Article

Influence of hospital- and surgeon-related factors on outcome after treatment of rectal cancer with or without preoperative radiotherapy

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Abstract

Background Preoperative radiotherapy reduces recurrence rates after surgery for rectal cancer but other variables may also affect outcome. The Stockholm Rectal Cancer Study Group has conducted two prospective randomized trials on preoperative radiotherapy in rectal cancer. Methods This study analysed postoperative morbidity and mortality, local recurrence rate and death from rectal cancer in 1399 patients, according to different hospital- and surgeon-related factors. Results Patients operated on by surgeons who were certified specialists for at least 10 years had a lower risk of local recurrence (relative risk 0.8 (95 per cent confidence interval (c.i.) 0.6-1.0)) and death from rectal cancer (relative risk 0.8 (95 per cent c.i. 0.7-0.9)). The risk was also lower for patients operated on in university hospitals (relative risk of local recurrence 0.7 (95 per cent c.i. 0.5-0.9), relative risk of death from rectal cancer 0.8 (95 per cent c.i. 0.7-1.0)) compared with community hospitals, although the results in some community hospitals were similar to those in university hospitals. The proportional reduction of local recurrence rate after preoperative radiotherapy was not significantly different for the studied institutions and surgeons. Conclusion There was a significant surgeon-related variation in patient outcome, which is probably related to the surgical technique. Although improved technique may reduce the local recurrence rate, preoperative radiotherapy is still beneficial concerning local control and survival.

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... 14,15 Surgeon experience was classified categorically according to number of years since starting their head and neck oncology fellowship (<10 and ≥ 10 years), based on a surgeon experience study in colorectal surgery. 16 The number of free flaps per center were divided into low to medium volume (0-30/year) and high volume (>30/year). 17 ...
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Purpose Reorganisation of cancer services in the UK and across Europe has led to elective surgery for colon cancer being increasingly, but not exclusively, delivered by specialist colorectal surgeons. This study examines survival after elective colon cancer surgery performed by specialist compared to non-specialist surgeons. Method Patients undergoing elective surgery for colon cancer in 16 hospitals between 2001 and 2004 were identified from a prospectively maintained regional audit database. Post-operative mortality (
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Chapter
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Article
Background: This is an update of the original review published in 2007.Carcinoma of the rectum is a common malignancy, especially in high income countries. Local recurrence may occur after surgery alone. Preoperative radiotherapy (PRT) has the potential to reduce the risk of local recurrence and improve outcomes in rectal cancer. Objectives: To determine the effect of preoperative radiotherapy for people with localised resectable rectal cancer compared to surgery alone. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; Issue 5, 2018) (4 June 2018), MEDLINE (Ovid) (1950 to 4 June 2018), and Embase (Ovid) (1974 to 4 June 2018). We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for relevant ongoing trials (4 June 2018). Selection criteria: We included randomised controlled trials comparing PRT and surgery with surgery alone for people with localised advanced rectal cancer planned for radical surgery. We excluded trials that did not use contemporary radiotherapy techniques (with more than two fields to the pelvis). Data collection and analysis: Two review authors independently assessed the 'Risk of bias' domains for each included trial, and extracted data. For time-to-event data, we calculated the Peto odds ratio (Peto OR) and variances, and for dichotomous data we calculated risk ratios (RR) using the random-effects method. Potential sources of heterogeneity hypothesised a priori included study quality, staging, and the use of total mesorectal excision (TME) surgery. Main results: We included four trials with a total of 4663 participants. All four trials reported short PRT courses, with three trials using 25 Gy in five fractions, and one trial using 20 Gy in four fractions. Only one study specifically required TME surgery for inclusion, whereas in another study 90% of participants received TME surgery.Preoperative radiotherapy probably reduces overall mortality at 4 to 12 years' follow-up (4 trials, 4663 participants; Peto OR 0.90, 95% CI 0.83 to 0.98; moderate-quality evidence). For every 1000 people who undergo surgery alone, 454 would die compared with 45 fewer (the true effect may lie between 77 fewer to 9 fewer) in the PRT group. There was some evidence from subgroup analyses that in trials using TME no or little effect of PRT on survival (P = 0.03 for the difference between subgroups).Preoperative radiotherapy may have little or