Systematic review and a meta-analysis of hospital and surgeon volume/outcome relationships in colorectal cancer surgery

Association of Medicaid expansion with access to thyroidectomy for benign disease at high-volume centers

BACKGROUND

Insurance-based disparities in access to thyroidectomy are well established. Patients undergoing thyroidectomy by high-volume surgeons have fewer complications and better postoperative outcomes. The aim of this study was to evaluate the association of Medicaid expansion with access to high-volume centers for thyroidectomy for benign disease.

METHODS

The Vizient Clinical Data Base was queried for adult operations for benign thyroid disease from 2010 to 2019. Centers were sorted by volume into quartiles. Difference-in-difference analysis evaluated changes in insurance populations in expansion and non-expansion states after Medicaid expansion. Odds of patients undergoing operations in the 4 volume quartiles after stratifying by insurance and Medicaid expansion status were calculated.

RESULTS

A total of 82,602 patients underwent operations at 364 centers. Expansion states increased Medicaid coverage in all volume quartiles compared to non-expansion states after Medicaid expansion (Q1, +4.87%, Q2, +5.35%, Q3, +8.57%, Q4, +4.62%, P < .002 for all). After Medicaid expansion, Medicaid patients had higher odds of undergoing operation at lower volume hospitals compared to the highest volume centers in both expansion states (Q1, ref, Q2, 1.82, Q3, 1.76, Q4, 1.67, P < .001) and non-expansion states (Q1, ref, Q2, 1.54, Q3, 2.04, Q4, 1.44, P < .001). Privately insured patients were most likely to undergo their operation at the highest volume centers in all states (E: Q1, ref, Q2, 0.78, Q3, 0.74, Q4, 0.66, P < .001; NE: Q1, ref, Q2, 0.89, Q3, 0.58, Q4, 0.85, P < .001).

CONCLUSION

Medicaid expansion increased Medicaid coverage in expansion states, but Medicaid patients in both expansion and non-expansion states were less likely to be operated on at the highest volume centers compared to privately insured patients. Persistent barriers to accessing high-volume care still exists for Medicaid patients.

Association of National Accreditation Program for Rectal Cancer Accreditation with Outcomes after Rectal Cancer Surgery

BACKGROUND

The National Accreditation Program for Rectal Cancer (NAPRC) defined a set of standards in 2017 centered on multidisciplinary program structure, evidence-based care processes, and internal audit to address widely variable rectal cancer practices and outcomes across US hospitals. There have been no studies to-date testing the association between NAPRC accreditation and rectal cancer outcomes.

STUDY DESIGN

This was a retrospective, observational study of Medicare beneficiaries aged 65 to 99 years with rectal cancer who underwent proctectomy from 2017 to 2020. The primary exposure was NAPRC accreditation and the primary outcomes included mortality (in-hospital, 30 day, and 1 year) and 30-day complications, readmissions, and reoperations. Associations between NAPRC accreditation and each outcome were tested using multivariable logistic regression with risk-adjustment for patient and hospital characteristics.

RESULTS

Among 1,985 hospitals, 65 were NAPRC-accredited (3.3%). Accredited hospitals were more likely to be nonprofit and teaching with 250 or more beds. Among 20,202 patients, 2,078 patients (10%) underwent proctectomy at an accredited hospital. Patients at accredited hospitals were more likely to have an elective procedure with a minimally invasive approach and sphincter preservation. Risk-adjusted in-hospital mortality (1.1% vs 1.3%; p = 0.002), 30-day mortality (2.1% vs 2.9%; p < 0.001), 30-day complication (18.3% vs 19.4%; p = 0.01), and 1-year mortality rates (11% vs 12.1%; p < 0.001) were significantly lower at accredited compared with nonaccredited hospitals.

CONCLUSIONS

NAPRC-accredited hospitals have lower risk-adjusted morbidity and mortality for major rectal cancer surgery. Although NAPRC standards address variability in practice, without directly addressing surgical safety, our findings suggest that NAPRC-accredited hospitals may provide higher quality surgical care.

Impact of surgical specialization on emergency upper gastrointestinal surgery outcomes: A systematic review and meta-analysis

BACKGROUND

Emergency presentations make up a large proportion of a general surgeon's workload. Patients who have emergency surgery carry a higher rate of mortality and complications. We aim to review the impact of surgical subspecialization on patients following upper gastrointestinal (UGI) emergency surgery.

METHODS

A systematic search of Ovid Embase, Ovid MEDLINE, and Cochrane databases using a predefined search strategy was completed reviewing studies published from 1st of January 1990 to August 27, 2023. The study was prospectively registered with PROSPERO (CRD42022359326). Studies were reviewed for the following outcomes: 30-day mortality, in-hospital mortality, conversion to open, length of stay, return to theater, and readmission.

RESULTS

Of 5181 studies, 24 articles were selected for full text review. Of these, seven were eligible and included in this study. There was a statistically significant improvement in 30-day mortality favoring UGI specialists (OR 0.71 [95% CI 0.55-0.92 and p = 0.009]) and in-hospital mortality (OR 0.29 [95% CI 0.14-0.60 and p = 0009]). There was a high degree of study heterogeneity in 30-day mortality; however, a low degree of heterogeneity within in-hospital mortality. There was no statistical significance when considering conversion to open and insufficient data to allow meta-analysis for return to theater or readmission rates.

CONCLUSION

In emergency UGI surgery, there was improved 30-day and in-hospital mortality for UGI specialists. Therefore, surgeons should consider early involvement of a subspecialist team to improve patient outcomes.

Robotic approach to colonic resection: For some or for all patients?

The robotic approach is rapidly gaining momentum in colorectal surgery. Its benefits in pelvic surgery have been extensively discussed and are well established amongst those who perform minimally invasive surgery. However, the same cannot be said for the robotic approach for colonic resection, where its role is still debated. Here we aim to provide an extensive debate between selective and absolute use of the robotic approach for colonic resection by combining the thoughts of experts in the field of robotic and minimally invasive colorectal surgery, dissecting all key aspects for a critical view on this exciting new paradigm in colorectal surgery.

Influence of hospital-level and surgeon factors on the outcomes after ileo-anal pouch surgery for inflammatory bowel disease: systematic review

BACKGROUND

Ileal pouch-anal anastomosis ('pouch surgery') provides a chance to avoid permanent ileostomy after proctocolectomy, but can be associated with poor outcomes. The relationship between hospital-level/surgeon factors (including volume) and outcomes after pouch surgery is of increasing interest given arguments for increasing centralization of these complex procedures. The aim of this systematic review was to appraise the literature describing the influence of hospital-level and surgeon factors on outcomes after pouch surgery for inflammatory bowel disease.

METHODS

A systematic review was performed of studies reporting outcomes after pouch surgery for inflammatory bowel disease. The MEDLINE (Ovid), Embase (Ovid), and Cochrane CENTRAL databases were searched (1978-2022). Data on outcomes, including mortality, morbidity, readmission, operative approach, reconstruction, postoperative parameters, and pouch-specific outcomes (failure), were extracted. Associations between hospital-level/surgeon factors and these outcomes were summarized. This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD42022352851).

RESULTS

A total of 29 studies, describing 41 344 patients who underwent a pouch procedure, were included; 3 studies demonstrated higher rates of pouch failure in lower-volume centres, 4 studies demonstrated higher reconstruction rates in higher-volume centres, 2 studies reported an inverse association between annual hospital pouch volume and readmission rates, and 4 studies reported a significant association between complication rates and surgeon experience.

CONCLUSION

This review summarizes the growing body of evidence that supports centralization of pouch surgery to specialist high-volume inflammatory bowel disease units. Centralization of this technically demanding surgery that requires dedicated perioperative medical and nursing support should facilitate improved patient outcomes and help train the next generation of pouch surgeons.

Outcomes Following Colorectal Cancer Surgeries at the Basildon and Thurrock University Hospital

Aim We reviewed surgical outcomes for patients with colorectal cancer resections in Basildon and Thurrock University Hospital between April 2019 and March 2020. Methods Clinical characteristics of 141 patients who underwent surgical resection for colorectal cancer at the district hospital were assessed and reported, including tumor site, disease stage, and type of surgical resection performed. We reviewed 30- and 90-day postoperative mortality, postoperative complications, return to the theater, and extended hospital stay data for these patients. The results of our review across measured outcomes were compared to the national average from the National Bowel Cancer Audit (NBOCA) Report. Results Clinical data and health outcomes for 141 patients with colorectal cancer resections within the index year were reviewed. The mean age at diagnosis was 68.9 (12.5) years. Among the patients, 61 (43.3%) were female, and 59 (41.8%) had Stage III and IV colorectal cancer. Around 95 (67.4%) had the colon as the primary tumor site, while 46 (32.6%) had the primary tumor site in the rectum. Of the patients, 17 (12.1%) had emergency surgeries, and 124 (87.9%) underwent laparoscopic surgery. Right hemicolectomy was the most common operation performed in 58 patients (41.1%). The average length of stay was 7.8 (6.6) days; the length of stay was similar for both colonic and rectal resections. Low 30-day and 90-day mortality rates of (1/141) 0.71% and (2/141) 1.4%, respectively, were observed compared to the 90-day United Kingdom (UK) national average mortality rate of 2.7% in 2019/20. Around 30 (21.3%) of the patients developed postoperative complications within 30 days of surgery. Only six out of 30 postoperative complications were classified as Clavien-Dindo Grade III. Conclusion Surgical outcomes for patients with colorectal cancer in our district general hospital are similar to or lower than the national averages estimated by NBOCA. To further strengthen surgical care delivery and improve patient outcomes in the United Kingdom, there is a need to improve surgical techniques and quality improvement processes.

