0.91), but there was no significant association with higher hospital caseload (OR=0.93, 95% CI 0.84 to 1.04) when only case-mix adjusted studies were included. There were differences in the effects of caseload depending on the level of case-mix adjustment and also whether the studies originated in the US or in other countries. For rectal cancer, there was a significant association between high-volume hospitals and improved 5-year survival (HR=0.85, 95% CI 0.77 to 0.93), but not with operative mortality (OR=0.97, 95% CI 0.70 to 1.33); surgeon caseload had no significant association with either 5-year survival (HR=0.99, 95% CI 0.86 to 1.14) or operative mortality (OR=0.86, 95% CI 0.62 to 1.19) when case-mix adjusted studies were reviewed. Higher hospital volume was associated with significantly lower rates of permanent stomas (OR=0.64, 95% CI 0.45 to 0.90) and APER (OR=0.55, 95% CI 0.42 to 0.72). High-volume surgeons and specialists also achieved lower rates of permanent stoma formation (0.75, 95% CI 0.64 to 0.88) and (0.70, 95% CI 0.53 to 0.94, respectively). AUTHORS' CONCLUSIONS The results confirm clearly the presence of a volume-outcome relationship in colorectal cancer surgery, based on hospital and surgeon caseload, and specialisation. The volume-outcome relationship appears somewhat stronger for the individual surgeon than for the hospital; particularly for overall 5-year survival and operative mortality, there were differences between US and non-US data, suggesting provider variability at hospital level between different countries, making it imperative that every country or healthcare system must establish audit systems to guide changes in the service provision based on local data, and facilitate centralisation of services as required. Overall quality of the evidence was low as all included studies were observational by design. In addition there were discrepancies in the definitions of caseload and colorectal specialist. However ethical challenges associated with the conception of randomised controlled trials addressing the volume outcome relationship makes this the best available evidence.
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Affiliation(s)
- David Archampong
- Department of Surgery, University Hospital Wales, Cardiff, Wales, UK.
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Brännström F, Jestin P, Matthiessen P, Gunnarsson U. Surgeon and hospital-related risk factors in colorectal cancer surgery. Colorectal Dis 2011; 13:1370-6. [PMID: 20969714 DOI: 10.1111/j.1463-1318.2010.02468.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to identify surgeon and hospital-related factors in a well-defined population-based cohort; the results of this study could possibly be used to improve outcome in colorectal cancer. METHOD Data from the colonic (1997-2006) and rectal (1995-2006) cancer registers of the Uppsala/Örebro Regional Oncology Centre were used to assess 1697 patients with rectal and 2692 with colonic cancer. Putative risk factors and their impact on long-term survival were evaluated using the Cox proportional hazard model. RESULTS The degree of specialization of the operating surgeon had no significant effect on long-term survival. When comparing the surgeons with the highest degree of specialization, noncolorectal surgeons demonstrated a slightly lower long-term survival for rectal cancer stage I and II (HR, 2.03; 95% CI, 1.05-3.92). Surgeons with a high case-load were not associated with better survival in any analysis model. Regional hospitals had a lower survival rate for rectal cancer stage III surgery (HR, 1.47; 95% CI, 1.08-2.00). CONCLUSION Degree of specialization, surgeon case-load and hospital category could not be identified as important factors when determining outcome in colorectal cancer surgery in this study.