no effect in reducing cause-specific mortality for rectal cancer (2 trials, 2145 participants; Peto OR 0.89, 95% CI 0.77 to 1.03; low-quality evidence).We found moderate-quality evidence that PRT reduces local recurrence (4 trials, 4663 participants; Peto OR 0.48, 95% CI 0.40 to 0.57). In absolute terms, 161 out of 1000 patients receiving surgery alone would experience local recurrence compared with 83 fewer with PRT. The results were consistent in TME and non-TME studies.There may be little or no difference in curative resection (4 trials, 4673 participants; RR 1.00, 95% CI 0.97 to 1.02; low-quality evidence) or in the need for sphincter-sparing surgery (3 trials, 4379 participants; RR 0.99, 95% CI 0.94 to 1.04; I2 = 0%; low-quality evidence) between PRT and surgery alone.Low-quality evidence suggests that PRT may increase the risk of sepsis from 13% to 16% (2 trials, 2698 participants; RR 1.25, 95% CI 1.04 to 1.52) and surgical complications from 25% to 30% (2 trials, 2698 participants; RR 1.20, 95% CI 1.01 to 1.42) compared to surgery alone.Two trials evaluated quality of life using different scales. Both studies concluded that sexual dysfunction occurred more in the PRT group. Mixed results were found for faecal incontinence, and irradiated participants tended to resume work later than non-irradiated participants between 6 and 12 months, but this effect had attenuated after 18 months (low-quality evidence). Authors' conclusions: We found moderate-quality evidence that PRT reduces overall mortality. Subgroup analysis did not confirm this effect in people undergoing TME surgery. We found consistent evidence that PRT reduces local recurrence. Risk of sepsis and postsurgical complications may be higher with PRT.The main limitation of the findings of the present review concerns their applicability. The included trials only assessed short-course radiotherapy and did not use chemotherapy, which is widely used in the contemporary management of rectal cancer disease. The differences between the trials regarding the criteria used to define rectal cancer, staging, radiotherapy delivered, the time between radiotherapy and surgery, and the use of adjuvant or postoperative therapy did not appear to influence the size of effect across the studies.Future trials should focus on identifying participants that are most likely to benefit from PRT especially in terms of improving local control, sphincter preservation, and overall survival while reducing acute and late toxicities (especially rectal and sexual function), as well as determining the effect of radiotherapy when chemotherapy is used and the optimal timing of surgery following radiotherapy.
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Article
BACKGROUND Improving quality and effectiveness of healthcare is one of the priorities of health policies. Hospital or physician volume represents a measurable variable with an impact on effectiveness of healthcare. An Italian law calls for the definition of «qualitative, structural, technological, and quantitative standards of hospital care». There is a need for an evaluation of the available scientific evidence in order to identify qualitative, structural, technological, and quantitative standards of hospital care, including the volume of care above or below which the public and private hospitals may be accredited (or not) to provide specific healthcare interventions. OBJECTIVES To identify conditions/interventions for which an association between volume and outcome has been investigated. To identify conditions/interventions for which an association between volume and outcome has been proved. To analyze the distribution of Italian health providers by volume of activity. To measure the association between volume of care and outcomes of the health providers of the Italian National Health Service (NHS). METHODS Systematic review An overview of systematic reviews was performed searching PubMed, EMBASE, and The Cochrane Library up to November 2016. Studies were evaluated by 2 researchers independently; quality assessment was performed using the AMSTAR checklist. For each health condition and outcome, if available, total number of studies, participants, high volume cut-off values, and metanalysis have been reported. According to the considered outcomes, health topics were classified into 3 groups: positive association: a positive association was demonstrated in the majority of studies/participants and/or a pooled measure (metanalysis) with positive results was reported; lack of association: both studies and/or metanalysis showed no association; no sufficient evidence of association: both results of single studies and metanalysis do not allow to draw firm conclusions on the association between volume and outcome. Analysis of the distribution of Italian hospitals by volume of activity and the association between volume of activity and outcomes: the Italian National Outcome evaluation Programme 2016 The analyses were performed using the Hospital Information System and the National Tax Register (year 2015). For each condition, the number of hospitals by volume of activity was calculated. Hospitals with a volume lower than 3-5 cases/year were excluded. For