Effect of Hospital Cancer Designation on use of Multimodal Therapy and Survival of Metastatic Colorectal Cancer: A State-Wide Analysis

BACKGROUND

Stage IV colorectal cancer (CRC) often requires multidisciplinary approach. However, multimodal treatment options (receipt of > 1 type of treatment) may not be uniformly delivered across health systems. We characterized the association between center-level cancer center designation and receipt of multimodal treatment and survival.

METHODS

The Texas Cancer Registry was used to identify patients diagnosed with stage IV CRC from 2004-2017. We identified those who received care at either: a National Cancer Institute-designated (NCI-D), an American College of Surgeons-Commission on Cancer-designated (ACS-D), or an undesignated facility. We used multivariable logistic regression and Cox regression for analysis to assess receipt of one or more treatment modality and 5-year overall survival.

RESULTS

Of 19,355 patients with stage IV CRC, 2955 (15%) received care at an NCI-D facility and 5871 (30%) received multimodal therapy. Both NCI-D (odds ratio [OR] 1.64; 95% confidence interval [CI] 1.49-1.81) and ACS-D (OR 1.37; 95% CI 1.27-1.48) were associated with increased likelihood of multimodal therapy compared with undesignated centers. NCI-D also was associated with significantly improved survival (hazard ratio [HR] 0.74; 95% CI 0.70-0.78), although ACS-D was associated with a modest improvement in survival (HR 0.95; 95% CI 0.92-0.99). Receipt of multimodal therapy was strongly associated with improved survival (HR 0.61; 95% CI 0.59-0.63).

CONCLUSIONS

In patients with stage IV CRC, treatment at ACS-D and NCI-D facilities was associated with increased use of multimodality therapy and improved survival. However, only a small proportion of patients have access to these specialized centers, highlighting a need for expanded access to multimodal therapies at other centers.

The value of national accreditation program for rectal cancer: A survey of accredited programs and programs seeking accreditation

BACKGROUND

Significant variation in rectal cancer care has been demonstrated in the United States. The National Accreditation Program for Rectal Cancer was established in 2017 to improve the quality of rectal cancer care through standardization and emphasis on a multidisciplinary approach. The aim of this study was to understand the perceived value and barriers to achieving the National Accreditation Program for Rectal Cancer accreditation.

METHODS

An electronic survey was developed, piloted, and distributed to rectal cancer programs that had already achieved or were interested in pursuing the National Accreditation Program for Rectal Cancer accreditation. The survey contained 40 questions with a combination of Likert scale, multiple choice, and open-ended questions to provide comments. This was a mixed methods study; descriptive statistics were used to analyze the quantitative data, and thematic analysis was used to analyze the qualitative data.

RESULTS

A total of 85 rectal cancer programs were sent the survey (22 accredited, 63 interested). Responses were received from 14 accredited programs and 41 interested programs. Most respondents were program directors (31%) and program coordinators (40%). The highest-ranked responses regarding the value of the National Accreditation Program for Rectal Cancer accreditation included "improved quality and culture of rectal cancer care," "enhanced program organization and coordination," and "challenges our program to provide optimal, high-quality care." The most frequently cited barriers to the National Accreditation Program for Rectal Cancer accreditation were cost and lack of personnel.

CONCLUSION

Our survey found significant perceived value in the National Accreditation Program for Rectal Cancer accreditation. Adhering to standards and a multidisciplinary approach to rectal cancer care are critical components of a high-quality care rectal cancer program.

Medical versus surgical causes of death following colorectal resection: a Queensland Audit of Surgical Mortality (QASM) study

BACKGROUND

The causes of death following colorectal resection remain poorly explored. Few studies have addressed whether early post-operative mortality is predominantly caused by a patient's medical co-morbidities, or from factors pertaining to the presenting surgical disease process itself. This study analyses data from the Queensland audit of surgical mortality (QASM) to report the causes of in-hospital death following colorectal resection, identifies whether these were due to either medical or surgical factors, and determines the patient characteristics associated with a medical cause of death.

METHODS

Through analysis of QASM Surgical Case Forms, the causes of in-hospital death were determined in 750 patients who died in Queensland following colorectal resection between January 2010 and December 2020. Deaths were attributed to a specific medical or surgical cause, with multivariate analysis used to identify independent risk factors associated with a medical cause of death.

RESULTS

In total, 395 patients (52.7%) died due to surgical causes and 355 (47.3%) died due to medical causes. Respiratory co-morbidities (OR 1.832, 95% CI: 1.267-2.650), advanced malignancy (OR 1.814, 95% CI: 1.262-2.607), neurological co-morbidities (OR 1.794, 95% CI: 1.168-2.757) and advanced age (OR 1.430, 95% CI: 1.013-2.017) were independent risk factors associated with increased risk of a medical cause of death.

CONCLUSION

Even in the absence of complicating surgical factors, a significant number of patients died in hospital following colorectal resection due to their underlying co-morbidities. Multi-disciplinary models of care which allow for the early recognition and treatment of medical complications may reduce post-operative mortality in these patients.

Diagnosing Provider, Referral Patterns, Facility Type, and Patient Satisfaction Among Iowa Rectal Cancer Patients

PURPOSE

Rectal cancer treatment at high-volume centers is associated with higher likelihood of guideline-concordant care and improved outcomes. Whether rectal cancer patients are referred for treatment at high-volume hospitals may depend on diagnosing provider specialty. We aimed to determine associations of diagnosing provider specialty with treating provider specialty and characteristics of the treating facility for rectal cancer patients in Iowa.

METHODS

Rectal cancer patients identified using the Iowa Cancer Registry completed a mailed survey on their treatment experience and decision-making process. Provider type was defined by provider specialty and whether the provider referred patients elsewhere for surgery. Multivariable-adjusted logistic regression models were used to examine predictors of being diagnosed by a general surgeon who also performed the subsequent surgery.

RESULTS

Of 417 patients contacted, 381 (76%) completed the survey; our final analytical sample size was 267. Half of respondents were diagnosed by a gastroenterologist who referred them elsewhere; 30% were diagnosed by a general surgeon who referred them elsewhere, and 20% were diagnosed by a general surgeon who performed the surgery. Respondents who were ≥ 65 years old, had less than a college education, and who made < $50,000 per year were more likely to be diagnosed by a general surgeon who performed surgery. In multivariable-adjusted models, respondents diagnosed and treated by the same general surgeon were more likely to have surgery at hospitals with low annual colorectal cancer surgery volume and less likely to be satisfied with their care.

CONCLUSIONS

Among rectal cancer patients in Iowa, respondents who were diagnosed and treated by the same provider were less likely to get treatment at a high-volume facility. This study informs the importance of provider referral in centralization of rectal cancer care.

Impact of hospital volume on failure to rescue for complications requiring reoperation after elective colorectal surgery: multicentre propensity score-matched cohort study

BACKGROUND

It has previously been reported that there are similar reoperation rates after elective colorectal surgery but higher failure-to-rescue (FTR) rates in low-volume hospitals (LVHs) versus high-volume hospitals (HVHs). This study assessed the effect of hospital volume on reoperation rate and FTR after reoperation following elective colorectal surgery in a matched cohort.

METHODS

Population-based retrospective multicentre cohort study of adult patients undergoing reoperation for a complication after an elective, non-centralized colorectal operation between 2006 and 2017 in 11 hospitals. Hospitals were divided into either HVHs (3 hospitals, median ≥126 resections per year) or LVHs (8 hospitals, <126 resections per year). Patients were propensity score-matched (PSM) for baseline characteristics as well as indication and type of elective surgery. Primary outcome was FTR.

RESULTS

A total of 6428 and 3020 elective colorectal resections were carried out in HVHs and LVHs, of which 217 (3.4%) and 165 (5.5%) underwent reoperation (P < 0.001), respectively. After PSM, 142 patients undergoing reoperation remained in both HVH and LVH groups for final analyses. FTR rate was 7.7% in HVHs and 10.6% in LVHs (P = 0.410). The median Comprehensive Complication Index was 21.8 in HVHs and 29.6 in LVHs (P = 0.045). There was no difference in median ICU-free days, length of stay, the risk for permanent ostomy or overall survival between the groups.

CONCLUSION

The reoperation rate and postoperative complication burden was higher in LVHs with no significant difference in FTR compared with HVHs.

Achieving Textbook Outcomes in Colorectal Cancer Surgery Is Associated with Improved Long-Term Survival: Results of the Multicenter Prospective Cohort Study

Background: The outcomes of patients with colorectal cancer greatly depend on the quality of their surgical care. However, relying solely on a single quality indicator does not adequately capture the multifaceted nature of modern perioperative care. A new tool-"Textbook Outcome" (TO)-has been suggested to provide a comprehensive evaluation of surgical quality. This study aims to examine how TO affects the long-term outcomes of colorectal cancer patients who are scheduled for surgery. Methods: The data of all patients undergoing elective colorectal cancer resection with primary anastomosis at two major cancer treatment centers in Lithuania-Vilnius University Hospital Santaros Klinikos and National Cancer Institute-between 2014 and 2018 were entered into the prospectively maintained database. The study defined TO as a composite quality indicator that incorporated seven parameters: R0 resection, retrieval of ≥12 lymph nodes, absence of postoperative complications during the intrahospital period, hospital stay duration of fewer than 14 days, no readmission within 90 days after surgery, no reinterventions within 30 days after surgery, and no 30-day mortality. Long-term outcomes between patients who achieved TO and those who did not were compared. Factors associated with failure to achieve TO were identified. Results: Of the 1524 patients included in the study, TO was achieved by 795 (52.2%). Patients with a higher ASA score (III-IV) were identified to have higher odds of failure to achieve TO (OR 1.497, 95% CI 1.203-1.863), while those who underwent minimally invasive surgery had lower odds for similar failure (OR 0.570, 95% CI 0.460-0.706). TO resulted in improved 5-year overall-(80.2% vs. 65.5%, p = 0.001) and disease-free survival (76.6% vs. 62.6%; p = 0.001) rates. Conclusions: Elective colorectal resections result in successful TO for 52.5% of patients. The likelihood of failure to achieve TO is increased in patients with a high ASA score, while minimally invasive surgery is associated with higher TO rates. Patients who fail to achieve successful surgical outcomes experience reduced long-term outcomes.