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Affiliation(s)
- F Brännström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
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Ostenfeld EB, Erichsen R, Iversen LH, Gandrup P, Nørgaard M, Jacobsen J. Survival of patients with colon and rectal cancer in central and northern Denmark, 1998-2009. Clin Epidemiol 2011; 3 Suppl 1:27-34. [PMID: 21814467 PMCID: PMC3144775 DOI: 10.2147/clep.s20617] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective The prognosis for colon and rectal cancer has improved in Denmark over the past decades but is still poor compared with that in our neighboring countries. We conducted this population-based study to monitor recent trends in colon and rectal cancer survival in the central and northern regions of Denmark. Material and methods Using the Danish National Registry of Patients, we identified 9412 patients with an incident diagnosis of colon cancer and 5685 patients diagnosed with rectal cancer between 1998 and 2009. We determined survival, and used Cox proportional hazard regression analysis to compare mortality over time, adjusting for age and gender. Among surgically treated patients, we computed 30-day mortality and corresponding mortality rate ratios (MRRs). Results The annual numbers of colon and rectal cancer increased from 1998 through 2009. For colon cancer, 1-year survival improved from 65% to 70%, and 5-year survival improved from 37% to 43%. For rectal cancer, 1-year survival improved from 73% to 78%, and 5-year survival improved from 39% to 47%. Men aged 80+ showed most pronounced improvements. The 1- and 5-year adjusted MRRs decreased: for colon cancer 0.83 (95% confidence interval CI: 0.76–0.92) and 0.84 (95% CI: 0.78–0.90) respectively; for rectal cancer 0.79 (95% CI: 0.68–0.91) and 0.81 (95% CI: 0.73–0.89) respectively. The 30-day postoperative mortality after resection also declined over the study period. Compared with 1998–2000 the 30-day MRRs in 2007–2009 were 0.68 (95% CI: 0.53–0.87) for colon cancer and 0.59 (95% CI: 0.37–0.96) for rectal cancer. Conclusion The survival after colon and rectal cancer has improved in central and northern Denmark during the 1998–2009 period, as well as the 30-day postoperative mortality.
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Affiliation(s)
- Eva B Ostenfeld
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Abstract
AIM A review of the literature was undertaken to provide an overview of the surgical management of locally recurrent rectal cancer (LRRC) after the introduction of total mesorectal excision (TME). METHOD A systematic literature search was undertaken using PubMed, Embase, Web of Science and Cochrane databases. Only studies on patients having surgery for their primary tumour after 1995, or if more than half of the patients were operated on after 1995, were considered for analysis. Studies concerning only palliative treatments were excluded. RESULTS A total of 19 studies fulfilled the inclusion criteria. Locally recurrent rectal cancer still occurred in 5-10% of the patients and was a major clinical problem, due to severe symptoms and poor survival. In most studies, 40-50% of all patients with LRRC could be expected to undergo surgery with a curative intent and of those, 30-45% would have R0 resection. Thus, only 20-30% of all patients with LRRC would have a potentially curative operation. The postoperative complication rate varied considerably, from 15 to 68%. The rate of re-recurrence varied from 4 to 54% after curative surgery. The 5-year overall survival varied between 9 and 39% and the median survival between 21 and 55 months. CONCLUSION Compared with previous studies, the proportion of potentially curative resections seems to have increased, probably due to improved staging, neoadjuvant treatment and increased surgical experience in dedicated centres, which has resulted in a tendency to improved survival.
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Affiliation(s)
- M B Nielsen
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark.
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Marshall CL, Balentine CJ, Robinson CN, Wilks JA, Anaya D, Artinyan A, Awad SS, Berger DH, Albo D. A multidisciplinary cancer center maximizes surgeons' impact. J Surg Res 2011; 171:15-22. [PMID: 21696763 DOI: 10.1016/j.jss.2010.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Revised: 11/21/2010] [Accepted: 12/06/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Colorectal cancer patients require care across different disciplines. Integration of multidisciplinary care is critical to accomplish excellent oncologic results. We hypothesized that the establishment of a dedicated colorectal cancer center (CRCC) around specialty-trained surgeons will lead to increased multidisciplinary management and improved outcomes in colorectal cancer patients. METHODS We analyzed data from three periods: a baseline group, a period after the recruitment of specialty-trained surgeons, and a period after the creation of a dedicated multidisciplinary cancer center. Data analyzed included surrogate markers of surgical oncologic care, multidisciplinary integration, and oncologic outcomes. RESULTS Recruitment of specialized surgeons led to improvements in surgical oncologic care; the establishment of the CRCC resulted in further improvements in surgical oncologic care and multidisciplinary integration. CONCLUSION Our study suggests that although the recruitment of specialty-trained surgeons in a high volume center leads to improvement in surgical oncologic care, it is the establishment of a multidisciplinary center around the surgeons that leads to integrated care and improvements in oncologic outcomes.