conditions with more than 1,500 cases/year and frequency of outcome ≥1%, the association between volume of care and outcome was analyzed estimating risk-adjusted outcomes. RESULTS Bibliographic searches identified 80 reviews, evaluating 48 different clinical areas. The main outcome considered was intrahospital/30-day mortality. The other outcomes vary depending on the type of condition or intervention in study. The relationship between hospital volume and outcomes was considered in 47 out of 48 conditions: 34 conditions showed evidence of a positive association; • 14 conditions consider cancer surgery for bladder, breast, colon, rectum, colon rectum, oesophagus, kidney, liver, lung, ovaries, pancreas, prostate, stomach, head and neck; • 11 conditions consider cardiocerebrovascular area: nonruptured and ruptured abdominal aortic aneurysm, acute myocardial infarction, brain aneurysm, carotid endarterectomy, coronary angioplasty, coronary artery bypass, paediatric heart surgery, revascularization of lower limbs, stroke, subarachnoid haemorrhage; • 2 conditions consider orthopaedic area: knee arthroplasty, hip fracture; • 7 conditions consider other areas: AIDS, bariatric surgery, cholecystectomy, intensive care unit, neonatal intensive care unit, sepsis, and traumas; for 3 conditions, no association was demonstrated: hip arthroplasty, dialysis, and thyroidectomy. for the remaining 10 conditions, the available evidence does not allow to draw firm conclusions about the association between hospital volume and considered outcomes: surgery for testicular cancer and intracranial tumours, paediatric oncology, aortofemoral bypass, cardiac catheterization, appendectomy, colectomy, inguinal hernia, respiratory failure, and hysterectomy. The relationship between volume of clinician/surgeon and outcomes was assessed only through the literature re view; to date, it is not possible to analyze this association for Italian health provider hospitals, since information on the clinician/surgeon on the hospital discharge chart is missing. The literature found a positive association for 21 conditions: 9 consider surgery for cancer: bladder, breast, colon, colon rectum, pancreas, prostate, rectum, stomach, and head and neck; 5 consider the cardiocerebrovascular area: ruptured and nonruptured abdominal aortic aneurysm, carotid endarterectomy, paediatric heart surgery, and revascularization of the lower limbs; 2 consider the orthopaedic area: knee and hip arthroplasty; 5 consider other areas: AIDS, bariatric surgery, hysterectomy, intensive care unit, and thyroidectomy. The analysis of the distribution of Italian hospitals concerned the 34 conditions for which the systematic review has shown a positive volume-outcome association. For the following, it was possible to conduct the analysis of the association using national data: unruptured abdominal aortic aneurysm, coronary angioplasty, hip arthroplasty, knee arthroplasty, coronary artery bypass, cancer surgery (colon, liver, breast, pancreas, lung, prostate, kidney, and stomach), laparoscopic cholecystectomy, hip fracture, stroke, acute myocardial infarction. For these conditions, the association between volume and outcome of care was observed. For laparoscopic cholecystectomy and surgery of the breast and stomach cancer, the association between the volume of the discharge (o dismissal) operating unit and the outcome was analyzed. The outcomes differ depending on the condition studied. The shape of the relationship is variable among different conditions, with heterogeneous slope of the curves. DISCUSSION For many conditions, the overview of systematic reviews has shown a strong evidence of association between higher volumes and better outcomes. The quality of the available reviews can be considered good for the consistency of the results between the studies and for the strength of the association; however, this does not mean that the included studies are of good quality. Analyzing national data, potential confounders, including age and comorbidities, have been considered. The systematic review of the literature does not permit to identify predefined volume thresholds. The analysis of national data shows a strong improvement in outcomes in the first part of the curve (from very low to higher volumes) for most conditions. In some cases, the improvement in outcomes remains gradual or constant with the increasing volume of care; in other, the analysis could allow the identification of threshold values beyond which the outcome does not further improve. However, a good knowledge of the relationship between effectiveness of treatments and costs, the geographical distribution and the accessibility to healthcare services are necessary to choose the minimum volumes of care, under which specific health procedures could not been provided in the NHS. Some potential biases due to the use of information systems data should also be considered. The different way of coding among hospitals could lead to a different selection of cases for some conditions. Regarding the definition of the exposure (volume of care), a possible bias could result from misclassification of health providers with high volume of activity. Performing the