Elucidating survival and functional outcomes in patients with primary head and neck malignancies treated in academic versus community settings

BACKGROUND

Differences in treatment outcomes between community or academic centers are incompletely understood.

METHODS

Retrospective review of head and neck cancer patients between 2010 and 2020 in a rural health region. Kaplan-Meier curves and log-rank tests were used to evaluate survival outcomes, along with bivariate and multivariable Cox proportional hazards models. Linear regression was used for functional outcomes of tracheotomy and gastrostomy tube dependence.

RESULTS

Two hundred and forty-eight patients treated at an academic center were compared with 94 patients treated in community centers. In multivariable analysis, the risk of death (HR = 0.60, p = 0.019), and risk of recurrence were lower (HR = 0.29, p < 0.001) for patients treated in academic centers. Patients treated in community centers had longer gastrostomy tube dependence (p = 0.002).

CONCLUSION

Our findings suggest that treatment at an academic center was associated with a lower risk of recurrence and shorter gastrostomy tube dependence compared to treatment in the community.

Effect of centre volume on pathological outcomes and postoperative complications after surgery for colorectal cancer: results of a multicentre national study

BACKGROUND

The association between volume, complications and pathological outcomes is still under debate regarding colorectal cancer surgery. The aim of the study was to assess the association between centre volume and severe complications, mortality, less-than-radical oncologic surgery, and indications for neoadjuvant therapy.

METHODS

Retrospective analysis of 16,883 colorectal cancer cases from 80 centres (2018-2021). Outcomes: 30-day mortality; Clavien-Dindo grade >2 complications; removal of ≥ 12 lymph nodes; non-radical resection; neoadjuvant therapy. Quartiles of hospital volumes were classified as LOW, MEDIUM, HIGH, and VERY HIGH. Independent predictors, both overall and for rectal cancer, were evaluated using logistic regression including age, gender, AJCC stage and cancer site.

RESULTS

LOW-volume centres reported a higher rate of severe postoperative complications (OR 1.50, 95% c.i. 1.15-1.096, P = 0.003). The rate of ≥ 12 lymph nodes removed in LOW-volume (OR 0.68, 95% c.i. 0.56-0.85, P < 0.001) and MEDIUM-volume (OR 0.72, 95% c.i. 0.62-0.83, P < 0.001) centres was lower than in VERY HIGH-volume centres. Of the 4676 rectal cancer patients, the rate of ≥ 12 lymph nodes removed was lower in LOW-volume than in VERY HIGH-volume centres (OR 0.57, 95% c.i. 0.41-0.80, P = 0.001). A lower rate of neoadjuvant chemoradiation was associated with HIGH (OR 0.66, 95% c.i. 0.56-0.77, P < 0.001), MEDIUM (OR 0.75, 95% c.i. 0.60-0.92, P = 0.006), and LOW (OR 0.70, 95% c.i. 0.52-0.94, P = 0.019) volume centres (vs. VERY HIGH).

CONCLUSION

Colorectal cancer surgery in low-volume centres is at higher risk of suboptimal management, poor postoperative outcomes, and less-than-adequate oncologic resections. Centralisation of rectal cancer cases should be taken into consideration to optimise the outcomes.

Hospital factors determining overall survival in cancer patients undergoing curative treatment

BACKGROUND

In oncology, overall survival (OS) and quality of life (QoL) are key indicators. The factors that affect OS and QoL include tumor-related characteristics (stage and grade), patient-related factors (performance status and comorbidities), and cancer-directed therapy (CDT)-related aspects. In addition, external factors such as governance or policy (e.g., inaccessibility to CDT, increased distance to service, poor socioeconomic status, lack of insurance), and hospital-related factors (e.g., facility volume and surgeon volume) can influence OS and QoL.

MATERIALS AND METHODS

The primary objective of this narrative review was to identify hospital-related factors that affect OS and QoL in patients receiving curative CDT. The authors defined extrinsic factors that can be modified at the hospital level as "hospital-related" factors. Only factors supported by randomized controlled trials (RCT), systematic reviews (SR) and/or meta-analyses (MA), and population database (PDB) analyses that address the relationship between OS and hospital factors were considered.

RESULTS

The literature review found that high hospital or oncologist volume, adherence to evidence-based medicine (EBM), optimal time-to-treatment initiation (TTI), and decreased overall treatment time (OTT) increase OS in patients undergoing curative CDT. The use of case management strategies was associated with better symptom management and treatment compliance, but had a mixed effect on QoL. The practice of enhanced recovery after surgery (ERAS) in cancer patients did not result in an increase in OS. There was insufficient evidence to support the impact of factors such as teaching or academic centers, hospital infrastructure, and treatment compliance on OS and QoL.

CONCLUSION

The authors conclude that hospital policies should focus on increasing hospital and oncologist volume, adhering to EBM, optimizing TTI, and reducing OTT for cancer patients receiving curative treatment.

Urban-Rural Differences in Receipt of Cancer Surgery at High-Volume Hospitals and Sensitivity to Hospital Volume Thresholds

Methods for identifying high-volume hospitals affect conclusions about rural cancer care access.

Impact of National Accreditation Program for Rectal Cancer guidelines on surgical margin status

BACKGROUND

The American College of Surgeons established the National Accreditation Program for Rectal Cancer (NAPRC) to standardize rectal cancer care. We sought to assess the impact of NAPRC guidelines at a tertiary care center on surgical margin status.

MATERIALS AND METHODS

The Institutional NSQIP database was queried for patients with rectal adenocarcinoma undergoing surgery for curative intent two years prior to and following implementation of NAPRC guidelines. Primary outcome was surgical margin status before (pre-NAPRC) versus after (post-NAPRC) implementation of NAPRC guidelines.

RESULTS

Surgical pathology in five (5%) pre-NAPRC and seven (8%) post-NAPRC patients had positive radial margins (p = 0.59); distal margins were positive in three (3%) post-NAPRC and six (7%) post-NAPRC patients (p = 0.37). Local recurrence was observed in seven (6%) pre-NAPRC patients, there were no recurrences to date in post-NAPRC patients (p = 0.15). Metastasis was observed in 18 (17%) pre-NAPRC patients and four (4%) post-NAPRC patients (p = 0.55).

CONCLUSION

NAPRC implementation was not associated with a change in surgical margin status for rectal cancer at our institution. However, the NAPRC guidelines formalize evidence-based rectal cancer care and we anticipate that improvements will be greatest in low-volume hospitals which may not utilize multidisciplinary collaboration.

Postoperative NSAIDs use and the risk of anastomotic leakage after restorative resection for colorectal cancer

BACKGROUND

Although non-steroidal anti-inflammatory drugs (NSAIDs) are useful options for multimodal opioid-sparing analgesia, their effect on anastomotic leakage (AL) after colorectal surgery remains unclear. We aimed to investigate the association between early postoperative NSAID use and AL occurrence in patients who underwent colorectal cancer surgery at a high-volume tertiary care center.

METHODS

This retrospective observational study included all adult patients who underwent elective colorectal cancer resection surgery during 2011-2021 at a tertiary teaching hospital. Based on NSAID use within five postoperative days, patients were classified into either NSAID or no NSAID groups. We performed multivariable logistic regression analysis for the primary outcome, AL, within the first 30 postoperative days, before and after propensity score analysis using stabilized inverse probability of treatment weighting (sIPTW).

RESULTS

Among the 7928 patients analyzed, 0.6% experienced AL after surgery. The occurrence rates of AL were 1.7% (12/714) and 0.5% (37/7214) in the NSAID and no NSAID groups, respectively. Multivariable logistic regression analysis revealed that early postoperative NSAID use was significantly associated with AL [odds ratio (OR), 3.41; 95% confidence interval (CI), 1.76-6.60; P < 0.001]. Significance was maintained after sIPTW (OR, 3.65; 95% CI, 1.86-6.72; P < 0.001).

CONCLUSION

Early postoperative NSAID use was significantly associated with AL in patients undergoing colorectal cancer surgery at a high-volume tertiary care center. Further prospective studies are required to investigate NSAIDs' clinically meaningful unfavorable effects following colorectal cancer surgery.

Intraoperative Anastomotic Evaluation Methods: Rigid Proctoscopy Versus Flexible Endoscopy

INTRODUCTION

Rigid proctosigmoidoscopy (RP) and flexible sigmoidoscopy (FS) are two modalities commonly used for intraoperative evaluation of colorectal anastomoses. This study seeks to determine whether there is an association between the endoscopic modality used to evaluate colorectal anastomoses and the rate of anastomotic leak (AL), organ space infection, and overall infectious complication.

METHODS

The 2012-2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing colorectal anastomoses. Anastomotic evaluation method (RP versus FS) was identified by Current Procedural Terminologycoding and used for group classification. Outcomes measured included AL, organ space infections, and overall infection. Multivariable logistic regression analysis for predicting AL was performed.