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Affiliation(s)
- Christy L Marshall
- Department of Surgery, The Michael E. DeBakey Veterans' Affairs Medical Center, Houston, Texas, USA
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Impact of surgeon volume on outcomes of rectal cancer surgery: A systematic review and meta-analysis. Surgeon 2010; 8:341-52. [DOI: 10.1016/j.surge.2010.07.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2010] [Accepted: 07/06/2010] [Indexed: 11/20/2022]
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White A, Vernon SW, Franzini L, Du XL. Racial disparities in colorectal cancer survival: to what extent are racial disparities explained by differences in treatment, tumor characteristics, or hospital characteristics? Cancer 2010; 116:4622-31. [PMID: 20626015 DOI: 10.1002/cncr.25395] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Racial/ethnic differences in colorectal cancer (CRC) survival have been documented throughout the literature. However, the reasons for these disparities are difficult to decipher. The objective of this analysis was to determine the extent to which racial/ethnic disparities in survival are explained by differences in sociodemographics, tumor characteristics, diagnosis, treatment, and hospital characteristics. METHODS A cohort of 37,769 Medicare beneficiaries who were diagnosed with American Joint Committee on Cancer stages I, II, and III CRC from 1992 to 2002 and resided in 16 Surveillance, Epidemiology, and End Results (SEER) regions of the United States was identified in the SEER-Medicare linked database. Survival was estimated using the Kaplan-Meier method. Cox proportional hazards modeling was used to estimate hazard ratios (HRs) of mortality and 95% confidence intervals (CIs). RESULTS Black patients had worse CRC-specific survival than white patients, but the difference was reduced after adjustment (adjusted HR [aHR], 1.24; 95% CI, 1.14-1.35). Asian patients had better survival than white patients after adjusting for covariates (aHR, 0.80; 95% CI, 0.70-0.92) for stages I, II, and III CRC. Relative to Asians, blacks and whites had worse survival after adjustment (blacks: aHR, 1.56; 95% CI, 1.33-1.82; whites: aHR, 1.26; 95% CI, 1.10-1.44). Comorbidities and socioeconomic Status were associated with a reduction in the mortality difference between blacks and whites and blacks and Asians. CONCLUSIONS Comorbidities and SES appeared to be more important factors contributing to poorer survival among black patients relative to white and Asian patients. However, racial/ethnic differences in CRC survival were not fully explained by differences in several factors. Future research should further examine the role of quality of care and the benefits of treatment and post-treatment surveillance in survival disparities.
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Affiliation(s)
- Arica White
- Division of Epidemiology, School of Public Health, University of Texas Health Science Center, Houston, Texas, USA.
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Borowski DW, Bradburn DM, Mills SJ, Bharathan B, Wilson RG, Ratcliffe AA, Kelly SB. Volume-outcome analysis of colorectal cancer-related outcomes. Br J Surg 2010; 97:1416-30. [PMID: 20632311 DOI: 10.1002/bjs.7111] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Significant associations between caseload and surgical outcomes highlight the conflict between local cancer care and the need for centralization. This study examined the effect of hospital volume on short-term outcomes and survival, adjusting for the effect of surgeon caseload. METHODS Between 1998 and 2002, 8219 patients with colorectal cancer were identified in a regional population-based audit. Outcomes were assessed using univariable and multivariable analysis to allow case mix adjustment. Surgeons were categorized as low (26 or fewer operations annually), medium (27-40) or high (more than 40) volume. Hospitals were categorized as low (86 or fewer), medium (87-109) or high (more than 109) volume. RESULTS Some 7411 (90.2 per cent) of 8219 patients underwent surgery with an anastomotic leak rate of 2.9 per cent (162 of 5581), perioperative mortality rate of 8.0 per cent (591 of 7411) and 5-year survival rate of 46.8 per cent. Medium- and high-volume surgeons were associated with significantly better operative mortality (odds ratio (OR) 0.74, P = 0.010 and OR 0.66, P = 0.002 respectively) and survival (hazard ratio (HR) 0.88, P = 0.003 and HR 0.93, P = 0.090 respectively) than low-volume surgeons. Rectal cancer survival was significantly better in high-volume versus low-volume hospitals (HR 0.85, P = 0.036), with no difference between medium- and low-volume hospitals (HR 0.96, P = 0.505). CONCLUSION This study has confirmed the relevance of minimum volume standards for individual surgeons. Organization of services in high-volume units may improve survival in patients with rectal cancer.