intervention in different departments/ units of the same hospital would result in an overestimation of the volume of care measured for hospital rather than for department/unit. For the conditions with a further fragmentation within the same structure, the association between volumes of discharge department and outcomes has also been evaluated. In this case, the two curves were different. The limit is to attribute the outcome to the discharge unit, which in case of surgery may not be the intervention unit. A similar bias could occur if the main determinant of the outcome of treatment was the caseload of each surgeon. The results of the analysis may be biased when different operators in the same hospital/unit carried out the same procedure. In any case, the observed association between volumes and outcome is very strong, and it is unlikely to be attributable to biases of the study design. Another aspect on which there is still little evidence is the interaction between volume of the hospital and of the surgeon. A MEDICARE study suggests that in some conditions, especially for specialized surgery, the effect of the surgeon's volume of activity is different depending on the structure volume, whereas it would not differ for some less specialized surgery conditions. The data here presented still show extremely fragmented volumes of both clinical and surgical areas, with a predominance of very low volume structures. Health systems operate, by definition, in a context of limited resources, especially when the amount of resources to allocate to the health system is reduced. In such conditions, the rationalization of the organization of health services based on the volume of care may make resources available to improve the effectiveness of interventions. The identification and certification of services and providers with high volume of activity can help to reduce differences in the access to non-effective procedures. To produce additional evidence to guide the reorganization of the national healthcare system, it will be necessary to design further primary studies to evaluate the effectiveness and safety of policies aimed at concentrating interventions in structures with high volumes of activity.
Chapter
Spinal cord stimulation (SCS) requires training to maximize its therapeutic effect and minimize surgical risks to the patients. Learning through the observation and operation in the operating room (OR) has been the majority of surgical training, which has faced many issues, including patient safety, work hour limitations, and cost of OR time. SCS has been developed as an established treatment for chronic neuropathic pain. Proper electrode insertion is one of the most important technical parts of SCS approach, which is related to a good outcome of patients. However, high levels of functioning in these patients with chronic pain have prevented hands-on training for surgeons. Simulation-based surgical training provides an opportunity to teach surgeons and allow them to practice surgical procedures outside the OR in high-quality and time-effective manner. This chapter focuses on the simulation of SCS procedure for treatment of chronic neuropathic pain.
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Background: Numerous hospitals worldwide are considering setting minimum volume standards for colorectal surgery. This study aims to examine the association between hospital and surgeon volume on outcomes for colorectal surgery. Methods: Two investigators independently reviewed six databases from inception to May 2016 for articles that reported outcomes according to hospital and/or surgeon volume. Eligible studies included those in which assessed the association hospital or surgeon volume with outcomes for the surgical treatment of colon and/or rectal cancer. Random effects models were used to pool the hazard ratios (HRs) for the association between hospital/surgeon volume with outcomes. Results: There were 47 articles pooled (1,122,303 patients, 9,877 hospitals and 9,649 surgeons). The meta-analysis demonstrated that there is a volume-outcome relationship that favours high volume facilities and high volume surgeons. Higher hospital and surgeon volume resulted in reduced 30-day mortality (HR: 0.83; 95% CI: 0.78-0.87, P<0.001 & HR: 0.84; 95% CI: 0.80-0.89, P<0.001 respectively) and intra-operative mortality (HR: 0.82; 95% CI: 0.76-0.86, P<0.001 & HR: 0.50; 95% CI: 0.40-0.62, P<0.001 respectively). Post-operative complication rates depended on hospital volume (HR: 0.89; 95% CI: 0.81-0.98, P<0.05), but not surgeon volume except with respect to anastomotic leak (HR: 0.59; 95% CI: 0.37-0.94, P<0.01). High volume surgeons are associated with greater 5-year survival and greater lymph node retrieval, whilst reducing recurrence rates, operative time, length of stay and cost. The best outcomes occur in high volume hospitals with high volume surgeons, followed by low volume hospitals with high volume surgeons. Conclusions: High volume by surgeon and high volume by hospital are associated with better outcomes for colorectal cancer surgery. However, this relationship is non-linear with no clear threshold of effect being identified and an apparent ceiling of effect.