RESULTS

We identified 7100 patients who underwent a colorectal anastomosis with intraoperative endoscopic evaluation. RP was utilized in 3397 (47.8%) and FS in 3703 (52.2%) patients. RP was used more commonly in diverticulitis (44.5% versus 36.2%, P < 0.01), while FS was used more frequently in malignancy (47.5% versus 36.7%, P < 0.01). Anastomotic evaluation with FS was associated with lower rates of organ space infection (3.8% versus 4.8%, P = 0.025) and AL (2.9% versus 3.8%, P = 0.028) compared to RP. On multivariate logistic regression modeling, anastomotic evaluation with RP was associated with a higher risk of AL (odds ratio 1.403, 95% CI 1.028-1.916, P = 0.033) compared to FS.

CONCLUSIONS

Compared to FS, rigid proctosigmoidoscopic evaluation of a colorectal anastomosis was associated with an increased rate of AL and organ space infection.

The impact of the institutional abdominoperineal resections volume on short-term outcomes and expenses: a nationwide study

BACKGROUND

The aim of this study was to evaluate the influence of the institutional volume of abdominoperineal resections (APR) on the short-term outcomes and costs in the Brazilian Public Health system.

METHODS

This population-based study evaluated the number of APRs by institutions performed in the Brazilian Public Health system from January/2010 to July/2022. Data were extracted from a public domain from the Brazilian Public Health system.

RESULTS

Four hundred and twelve hospitals performed APRs and were included. Only 23 performed at least 5 APRs per year on average and were considered high-volume institutions. The linear regression model showed that the number of hospital admissions for APRs was negatively associated with in-hospital mortality (Coef. = - 0.001; p = 0.013) and length of stay in the intensive care unit (Coef. = - 0.006; p = 0.01). The number of hospital admissions was not significantly associated with personnel, hospital, and total costs. The in-hospital mortality in high-volume institutions was significantly lower than in low-volume institutions (2.5 vs. 5.9%; p: < 0.001). The mean length of stay in the intensive care unit was shorter in high-volume institutions (1.23 vs. 1.79 days; p = 0.021). In high-volume institutions, the personnel (R$ 952.23 [US$ 186.64] vs. R$ 11,129.04 [US$ 221.29]; p = 0.305), hospital (R$ 4078.39 [US$ 799.36] vs. R$ 4987.39 [US$ 977.53]; p = 0.111), and total costs (R$ 5030.63 [US$ 986.00] vs. R$ 6116.71 [US$ 1198.88]; p = 0.226) were lower.

CONCLUSIONS

Higher institutional APR volume is associated with lower in-hospital mortality and less demand for intensive care. The findings of this nationwide study may affect how Public Health manages APR care.

A long-term retrospective observational study at a medium-sized medical oncology service in Switzerland: comparison of overall survival with a national cohort and adherence to treatment guidelines

AIMS

There is a lack of national and international publicly available long-term survival outcome data from individual healthcare providers in medical oncology. In this study, the overall survival at a medium-sized medical oncology service at Olten Cantonal Hospital was evaluated and compared as a local benchmark report with national data from the Swiss Cancer Registries. Furthermore, adherence to treatment guidelines was investigated as an additional quality indicator.

METHODS

The 1- and 5-year overall survival of all patients with breast cancer, testicular cancer, colon cancer, non-small-cell lung cancer, Hodgkin lymphoma, and diffuse large B-cell lymphoma in Switzerland from 2008 to 2017 with at least one outpatient visit at the in-house medical oncology service at Olten Cantonal Hospital was analysed and compared with the specific overall population-based outcome data provided by the National Agency for Cancer Registration (NACR), which were set as a national benchmark. Until 2020, no data from the Canton of Solothurn, to which Olten belongs, were reported to the NACR. Further, adherence to internationally recognized clinical guidelines for stage-specific treatment was assessed.

RESULTS

Until September 8, 2020, data on 842 patients with a median follow-up period of 70 months were collected and analysed. The 1- and 5-year overall survival for colon and non-small cell cancer, Hodgkin lymphoma, and diffuse large B-cell lymphoma and the 5-year overall survival for testicular cancer in the Olten cohort did not significantly differ from the NACR data. The 1-year overall survival for testicular cancer was not comparable statistically. The 5-year overall survival for breast cancer (unadjusted for stage) was significantly higher in the NACR collective (84.5%) than in the Olten collective (79.7%) but not for the individual breast cancer stages. The Olten collective included approximately 2.5 times as many patients with stage 4 breast cancer (17.5%) as the NACR collective (6.9%). Approximately 92.4% of the patients in the curative setting and 85.8% of the patients in the palliative setting received first-line treatment according to guidelines.

CONCLUSIONS

The statistically comparable local 1- and 5-year overall survival of the analysed malignancies, with adjustment for stage for the 5-year overall survival for breast cancer, is in line with the national benchmark. Adherence to treatment guidelines is high.

Complications after open and laparoscopic right-sided colectomy with central lymphadenectomy for colon cancer: randomized controlled trial

BACKGROUND

A central lymphadenectomy in right-sided colon cancer involves dissection along the superior mesenteric axis, but the extent is debated due to a lack of consensus and the fear of major complications. This randomized controlled trial compared the rate of postoperative morbidity in patients undergoing laparoscopic versus open right-sided colectomy with central lymphadenectomy.

METHODS

This open, prospective, randomized controlled trial compared patients operated on with open and laparoscopic right-sided colectomy (cStages I-III) with a central lymphadenectomy at two Norwegian institutions between October 2016 and December 2021. Dissections were conducted along the superior mesenteric vein in the laparoscopic group, and along the left anterior border of the superior mesenteric artery in the open group, both according to complete mesocolic excision principles. Surgery was standardized and performed by three experienced surgeons for each study group. The primary outcome of interest was to measure postoperative 30-day complications (Clavien-Dindo ≥ grade II).

RESULTS

Of 273 eligible patients, 135 were randomized and 128 analysed (63 operated on with open and 65 using laparoscopic procedures). Postoperative complications occurred in 42.8 per cent of the patients treated with open and 38.4 per cent of the patients treated using laparoscopic surgery, P = 0.372. The incidence of Clavien-Dindo grade IIIb complications was 7.9 per cent in the open versus 4.6 per cent in the laparoscopic group, P = 0.341. There were no grade IV or V complications, and no re-operations due to anastomotic leakages. There was no significant difference in the mean(s.e.m.) number of removed lymph nodes (open versus laparoscopic respectively: 31.9(1.8) versus 29.3(1.3); P = 0.235).

CONCLUSION

There was no significant difference in complications between the two groups. Standardized oncologic right-sided colectomy with central lymphadenectomy along the mesenterial root was performed safely, both open and laparoscopic, with incidence of major complications ranging between 4.6 and 7.9 per cent and no re-operations for anastomotic leakage. Radicality in terms of lymphadenectomy was comparable between the two groups.Registration number: NCT03776591 (http://www.clinicaltrials.gov).

How to create value with constrained budgets in oncological care? A narrative review

INTRODUCTION

As a result of an increasing focus on patient-centered care within oncology and more pressure on the sustainability of health-care systems, the discussion on what exactly constitutes value re-appears. Policymakers seek to improve patient values; however, funding all values is not sustainable.

AREAS COVERED

We collect available evidence from scientific literature and reflect on the concept of value, the possible incorporation of a wide spectrum of values in reimbursement decisions, and alternative strategies to increase value in oncological care.

EXPERT OPINION

We state that value holds many different aspects. For reimbursement decisions, we argue that it is simply not feasible to incorporate all patient values because of the need for efficient resource allocation. We argue that we should shift the value debate from the individual perspective of patients to creating value for the cancer population at large. The different strategies we address are as follows: (1) shared decision-making; (2) biomarkers and molecular diagnostics; (3) appropriate evaluation, payment and use of drugs; (4) supportive care; (5) cancer prevention and screening; (6) monitoring late effect; (7) concentration of care and oncological networking; and (8) management of comorbidities. Important preconditions to support these strategies are strategic planning, consistent cancer policies and data availability.

Hospital surgical volume and colorectal cancer survival in Norway: A nationwide cohort study

BACKGROUND

Studies of hospital surgical volume and colorectal cancer survival are inconclusive. We investigated whether surgical volume was associated with survival of patients operated for colorectal cancer in Norway.

METHODS

Using Cancer Registry of Norway data, we compared excess mortality from colorectal cancer by hospital surgical volume among 26,989 colon and 9779 rectal cancer patients diagnosed 2009-2020 and followed-up to 31.12.2021. Hospitals were divided into terciles according to their three-year average annual surgical volume; colon: low (< 22), middle (22-73), high (> 73); rectal: low (< 17), middle (17-38), high (> 38). We estimated excess hazard ratios (EHR) with flexible parametric models adjusted for age, year, stage, surgical urgency and surgery location (within/outside patient's residential health trust).

RESULTS

Low-volume hospitals had the highest proportion of late-stage or acutely operated colon cancer patients. Colon cancer patients operated at low- versus high-volume hospitals had significantly increased crude excess mortality (EHR = 1.30; 95 % CI = 1.14-1.48) but no difference after adjustment for age, year, and stage (EHR = 0.97; 0.85-1.11). High-volume hospitals had the highest proportion of late-stage rectal cancer patients and patients operated outside their residential area. Rectal cancer patients operated at low- versus high-volume hospitals did not have significantly different excess mortality before (EHR = 0.84; 0.64-1.10) or after (EHR = 1.03; 0.79-1.35) adjustment for age, year, stage, surgical urgency and surgery location. After accounting for case-mix, hospital surgical volume was not associated with excess mortality from colon (P = 0.40) or rectal cancer (P = 0.22).

CONCLUSION

Low hospital surgical volume was not associated with poorer colorectal cancer survival.