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Affiliation(s)
- D W Borowski
- Department of Surgery, North Tyneside General Hospital, North Shields, UK
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Abstract
AIM In 1996, rectal cancer surgery in the Swedish county of Vstmanland was centralized to a single colorectal unit. At the same time, total mesorectal excision and multidisciplinary team meetings were introduced. The aim of this audit was to determine the long-term results before and after centralization. METHOD All consecutive rectal cancer patients who underwent curative or palliative surgery at one of the county's four hospitals between 1993 and 1996 (n = 133, group 1) were compared with patients operated at the new centralized colorectal unit between 1996 and 1999 (n = 144, group 2). RESULTS Preoperative radiotherapy was common in both groups, but in group 2, it was planned using MRI. Local recurrences were detected in 8% of all patients operated in group 1 vs 3.5% in group 2 (P = 0.043). The overall 5-year survival for all patients in group 1 was 38 vs 62% in group 2 (P = 0.003). According to multivariate analysis, the new colorectal unit was an independent predictor for improved long-term survival. CONCLUSION This population-based audit shows reduced local recurrence rate and prolonged overall survival for rectal cancer patients after centralization to a single colorectal unit with multidisciplinary management and increased subspecialization.
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Affiliation(s)
- M Hosseinali Khani
- Colorectal Unit, Department of Surgery and Centre for Clinical Research of Uppsala University, Central Hospital, Västerås, Sweden.
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The RN first assistant: an expert resource for surgical site infection prevention. AORN J 2009; 89:1093-7. [PMID: 19500700 DOI: 10.1016/j.aorn.2009.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2009] [Revised: 03/23/2009] [Accepted: 03/27/2009] [Indexed: 11/23/2022]
Abstract
The role of the RN first assistant (RNFA) has expanded and evolved during the past three decades. Studies that have examined patient care outcomes relative to RNFAs substituting for surgeons as first assistants have noted no resulting adverse consequences, and the use of RNFAs in surgery may improve patient outcomes. This article reports on an intervention to improve surgical outcomes in patients undergoing cardiac surgery that involved replacing surgical residents with RNFAs for the harvesting of saphenous vein grafts. The resulting benefits were a significant decrease in surgical times as well as improvement in surgical site infection rates.
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Kressner M, Bohe M, Cedermark B, Dahlberg M, Damber L, Lindmark G, Ojerskog B, Sjödahl R, Johansson R, Påhlman L. The impact of hospital volume on surgical outcome in patients with rectal cancer. Dis Colon Rectum 2009; 52:1542-9. [PMID: 19690480 DOI: 10.1007/dcr.0b013e3181af58f4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to investigate, in a population-based setting, the surgical outcome in patients with rectal cancer according to the hospital volume. METHODS Since 1995 all patients with rectal cancer have been registered in the Swedish Rectal Cancer Registry. Hospitals were classified, according to number treated per year, as low-volume, intermediate-volume, or high-volume hospitals (<11, 11-25, or >25 procedures per year). Postoperative mortality, reoperation rate within 30 days, local recurrence rate, and overall five-year survival were studied. For postoperative morbidity and mortality the whole cohort from 1995 to 2003 (n = 10,425) was used. For cancer-related outcome only, those with five-year follow-ups, from 1995 to 1998, were used (n = 4,355). RESULTS In this registry setting the postoperative mortality rate was 3.6% in low-volume hospitals, and 2.2% in intermediate-volume and high-volume hospitals (P = 0.002). The reoperation rate was 10%, with no differences according to volume. The overall local recurrence rates were 9.4%, 9.3%, and 7.5%, respectively (P = 0.06). Significant difference was found among the nonirradiated patients (P = 0.004), but not among the irradiated patients (P = 0.45). No differences were found according to volume in the absolute five-year survival. CONCLUSION Postoperative mortality and local recurrence in nonirradiated patients were lower in high-volume hospitals. No difference was seen between volumes in reoperation rates, overall local recurrence, or absolute five-year survival.
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Affiliation(s)
- Marit Kressner
- Department of Surgery, Ersta Hospital, Stockholm, Sweden.
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