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Background: Anastomotic leak (AL) increases costs and cancer recurrence. Studies show decreased AL with side-to-side stapled anastomosis (SSA), but none identify risk factors within SSAs. We hypothesized that stapler characteristics and closure technique of the common enterotomy affect AL rates. Methods: Retrospective review of bowel SSAs was performed. Data included stapler brand, staple line oversewing, and closure method (handsewn, HC; linear stapler [Barcelona technique], BT; transverse stapler, TX). Primary endpoint was AL. Statistical analysis included Fisher's test and logistic regression. Results: 463 patients were identified, 58.5% BT, 21.2% HC, and 20.3% TX. Covidien staplers comprised 74.9%, Ethicon 18.1%. There were no differences between stapler types (Covidien 5.8%, Ethicon 6.0%). However, AL rates varied by common side closure (BT 3.7% vs. TX 10.6%, p = 0.017), remaining significant on multivariate analysis. Conclusion: Closure method of the common side impacts AL rates. Barcelona technique has fewer leaks than transverse stapled closure. Further prospective evaluation is recommended.
Article
Aim: There is wide disparity in the care of patients with multi-visceral involvement of rectal cancer. The results of treatment of advanced and recurrent colorectal cancer are presented from a centre where a dedicated Multidisciplinary Team (MDT) is central to the management. Method: All consecutive MDT referrals between 2010 and 2014 were examined. Analysis was undertaken of the referral pathway, site, selection process, management decision, R0 resection rate, mortality / morbidity / Clavien-Dindo (CD) classification of morbidity, length of stay (LOS), and improvement of quality of life. Results: There were 954 referrals. These included locally advanced primary rectal cancer (LAPRC b-TME) [39.0%], rectal recurrence (RR) [22.0%], locally advanced primary colon cancer (LAPCC T3c/d-T4) [21.1%], colon cancer recurrence (CR) 12.4%, locally advanced primary anal cancer (LAPAC-failure of CRT/ T3c/d-T4) [3.0%] and anal cancer recurrence (AR) [2.2%]. Among these patients 271 operations were performed, 212 primary and 59 for recurrence. These included 16 sacrectomies, 134 total pelvic exenterations) and 121 other multi-visceral exenterative procedures. An R0 resection (no microscopic margin involvement) was achieved in 94.4% and R1 (microscopic margin involvement) in 5.1%. In LAPRC b-TME the R0 rate was 96.1% and for RR it was 79%. The length of stay (LOS) varied from 13.3-19.9 days. RR operations had the highest morbidity (Clavien-Dindo [CD] 1-2 33.3%) and LAPRC operations had the highest rate of CD 3-4 complications (18.4%). Most (39.6%) of the referred patients were from other UK hospitals CONCLUSION: Advanced colorectal cancer can be successfully treated in a dedicated referral centre, achieving R0 resection in over 90% with low morbidity and mortality. Implementation of a standardised referral pathway is encouraged. This article is protected by copyright. All rights reserved.