Patterns of Care and Outcomes of Rectal Cancer Patients from the Iowa Cancer Registry: Role of Hospital Volume and Tumor Location

BACKGROUND

Centralization of rectal cancer surgery has been associated with high-quality oncologic care. However, several patient, disease and system-related factors can impact where patients receive care. We hypothesized that patients with low rectal tumors would undergo treatment at high-volume centers and would be more likely to receive guideline-based multidisciplinary treatment.

METHODS

Adults who underwent proctectomy for stage II/III rectal cancer were included from the Iowa Cancer Registry and supplemented with tumor location data. Multinomial logistic regression was employed to analyze factors associated with receiving care in high-volume hospital, while logistic regression for those associated with ≥ 12 lymph node yield, pre-operative chemoradiation and sphincter-preserving surgery.

RESULTS

Of 414 patients, 38%, 39%, and 22% had low, mid, and high rectal cancers, respectively. Thirty-two percent were > 65 years, 38% female, and 68% had stage III tumors. Older age and rural residence, but not tumor location, were associated with surgical treatment in low-volume hospitals. Higher tumor location, high-volume, and NCI-designated hospitals had higher nodal yield (≥ 12). Hospital-volume was not associated with neoadjuvant chemoradiation rates or circumferential resection margin status. Sphincter-sparing surgery was independently associated with high tumor location, female sex, and stage III cancer, but not hospital volume.

CONCLUSIONS

Low tumor location was not associated with care in high-volume hospitals. High-volume and NCI-designated hospitals had higher nodal yields, but not significantly higher neoadjuvant chemoradiation, negative circumferential margin, or sphincter preservation rates. Therefore, providing educational/quality improvement support in lower volume centers may be more pragmatic than attempting to centralize rectal cancer care among high-volume centers.

Minimum Volume Standards: An Incentive To Perform More Radical Cystectomies?

Background

Minimum volume standards (MVS) for hospitals and/or surgeons remain a subject of debate. Opponents of MVS emphasize the possible negative effects of centralization, such as an unwanted incentive to perform surgery.

Objective

To evaluate whether the introduction of MVS for radical cystectomy (RC) in the Netherlands resulted in more RCs outside guideline-recommended indications.

Design setting and participants

All RCs performed for bladder cancer in the Netherlands between January 1, 2006 and December 31, 2017 were identified in the Netherlands Cancer Registry. During this period, two MVS were sequentially implemented for RC. RCs in intermediate-volume hospitals (hospitals that approximated the MVS) were compared with RCs in high-volume hospitals (hospitals exceeding the MVS by ≥5 RCs/yr) in a period before and a period after implementation of each of the two MVS.

Outcomes measurements and statistical analysis

Descriptive analyses were performed to evaluate whether hospitals performed more RCs outside the recommended indication (cT2-4a N0 M0) and whether an increase in the number of RCs towards the end of the year could be observed.

Results and limitations

After MVS implementation, no clear shift towards disease stages outside the recommended indication for RC was observed in comparison to the period before the MVS. Results for high-volume and intermediate-volume hospitals were similar. In addition, no increase in RCs towards the end of the year was evident.

Conclusions

We did not find evidence indicating an unwanted incentive to perform more RCs as a result of MVS in the Netherlands. Our results further strengthen the case for MVS implementation.

Patient summary

We evaluated whether criteria for the minimum number of radical cystectomies (surgical removal of the bladder) that hospitals have to perform caused urologists to perform more of these operations than necessary in order to meet the minimum level. We found no evidence that minimum criteria led to such an unwanted incentive.

The influence of socioeconomic aspects and hospital case volume on survival in colorectal cancer in Saxony, Germany

BACKGROUND

Colorectal cancer (CRC) is one of the most common types of cancer in Western civilization and responsible for a high number of yearly deaths. Long-term outcome is influenced by many factors, potentially including socioeconomic aspects like income, education, and employment. Furthermore, annual surgical case volume plays a major role in achieving good oncological results. In our retrospective study, we evaluated the effect of socioeconomic deprivation and hospital volume on overall survival (OS) in the federal state of Saxony, Germany.

METHODS

All patients with CRC who underwent surgery in Saxony, Germany between 2010 and 2020 and were living in Saxony at the time of diagnosis were included in our retrospective analysis. Uni- and multivariate analyses were conducted considering age, sex, tumor localization, UICC tumor stage, surgical approach (open/laparoscopic), number of resected lymph nodes, adjuvant chemotherapy, year of surgery, and hospital case volume. In addition, our model was adjusted for social disparity using the German Index of Socioeconomic Deprivation (GISD).

RESULTS

A total of 24,085 patients were analyzed (15,883 with colon cancer and 8,202 with rectal cancer). Age, sex, UICC tumor stage and tumor localization were distributed as expected for CRC. Median overall survival time was 87.9 months for colon cancer and 110.0 months for rectal cancer. Univariate analysis revealed laparoscopic surgery (colon and rectum P < 0.001), high case volume (rectum: P = 0.002) and low levels of socioeconomic deprivation (colon and rectum P < 0.001) to be significantly associated with better survival. In multivariate analyses, the associations of laparoscopic surgery (colon: HR = 0.76, P < 0.001; rectum: HR = 0.87, P < 0.01), and mid-low to mid-high socioeconomic deprivation (colon: HR = 1.18-1.22, P < 0.001; rectum: HR = 1.18-1.36, P < 0.001-0.01) remained statistically significant. Higher hospital case volume was associated with better survival only in rectal cancer (HR = 0.89; P < 0.01).

CONCLUSION

In Saxony, Germany, better long-term survival after CRC surgery was associated with low socioeconomic deprivation, laparoscopic surgery and partly with high hospital case volume. Thus, there is a need to reduce social differences in access to high-quality treatment and prevention and increase hospital patient volume.

Disparities in Benign Gynecologic Surgical Care

A person's health is not only affected by their disease states, but also the quality of care and posttreatment sequelae. Research shows that disparities exist in benign gynecologic surgery access to care, techniques, and perioperative outcomes. Surgical education, pathways that emphasize minimally invasive approaches, and patient-centered care that recognizes historical influences on patient perspectives are critical to dampening these disparities.

How Far Is Too Far? Cost-Effectiveness Analysis of Regionalized Rectal Cancer Surgery

BACKGROUND

Regionalized rectal cancer surgery may decrease postoperative and long-term cancer-related mortality. However, the regionalization of care may be an undue burden on patients.

OBJECTIVE

This study aimed to assess the cost-effectiveness of regionalized rectal cancer surgery.

DESIGN

Tree-based decision analysis.

PATIENTS

Patients with stage II/III rectal cancer anatomically suitable for low anterior resection were included.

SETTING

Rectal cancer surgery performed at a high-volume regional center rather than the closest hospital available.

MAIN OUTCOME MEASURES

Incremental costs ($) and effectiveness (quality-adjusted life year) reflected a societal perspective and were time-discounted at 3%. Costs and benefits were combined to produce the incremental cost-effectiveness ratio ($ per quality-adjusted life year). Multivariable probabilistic sensitivity analysis modeled uncertainty in probabilities, costs, and effectiveness.

RESULTS

Regionalized surgery economically dominated local surgery. Regionalized rectal cancer surgery was both less expensive on average ($50,406 versus $65,430 in present-day costs) and produced better long-term outcomes (10.36 versus 9.51 quality-adjusted life years). The total costs and inconvenience of traveling to a regional high-volume center would need to exceed $15,024 per patient to achieve economic breakeven alone or $112,476 per patient to satisfy conventional cost-effectiveness standards. These results were robust on sensitivity analysis and maintained in 94.6% of scenario testing.

LIMITATIONS

Decision analysis models are limited to policy level rather than individualized decision-making.

CONCLUSIONS

Regionalized rectal cancer surgery improves clinical outcomes and reduces total societal costs compared to local surgical care. Prescriptive measures and patient inducements may be needed to expand the role of regionalized surgery for rectal cancer. See Video Abstract at http://links.lww.com/DCR/C83 .

QU TAN LEJOS ES DEMASIADO LEJOS ANLISIS DE COSTOEFECTIVIDAD DE LA CIRUGA DE CNCER DE RECTO REGIONALIZADO

ANTECEDENTES:La cirugía de cáncer de recto regionalizado puede disminuir la mortalidad posoperatoria y a largo plazo relacionada con el cáncer. Sin embargo, la regionalización de la atención puede ser una carga indebida para los pacientes.OBJETIVO:Evaluar la rentabilidad de la cirugía oncológica de recto regionalizada.DISEÑO:Análisis de decisiones basado en árboles.PACIENTES:Pacientes con cáncer de recto en estadio II/III anatómicamente aptos para resección anterior baja.AJUSTE:Cirugía de cáncer rectal realizada en un centro regional de alto volumen en lugar del hospital más cercano disponible.PRINCIPALES MEDIDAS DE RESULTADO:Los costos incrementales ($) y la efectividad (años de vida ajustados por calidad) reflejaron una perspectiva social y se descontaron en el tiempo al 3%. Los costos y los beneficios se combinaron para producir la relación costo-efectividad incremental ($ por año de vida ajustado por calidad). El análisis de sensibilidad probabilístico multivariable modeló la incertidumbre en las probabilidades, los costos y la efectividad.RESULTADOS:La cirugía regionalizada predominó económicamente la cirugía local. La cirugía de cáncer de recto regionalizado fue menos costosa en promedio ($50 406 versus $65 430 en costos actuales) y produjo mejores resultados a largo plazo (10,36 versus 9,51 años de vida ajustados por calidad). Los costos totales y la inconveniencia de viajar a un centro regional de alto volumen necesitarían superar los $15,024 por paciente para alcanzar el punto de equilibrio económico o $112,476 por paciente para satisfacer los estándares convencionales de rentabilidad. Estos resultados fueron sólidos en el análisis de sensibilidad y se mantuvieron en el 94,6% de las pruebas de escenarios.LIMITACIONES:Los modelos de análisis de decisiones se limitan al nivel de políticas en lugar de la toma de decisiones individualizada.CONCLUSIONES:La cirugía de cáncer de recto regionalizada mejora los resultados clínicos y reduce los costos sociales totales en comparación con la atención quirúrgica local. Es posible que se necesiten medidas prescriptivas e incentivos para los pacientes a fin de ampliar el papel de la cirugía regionalizada para el cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/C83 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Postoperative outcomes of right hemicolectomy for cancer in 11 countries of Latin America: A multicentre retrospective study

AIM

There is scant evidence regarding surgical outcomes of patients with colon cancer in Latin America. The aim of this work was to compare perioperative (30 day) outcomes of patients undergoing surgery for right colon cancer in Latin America based on centre volume.

METHOD

This is a multi-institutional retrospective cohort study. Individuals operated on for right colon cancer with curative intent in an urgent or elective setting between 2016 and 2021 were eligible for inclusion in the study. Patients were divided into two groups according to whether they were operated on in low-volume or high-volume centres (defined as more than 30 cases/year).

RESULTS

A total of 2676 patients from 46 hospitals in 11 countries of Latin America were included, with 389 (14.5%) in the low-volume group. The median age was 67.37 years. The high-volume group presented higher rates of laparoscopic procedures (56.8 vs. 35.7%, p < 0.001, OR 2.36), with lower conversion rates, fewer intraoperative complications and a shorter operating time. The high-volume group had a shorter length of hospital stay. The overall complication rate for the whole group was 15.9%, with a lower incidence of these events in the high-volume group (13.7 vs. 28.7%, p < 0.001, OR 0.40). Overall, anastomotic leakage, reoperation and mortality rates were 5.6%, 9.2% and 6.1%, respectively, with differences favouring high-volume centres. On multivariate analysis, low-volume group, history of cardiac disease, emergency surgery, operation performed by a general surgeon, open approach and intraoperative complications were independent predictors of major postoperative complications.

CONCLUSION

This is the first study in Latin America to show better postoperative outcomes at a regional scale when surgery for right colon cancer is performed in high-volume centres. Further studies are needed to validate these data and to identify which of the factors can explain the present results.

Facility Volume Thresholds for Optimization of Short- and Long-Term Outcomes in Patients Undergoing Hepatectomy for Primary Liver Tumors

BACKGROUND

Volume-outcome relationships have been described for a variety of surgical procedures. We aimed to define the facility volume threshold at which postoperative mortality after hepatectomy was optimal.

METHODS

We determined volume percentiles for institutions performing hepatectomy for any primary liver tumor within the National Cancer Database (2004-2017). Marginal structural logistic regression defined the volume percentile (Vmin) at which the odds of 90-day mortality were optimally reduced in patients with hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma (ICC). Short-term postoperative and survival outcomes were compared between patients treated at facilities above and below Vmin.

RESULTS

Thresholds for the 10^th/25^th/50^th/75^th/90^th percentiles were 2/7/26/46/59 hepatectomies/year. A total of 17,833 patients underwent resection of HCC or ICC. The 90-day postoperative mortality was optimized at the 75^th percentile for all hepatectomies (IP-weighted OR = 0.67, 95% CI = 0.52-0.87) and major hepatectomy (IP-weighted OR = 0.62, 95% CI = 0.49-0.80). Seven of 446 facilities met the Vmin threshold. The odds of 30-day mortality were also reduced for all hepatectomies (IP-weighted OR = 0.55, 95% CI = 0.42-0.73) and major hepatectomy (IP-weighted OR = 0.58, 95% CI = 0.41-0.75). There were no differences in length of stay or 30-day readmission rate. Patients with HCC or ICC treated at facilities ≥ 10^th percentile had an associated improvement in overall survival.

CONCLUSIONS

Resection of HCC and ICC is performed at a large number of facilities. Postoperative mortality is optimally reduced at facilities performing at least 46 liver operations annually. Regionalization of surgical care among patients with primary liver malignancies to high-volume centers may result in improved outcomes.

Training curriculum in minimally invasive emergency digestive surgery: 2022 WSES position paper

BACKGROUND

Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, is widely adopted in elective digestive surgery, but selectively used for surgical emergencies. The present position paper summarizes the available evidence concerning the learning curve to achieve proficiency in emergency MIS and provides five expert opinion statements, which may form the basis for developing standardized curricula and training programs in emergency MIS.

METHODS

This position paper was conducted according to the World Society of Emergency Surgery methodology. A steering committee and an international expert panel were involved in the critical appraisal of the literature and the development of the consensus statements.

RESULTS

Thirteen studies regarding the learning curve in emergency MIS were selected. All but one study considered laparoscopic appendectomy. Only one study reported on emergency robotic surgery. In most of the studies, proficiency was achieved after an average of 30 procedures (range: 20-107) depending on the initial surgeon's experience. High heterogeneity was noted in the way the learning curve was assessed. The experts claim that further studies investigating learning curve processes in emergency MIS are needed. The emergency surgeon curriculum should include a progressive and adequate training based on simulation, supervised clinical practice (proctoring), and surgical fellowships. The results should be evaluated by adopting a credentialing system to ensure quality standards. Surgical proficiency should be maintained with a minimum caseload and constantly evaluated. Moreover, the training process should involve the entire surgical team to facilitate the surgeon's proficiency.

CONCLUSIONS

Limited evidence exists concerning the learning process in laparoscopic and robotic emergency surgery. The proposed statements should be seen as a preliminary guide for the surgical community while stressing the need for further research.

Leveraging large, real-world data through machine-learning to increase efficiency in robotic-assisted total knee arthroplasty

PURPOSE

Increased operative time can be due to patient, surgeon and surgical factors, and may be predicted by machine learning (ML) modeling to potentially improve staff utilization and operating room efficiency. The purposes of our study were to: (1) determine how demographic, surgeon, and surgical factors affected operative times, and (2) train a ML model to estimate operative time for robotic-assisted primary total knee arthroplasty (TKA).

METHODS

A retrospective study from 2007 to 2020 was conducted including 300,000 unilateral primary TKA cases. Demographic and surgical variables were evaluated using Wilcoxon/Kruskal-Wallis tests to determine significant factors of operative time as predictors in the ML models. For the ML analysis of robotic-assisted TKAs (> 18,000), two algorithms were used to learn the relationship between selected predictors and operative time. Predictive model performance was subsequently assessed on a test data set comparing predicted and actual operative time. Root mean square error (RMSE), R² and percentage of predictions with an error < 5/10/15 min were computed.

RESULTS

Males, BMI > 40 kg/m² and cemented implants were associated with increased operative time, while age > 65yo, cementless, and high surgeon case volume had reduced operative time. Robotic-assisted TKA increased operative time for low-volume surgeons and decreased operative time for high-volume surgeons. Both ML models provided more accurate operative time predictions than standard time estimates based on surgeon historical averages.

CONCLUSIONS

This study demonstrated that greater surgeon case volume, cementless fixation, manual TKA, female, older and non-obese patients reduced operative time. ML prediction of operative time can be more accurate than historical averages, which may lead to optimized operating room utilization.

LEVEL OF EVIDENCE

III.

Who should operate patients presenting with emergent colon cancer? A comparison of short- and long-term outcome depending on surgical sub-specialization

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.

Utilization Trends and Volume-outcomes Relationship of Endoscopic Resection for Early Stage Esophageal Cancer

OBJECTIVES

We describe utilization trends and center volume-outcomes relationship of ER of early stage esophageal cancer using a large hospitalbased registry.

SUMMARY OF BACKGROUND DATA

ER is increasingly accepted as the preferred treatment for early stage esophageal cancer, however its utilization and the center volume-outcomes relationship in the United States is unknown.

METHODS

The National Cancer Database was used to identify patients with cT1N0M0 esophageal cancer treated with ER or esophagectomy between 2004 and 2015. Relative frequencies were plotted over time. Restricted cubic splines and maximally selected rank statistics were used to identify an inflection point of center volume and survival.

RESULTS

A total of 1136 patients underwent ER and 2829 patients underwent esophagectomy during the study period. Overall utilization of ER, and relative use compared to esophagectomy, increased throughout the study period. Median annualized center ER volume was 1.9 cases per year (interquartile range 0.5-5.8). Multivariable Cox regression showed increasing annualized center volume by 1 case per year was associated with improved survival. Postoperative 30- or 90-day mortality, 30-day readmission, and pathologic T upstaging rates were similar irrespective of center volume.

CONCLUSIONS

Utilization of ER compared to esophagectomy for stage I esophageal cancer has increased over the past decade, though many individual centers perform fewer than 1 case annually. increasing annualized center volume by one procedure per year was associated with improved survival. increased volume beyond this was not associated with survival benefit. Referral to higher volume centers for treatment of superficial esophageal cancer should be considered.

C-reactive Protein and Procalcitonin Levels to Predict Anastomotic Leak After Colorectal Surgery: Systematic Review and Meta-analysis

BACKGROUND

Anastomotic leak (AL) is a feared complication after colorectal surgery. Prompt diagnosis and treatment are crucial. C-reactive protein (CRP) and procalcitonin (PCT) have been proposed as early AL indicators. The aim of this systematic review was to evaluate the CRP and CPT predictive values for early AL diagnosis after colorectal surgery.

METHODS

Systematic literature search to identify studies evaluating the diagnostic accuracy of postoperative CRP and CPT for AL. A Bayesian meta-analysis was carried out using a random-effects model and pooled predictive parameters to determine postoperative CRP and PCT cut-off values at different postoperative days (POD).