Article
Objective: Systematic review of the effect of intraoperative technical performance on patient outcomes. Background: The operating room is a high-stakes, high-risk environment. As a result, the quality of surgical interventions affecting patient outcomes has been the subject of discussion and research for years. Methods: MEDLINE, EMBASE, PsycINFO, and Cochrane databases were searched. All surgical specialties were eligible for inclusion. Data were reviewed in regards to the methods by which technical performance was measured, what patient outcomes were assessed, and how intraoperative technical performance affected patient outcomes. Quality of evidence was assessed using the Medical Education Research Study Quality Instrument (MERSQI). Results: Of the 12,758 studies initially identified, 24 articles (7775 total participants) were ultimately included in this review. Seventeen studies assessed the performance of the faculty alone, 2 assessed both the faculty and trainees, 1 assessed trainees alone, and in 4 studies, the level of the operating surgeon was not specified. In 18 studies, a performance assessment tool was used. Patient outcomes were evaluated using intraoperative complications, short-term morbidity, long-term morbidity, short-term mortality, and long-term mortality. The average MERSQI score was 11.67 (range 9.5-14.5). Twenty-one studies demonstrated that superior technical performance was related to improved patient outcomes. Conclusions: The results of this systematic review demonstrated that superior technical performance positively affects patient outcomes. Despite this initial evidence, more robust research is needed to directly assess intraoperative technical performance and its effect on postoperative patient outcomes using meaningful assessment instruments and reliable processes.
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In the clinical setting, the term 'unwarranted variation' refers to variations in patient outcomes that cannot be explained by the patient's underlying illness or medical needs, or the dictates of evidence-based medicine. These types of variations persist even after adjusting for patient-specific factors. Unwarranted variation depends on a complex mix of disparities, including inequalities in access to appropriate care in a wide variety of geographical and cultural settings, in the uptake and application of clinical knowledge, in the prioritization and allocation of resources, and differences in organizational and professional culture. Nevertheless, unwarranted variation has been inexorably linked with clinical practice. Thus, awareness of the antecedents of unwarranted variations in clinical practice is strategically important. In this Perspective, we discuss these antecedents in colorectal cancer clinical care pathways with an emphasis upon the multidisciplinary team (MDT), and suggest pragmatic steps that could be taken to address latent unwarranted variation.
Chapter
The first successful operation for rectal cancer was performed by Lisfranc in 1826 (1). This consisted of excising the anus and rectum via the perineum, which resulted in the functional equivalent of a perineal colostomy. As surgical techniques improved and general anesthesia developed, more extensive resections were undertaken. However exposure to the upper rectum was limited, and in an attempt to improve access, Verneuil (1873) and Kocher (1876) excised the coccyx and portion of the sacrum. It was Kraske (1885), after whom the procedure was named, who introduced the posterior approach of resecting the rectum through the sacrum while preserving the anus and sphincter muscles (2).
Chapter
The grim surgical reality that accompanies colorectal cancer resection suggests that approximately 50% of patients who come to the surgeon with a contained malignancy have this cancer converted to a disseminated disease process. Flawed surgical technology causes a surgically induced dissemination of microscopic residual disease in a large percentage of patients. Inadequate exposure, imperfect hemostasis, inadequate lymphadenectomy, and qualitatively poor margins of excision lead to the spillage of cancer cells in 30–50% of patients. Minor technical changes in the surgical approach to this disease can make a great difference in survival. The goal of cancer surgery for large bowel cancer is complete clearance and containment. Surgeons must believe that they are the most important prognostic variables before finding the commitment required to modify the current surgical approach.
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The Spanish Rectal Cancer Project was established in 2006, inspired by the Norwegian Rectal Cancer Project. It consisted of an educational project aiming to introduce mesorectal excision surgery to surgeons, pathologists and radiologists to establish a network of the Spanish National Health Service in Spain. Methods: All hospitals covering a population area of at least 300,000 inhabitants and operating on more than 12 patients per year were invited to participate. The project was carried out similarly to the Norwegian one. Several “hands on” workshops were arranged yearly between 2006 and 2012. A central registry measured the effectiveness of the project with feedback to participating institutions of their own results compared with the national average. Results: The National Health System consists of 261 hospitals of which 103 were included in the project. Of these 23 were excluded due to non-compliance with data registration. Therefore, the analysis included results from 80 hospitals covering a geographical area with 19,329,992 inhabitants. From 2006 to 2015 a total of 14,815 patients had a curative resection. The postoperative mortality rate was 1.8%; postoperative complications were observed in 39.9% patients; 10% developed anastomotic leakage and 9% required reoperation. The outcomes observed in 3088 cancer patients who have completed a five-year follow-up were: 6.2% local recurrence, metastasis 18.8% and 73.5% overall survival. Conclusions: This project shows that the results obtained in Scandinavia have been reproduced in a larger population in Spain applying a similar methodology focused on the spread of competence and auditing of results.