RESULTS

Twenty-five studies (11,144 patients) were included. The pooled prevalence of AL was 8% (95 CI 7-9%), and the median time to diagnosis was 6.9 days (range 3-10). The derived POD3, POD4 and POD5 CRP cut-off were 15.9 mg/dl, 11.4 mg/dl and 10.9 mg/dl respectively. The diagnostic accuracy was comparable with a pooled area under the curve (AUC) of 0.80 (95% CIs 0.23-0.85), 0.84 (95% CIs 0.18-0.86) and 0.84 (95% CIs 0.18-0.89) respectively. Negative likelihood ratios (LR-) showed moderate evidence to rule out AL on POD 3 (LR- 0.29), POD4 (LR- 0.24) and POD5 (LR- 0.26). The derived POD3 and POD5 CPT cut-off were 0.75 ng/ml (AUC = 0.84) and 0.9 ng/ml (AUC = 0.92) respectively. The pooled POD5 negative LR (-0.18) showed moderate evidence to rule out AL.

CONCLUSIONS

In the setting of colorectal surgery, CRP and CPT serum concentrations lower than the derived cut-offs on POD3-POD5, may be useful to rule out AL thus possibly identifying patients at low risk for AL development.

Racial Disparities in Surgical Outcomes Among Women with Endometrial Cancer

PURPOSE

Endometrial cancer (EC) is the most common gynecological cancer among women in the United States. Despite well-documented racial/ethnic disparities in EC incidence and mortality rates, limited data exist regarding disparities in hysterectomy surgical outcomes. We evaluated associations of race/ethnicity with postoperative complications, serious adverse events (SAEs), and length of hospital stay among women undergoing EC-related hysterectomy.

METHODS

Using National Surgical Quality Improvement Program (NSQIP) data, we identified women (≥18 years) undergoing hysterectomy to treat EC between 2014 and 2020. We used multivariable logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations of race/ethnicity (white, black, and Latina) with postoperative complications and SAEs. We used Poisson regression with robust standard errors to calculate incidence rate ratios (IRRs) and 95% CIs for the association of race/ethnicity with length of hospital stay.

RESULTS

Of 22,778 women undergoing EC-related hysterectomy, 3.1% developed postoperative complications. Black (adjusted OR: 1.62; 95% CI 1.05-2.48) and Latina women (adjusted OR: 1.79; 95% CI 1.04-3.09) had higher postoperative complication risks than white women. The overall SAE incidence was 5.0%. Black women (adjusted OR: 1.55, 95% CI 1.13-2.15) had higher SAE risks than white women. Length of hospital stay was significantly longer for black women than white women (IRR: 1.18; 95% CI 1.07-1.30).

CONCLUSIONS

We observed racial/ethnic disparities in EC-related hysterectomy surgical outcomes in a large, diverse sample of U.S. women between 2014 and 2020. Studies to elucidate the underlying mechanisms of these racial disparities, with a focus on social context remain necessary.

Trends in infectious complications after partial colectomy for colon cancer over a decade: A national cohort study

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program helps participating hospitals track and report surgical complications with the goal of improving patient care. We sought to determine whether postoperative infectious complications after elective colectomy for malignancy improved among participating centers over time.

METHODS

Patients with colon malignancies who underwent elective partial colectomy with primary anastomosis (categorized as low or non-low) were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2011-2019). Thirty-day postoperative infectious complications analyzed by year included superficial, deep, and organ space surgical site infections, urinary tract infection, pneumonia, and sepsis. Trends in patient and treatment characteristics were investigated using log-linear regression along with their association with infectious outcomes.

RESULTS

Of the 78,827 patients identified, 51% were female, and the median age was 68. The majority (84%) underwent partial colectomy without a low anastomosis. There was a decrease in all infectious complications except for organ space infections which increased 35% overall from 2.0 to 2.7% (P = .037), driven by patients without a low anastomosis (1.9%-2.7%, P = .01). There was no change in most patient factors associated with organ space infections, except for a notable increase in American Society of Anesthesiologists class III and IV-V patients over time, both associated with organ space infections (P < .001; P = .002).

CONCLUSION

Infectious complications have decreased significantly overall after colectomy for colon cancer, whereas there has been an increase in organ space infection rates specifically. Although changing patient characteristics may contribute to this observed trend, further study is needed to better understand its etiology to help mitigate this complication.

Annual Case Volume and One-Year Mortality for Endovascular Treatment in Acute Ischemic Stroke

BACKGROUND

The association between endovascular treatment (EVT) case volume per hospital and clinical outcomes has been reported, but the exact volume threshold has not been determined. This study aimed to examine the case volume threshold in this context.

METHODS

National audit data on the quality of acute stroke care in patients admitted via emergency department, within 7 days of onset, in hospitals that treated ≥ 10 stroke cases during the audit period were analyzed. Ischemic stroke cases treated with EVT during the last three audits (2013, 2014, and 2016) were selected for the analysis. Annual EVT case volume per hospital was estimated and analyzed as a continuous and a categorical variable (in quartiles). The primary outcome measure was 1-year mortality as a surrogate of 3-month functional outcome. As post-hoc sensitivity analysis, replication of the study results was examined using the 2018 audit data.

RESULTS

We analyzed 1,746 ischemic stroke cases treated with EVT in 120 acute care hospitals. The median annual EVT case volume was 12.0 cases per hospital, and mortality rates at 1 month, 3 months, and 1 year were 12.7%, 16.6%, and 23.3%, respectively. Q3 and Q4 had 33% lower odds of 1-year mortality than Q1. Adjustments were made for predetermined confounders. Annual EVT case volume cut-off value for 1-year mortality was 15 cases per year (P < 0.02). The same cut-off value was replicated in the sensitivity analysis.

CONCLUSION

Annual EVT case volume was associated with 1-year mortality. The volume threshold per hospital was 15 cases per year.

Current trends in nonoperative management for rectal adenocarcinoma: An unequal playing field?

BACKGROUND AND OBJECTIVES

Increasing evidence suggests patient-oriented benefits of nonoperative management (NOM) for rectal cancer. However, vigilant surveillance requires excellent access to care. We sought to examine patient, socioeconomic, and facility-level factors associated with NOM over time.

METHODS

Using the National Cancer Database (2006-2017), we examined patients with Stage II-III rectal adenocarcinoma, who received neoadjuvant chemoradiation and received NOM versus surgery. Factors associated with NOM were assessed using multivariable logistic regression with backward stepwise selection.

RESULTS

There were 59,196 surgical and 8520 NOM patients identified. NOM use increased from 12.9% to 15.9% between 2006 and 2017. Patients who were Black (adjusted odds ratio [aOR]: 1.36, 95% confidence interval [CI]: 1.26-1.47), treated at community cancer centers (aOR: 1.22, 95% CI: 1.12-1.30), without insurance (aOR: 1.87, 95% CI: 1.68-2.09), and with less education (aOR: 1.53, 95% CI: 1.42-1.65) exhibited higher odds of NOM. Patients treated at high-volume centers (aOR: 0.79, 95% CI: 0.74-0.84) and those who traveled >25.6 miles for care (aOR: 0.59, 95% CI: 0.55-0.64) had lower odds of NOM.

CONCLUSIONS

Vulnerable groups who traditionally have difficulty accessing comprehensive cancer care were more likely to receive NOM, suggesting that healthcare disparities may be driving utilization. More research is needed to understand NOM decision-making in rectal cancer treatment.

Relationships between multiple patient safety outcomes and healthcare and hospital-related risk factors in colorectal resection cases: cross-sectional evidence from a nationwide sample of 232 German hospitals

OBJECTIVES

Studies analysing colorectal resections usually focus on a specific outcome (eg, mortality) and/or specific risk factors at the individual (eg, comorbidities) or hospital (eg, volume) level. Comprehensive evidence across different patient safety outcomes, risk factors and patient groups is still scarce. Therefore the aim of this analysis was to investigate consistent relationships between multiple patient safety outcomes, healthcare and hospital risk factors in colorectal resection cases.

DESIGN

Cross-sectional study.

SETTING

German inpatient routine care data of colorectal resections between 2016 and 2018.

PARTICIPANTS

We analysed 54 168 colon resection and 20 395 rectum resection cases treated in German hospitals. The German Inpatient Quality Indicators were used to define colon resections and rectum resections transparently.

PRIMARY OUTCOME MEASURES

Additionally to in-hospital death, postoperative respiratory failure, renal failure and postoperative wound infections we included multiple patient safety outcomes as primary outcomes/dependent variables for our analysis. Healthcare (eg, weekend surgery), hospital (eg, volume) and case (eg, age) characteristics served as independent covariates in a multilevel logistic regression model. The estimated regression coefficients were transferred into ORs.

RESULTS

Weekend surgery, emergency admissions and transfers from other hospitals were significantly associated (ORs ranged from 1.1 to 2.6) with poor patient safety outcome (ie, death, renal failure, postoperative respiratory failure) in colon resections and rectum resections. Hospital characteristics showed heterogeneous effects. In colon resections hospital volume was associated with insignificant or adverse associations (postoperative wound infections: OR 1.168 (95% CI 1.030 to 1.325)) to multiple patient safety outcomes. In rectum resections hospital volume was protectively associated with death, renal failure and postoperative respiratory failure (ORs ranged from 0.7 to 0.8).

CONCLUSIONS

Transfer from other hospital and emergency admission are constantly associated with poor patient safety outcome. Hospital variables like volume, ownership or localisation did not show consistent relationships to patient safety outcomes.

TRIAL REGISTRATION NUMBER

ISRCTN10188560.

Qualitative Study of Medical Doctors on Their Experiences and Opinions of the Characteristics of Exceptionally Good Doctors

BACKGROUND

It is generally accepted that there is a therapist effect in psychotherapy, with master therapists being studied using qualitative methods. There are surgeons with exceptionally positive patients' physical health outcomes, and qualitative research on what makes good doctors. However, characteristics of exceptionally good doctors are less studied and understood.

OBJECTIVE

To qualitatively study the opinions of physicians on exceptionally good doctors.

METHODS

Thirteen semi-structured interviews of English-speaking medical doctors of any specialty were conducted. Recruitment was achieved through the authors' network; contacting authors of relevant research papers; and Bond University's General Practitioner recruitment program. Their opinion was sought on what makes an exceptionally good doctor, whether they have met such a person, what was their experience of that person, and whether they consider themselves as exceptionally good doctors.

ANALYSIS

A six-phase thematic analysis in an experiential framework, as per Braun and Clarke, was implemented to identify themes and their details in an inductive approach with a realist epistemological position, ie, assuming truthful knowledge on what makes exceptionally good doctors can be obtained.

RESULTS

Each interviewee had met and been inspired by exceptionally good doctors. Descriptions covered six themes: character traits; other characteristics; patient relationships; peer and health care system relations; education; and treatment examples. Exceptionally good doctors were found to have up-to-date extensive medical knowledge and skills, relate well with patients, and have excellent diagnostic abilities. They tend to be humble, approachable, inspiring, and are long-remembered role models. However, they may not always be appreciated by their peers and their health care system because of their exceptional abilities.

DISCUSSION AND CONCLUSION

Exceptional doctors are beneficial for their peers, their patients, and their health care system. Identifying, acknowledging, and making such doctors more accessible to medical students and junior doctors could have a positive impact on medical practice.

Referrals and Decision-Making Considerations Involved in Selecting a Surgeon for Rectal Cancer Treatment in the Midwestern United States

BACKGROUND

Despite evidence of superior outcomes for rectal cancer at high-volume, multidisciplinary cancer centers, many patients undergo surgery in low-volume hospitals.

OBJECTIVE

This study aimed to examine considerations of former patients with rectal cancer when selecting their surgeon and to evaluate which considerations were associated with surgery at high-volume hospitals.

DESIGN

In this retrospective cohort study, patients were surveyed about what they considered when selecting a cancer surgeon.

SETTINGS

Study data were obtained via survey and the statewide Iowa Cancer Registry.

PATIENTS

All eligible individuals diagnosed with invasive stages II/III rectal cancer from 2013 to 2017 identified through the registry were invited to participate.

MAIN OUTCOME MEASURES

The primary outcomes were the characteristics of the hospital where they received surgery (ie, National Cancer Institute designation, Commission on Cancer accreditation, and rectal cancer surgery volume).

RESULTS

Among respondents, 318 of 417 (76%) completed surveys. Sixty-nine percent of patients selected their surgeon based on their physician's referral/recommendation, 20% based on surgeon/hospital reputation, and 11% based on personal connections to the surgeon. Participants who chose their surgeon based on reputation had significantly higher odds of surgery at National Cancer Institute-designated (OR 7.5; 95% CI, 3.8-15.0) or high-volume (OR 2.6; 95% CI, 1.2-5.7) hospitals than those who relied on referral.

LIMITATIONS

This study took place in a Midwestern state with a predominantly white population, which limited our ability to evaluate racial/ethnic associations.

CONCLUSION

Most patients with rectal cancer relied on referrals in selecting their surgeon, and those who did were less likely to receive surgery at a National Cancer Institute-designated or high-volume hospitals compared to those who considered reputation. Future research is needed to determine the impact of these decision factors on clinical outcomes, patient satisfaction, and quality of life. In addition, patients should be aware that relying on physician referral may not result in treatment from the most experienced or comprehensive care setting in their area. See Video Abstract at http://links.lww.com/DCR/B897.REMISIONES Y CONSIDERACIONES PARA LA TOMA DE DECISIONES RELACIONADAS CON LA SELECCIÓN DE UN CIRUJANO PARA EL TRATAMIENTO DEL CÁNCER DE RECTO EN EL MEDIO OESTE DE LOS ESTADOS UNIDOSANTECEDENTES:A pesar de la evidencia de resultados superiores para el tratamiento del cáncer de recto en centros oncológicos de gran volumen y multidisciplinarios, muchos pacientes se someten a cirugía en hospitales de bajo volumen.OBJETIVOS:Examinar las consideraciones de los antiguos pacientes con cáncer de recto al momento de seleccionar a su cirujano y evaluar qué consideraciones se asociaron con la cirugía en hospitales de gran volumen.DISEÑO:Encuestamos a los pacientes sobre qué aspectos consideraron al elegir un cirujano oncológico para completar este estudio de cohorte retrospectivo.AJUSTE:Los datos del estudio se obtuvieron mediante una encuesta y el Registro de Cáncer del estado de Iowa.PACIENTES:Se invitó a participar a todas las personas elegibles diagnosticadas con cáncer de recto invasivo en estadios II/III entre 2013 y 2017 identificadas a través del registro.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados principales fueron las características del hospital donde fue realizada la cirugía (es decir, designación del Instituto Nacional del Cáncer, acreditación de la Comisión de Cáncer y volumen de cirugía del cáncer de recto).RESULTADOS:Hubo 318 de 417 (76%) encuestas completadas. El sesenta y nueve por ciento seleccionó a su cirujano en función de la referencia / recomendación de su médico, el 20% por la reputación del cirujano/hospital, y el 11% por sus conexiones personales con el cirujano. Los participantes que eligieron a su cirujano en función a la reputación tuvieron probabilidades significativamente más altas de cirugía en el Instituto Nacional del Cáncer designado (OR = 7,5, IC del 95%: 3,8-15,0) o en hospitales de alto volumen (OR = 2,6, IC del 95%: 1,2-5,7) que aquellos que dependían de la derivación.LIMITACIONES:Este estudio se llevó a cabo en un estado del medio oeste con una población predominantemente blanca, lo que limitó nuestra capacidad para evaluar las asociaciones raciales/étnicas.CONCLUSIONES:La mayoría de los pacientes con cáncer de recto dependían de las derivaciones para seleccionar a su cirujano, y los que lo hacían tenían menos probabilidades de recibir cirugía en un hospital designado por el Instituto Nacional del Cáncer o en hospitales de gran volumen en comparación con los que consideraban la reputación. Se necesitan investigaciones a futuro para determinar el impacto de estos factores de decisión en los resultados clínicos, la satisfacción del paciente y la calidad de vida. Además, los pacientes deben ser conscientes de que depender de la remisión de un médico puede no resultar en el tratamiento más experimentado o integral en su área. Consulte Video Resumen en http://links.lww.com/DCR/B897. (Traducción-Dr Osvaldo Gauto).

Laparoscopic vs. open resection for colon cancer‑quality of oncologic resection evaluation in a medium volume center

Despite concerns regarding oncologic safety, laparoscopic surgery for colon cancer has been proven in several trials in the lasts decades to be superior to open surgery. In addition, the benefits of laparoscopic surgery can be offered to other patients with malignant disease. The aim of the present study was to compare the quality of oncologic resection for non-metastatic, resectable colon cancer between laparoscopic and open surgery in terms of specimen margins and retrieved lymph nodes in a medium volume center in Romania. A total of 219 patients underwent surgery for non-metastatic colon cancer between January 2017 and December 2020. Of these, 52 underwent laparoscopic resection, while 167 had open surgery. None of the patients in the laparoscopic group had positive circumferential margins (P=0.035) while 12 (7.19%) patients in the open group (OG) had positive margins. A total of three patients in the laparoscopic group (5.77%) and seven patients (4.19%) in the OG had invaded axial margins. While the number of retrieved lymph nodes was not correlated with the type of procedure [laparoscopic group 16.12 (14±6.56), OG 17.31 (15±8.42), P=0.448], the lymph node ratio was significantly higher in the OG (P=0.003). Given the results of the present study, it is safe to conclude that laparoscopic surgery is not inferior to open surgery for non-metastatic colon cancer in a medium volume center.

Race-based disparities in access to surgical palliation for hypoplastic left heart syndrome

BACKGROUND

Racial disparities in outcomes have been shown to persist in many operative specialties, including the management of congenital heart disease. Using a demographic-adjusted methodology, we examined whether patient race influenced access to high-performing centers for the operative management of hypoplastic left heart syndrome.

METHODS

The 2005-2017 National Inpatient Sample was queried to identify all pediatric (≤5 years) hospitalizations with an operation for hypoplastic left heart syndrome. A racial disparity index was generated for each hospital and defined as the proportion of White patients receiving operative management for hypoplastic left heart syndrome divided by the proportion of White patients admitted for respiratory failure. This methodology quantified hospital-level racial variation while adjusting for the local racial makeup of each center.

RESULTS

Of the 17,275 patients who met inclusion criteria, 64.1% were managed at high-volume centers. Patients at high-volume centers had a similar distribution of operative type, age, and burden of comorbidities. The mean racial disparity index steadily grew from 1.06 at the lowest volume decile of operative volume to 1.51 at the highest, indicating an increasing proportion of White patients as volume increased. Using risk-adjusted analysis, each decile increase in hospital volume was associated with a 14% relative reduction in odds of mortality and a 0.06 increase in predicted racial disparity index. Increasing volume was further associated with reduced odds of non-home discharge but did not alter resource utilization.

CONCLUSION

We demonstrate that high-volume centers disproportionally serve White patients and have superior clinical outcomes compared to low-volume centers. This study highlights the critical importance of equitable access to expert care for high-risk conditions such as hypoplastic left heart syndrome.