Chapter
The quality of randomized trials is relevant for their respective evidence grade. Studies involving operative treatment must aim at precise description of procedures and high surgical quality. The overall quality of studies can be described in terms of planning, statistical analysis and presentation using sum scores.
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Despite of improvement of results in rectum cancer treatment after systematical introduction of total mesorectal excision as a standard procedure to control the compartment disease, surgical radicality may be limited in cases with large tumours in ventral position because of excentric location of the rectum in the perirectal fat. In these cases (neo)adjuvant treatment with a 45-54 Gy dose radiotherapy and 5 FU-based chemotherapy seems to be useful to minimize local recurrence and distant metastases and also to provide a better outcome.
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Background Previous studies have suggested that, following surgery for colorectal cancer, there are significant differences in outcome amongst surgeons. Methods The following measures of outcome in 1128 patients undergoing surgery for colorectal cancer were analysed on an individual surgeon basis: postoperative complications, postoperative mortality, local recurrence rates, survival and hazard ratios. Results The proportion of patients undergoing apparently curative resection varied among surgeons from 39% to 65%; overall postoperative mortality varied from 8% to 26%. After curative resection the anastomotic leak rate varied from 0% to 29%, postoperative mortality from 0% to 14% and local recurrence within 2 years from 5% to 26%. Survival at 5 years following curative resection varied from 22% to 61%; survival following palliative resection varied from 7% to 31% at 2 years. The hazard ratios for mortality, taking into account the identified risk factors, varied among individual surgeons from 0.54 to 1.79, from 0.39 to 1.57 and from 0.66 to 1.19 for curative resection, palliative resection and all cases respectively. Conclusion There mere significant surgeon-related variations in patient outcome; these variations in outcome need to be addressed if survival following colorectal cancer surgery is to improve.
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Three years after the consensus conference on the therapeutic options for rectal cancer, a recent litterature review gave us some decision elements. Quality of the surgical resection appears to be the most important therapeutic factor in the prognosis of rectal cancer. Total mesorectal excision was followed by a significant decrease of locoregional recurrence rate for the tumor of the two lower thirds of rectum. Tn this way, it has been shown that pelvic nerves can be easily preserved. Which nerves are important for a good postoperative sexual activity remains however debated. Furthermore, whether the nerve sparing techniques influence the prognosis is also a matter of controversy. On the other hand, abdominoperineal resection is still indicated in most lower tumors to prevent local recurrences. Preoperative radiation therapy appears more effective than the postoperative one to decrease postoperative local recurrence rate after B2 (Astler-Coller) or T3 (TNM) tumors. At present, only one study showed that preoperative radiation therapy improved five-year survival. Combination of radiotherapy and chemotherapy improves also five-year survival, but this option leads to high toxicity. Thus the best adjuvent treatment remains to be defined. Awaiting for this, the good quality of surgical resection is mandatory.
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The authors review the recent literature about total mesorectal excision for rectal cancer. They report the actual management of such patients.
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Criteria of surgical quality in oncological operations are: number of removed lymph nodes, perioperative complications, lethality, local recurrence rate, tumor stage related survival rate and the quality of life postoperatively. The length of the operation time as well as the length of the in hospital stay cannot be regarded - different to other surgical procedures - as quality parameters in oncological surgery. In order to guarantee a realistic financing of surgical interventions with a high quality standard the project "Operative Oncology" was initiated by the Department of Surgery University of Kiel in 1996. Therefore, the treatment costs for various oncological operations were calculated according to the Patient Management Path (PMP) system. Between 4/98 and 12/98 245 patients have been proceeded according to the evaluated comprehensive prices. The first intermediate evaluation of 130 cases showed that the calculated flat rates seem to be realistic.
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Introduction: surgeon influence on colorectal cancer surgery outcomes has been repeatedly studied in the scientific literature, but conclusions have been contradictory. Here we study whether surgeon specialization is a determinant factor for outcome in these patients. The importance of propensity scores (PS) in surgical research is also studied. Patients and methods: a retrospective study was performed and medical records were reviewed for 236 patients who were intervened for colon cancer in Castellon General Hospital (Spain). Cases were divided into two groups (specialist and non-specialist surgeons), and both 5-year surveillance and disease free survival were compared. Comparisons were first made with no adjustments, and then subsequently using PS analysis. Results: the initial (non-adjusted) analysis was clearly favourable for the specialist surgeon group (5-year surveillance, 64.3 us. 79.3%, p = 0.028). After adjusting for PS no statistical significance was obtained. Conclusions: surgeon specialization had no significant impact on patient outcome after colon cancer surgery. Propensity score analysis is an important tool in the analysis of surgical non-randomized studies, particularly when events under scrutiny are rare.
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This chapter focuses on the recent and possible future developments in the management of adeno-carcinoma of the colon and rectum. Imaging techniques for accurate diagnosis and staging are discussed, together with the impact of neoadjuvant therapy and high-quality surgery on clinical outcomes. Topical issues including the role of super-specialisation and the importance of multidisciplinary teams are highlighted. An overview of laparoscopic and robotically assisted colorectal surgery is presented, with a progress report on emerging technologies such as image-enhanced surgery, natural orifice transluminal endoscopic surgery and biological targeting of chemotherapy regimens.
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It has been well documented that the cancer yield from 2-week-wait (2ww) colorectal referrals is low. Many patients diagnosed with colorectal cancer (CRC) are referred via non-2ww pathways. In the author's unit, 82% of colorectal cancers were diagnosed via routine pathways, some taking up to 6 months from referral to diagnosis. Therefore, in 2008, a colorectal telephone assessment pathway (CTAP) was introduced. Results show that the time to diagnosis decreased from 23 to 4 weeks, with high GP- And patient-satisfaction rates. This article describes how the CTAP was set up by the consultant nurse, and explores the issues involved and how they were addressed. It explains how results were achieved at no extra cost, and in reality, generated income. Development of this pathway has been proposed, but goes against existing Department of Health guidance. This is also explored, alongwith the dissemination work underway via an NHS Improving Quality initiative.
Chapter
This chapter provides a comprehensive overview of essential concepts relating to the operative approach and strategy for colon and rectal surgery. Diverticula may be true, containing all layers of the colon wall, or false, lacking the muscular layer of the colon wall. In North America, almost all colonic diverticula are acquired, false pulsion diverticula that most frequently affect the sigmoid colon. Thirty-five percent of patients will also have more proximal colonic diverticula, and a minority will have pancolonic diverticulosis. Prevalence correlates with age and geographic location; approximately 30 % of adults living in industrialized countries will acquire diverticular disease by age 60 while up to 80 % of those aged 80 years and older are affected. The majority of patients with diverticular disease are asymptomatic; only 1 % of patients will eventually require surgery.
Article
This study aimed to investigate the outcome for stage II and III rectal cancer patients compared to stage II and III colonic cancer patients with regard to 5-year cause-specific survival (CSS), overall survival, and local and combined recurrence rates over time. This prospective cohort study identified 3,355 consecutive patients with adenocarcinoma of the colon or rectum and treated in our colorectal unit between 1981 and 2011, for investigation. The study was restricted to International Union Against Cancer (UICC) stages II and III. Postoperative mortality and histological incomplete resection were excluded, which left 995 patients with colonic cancer and 726 patients with rectal cancer for further analysis. Five-year CSS rates improved for colonic cancer from 65.0 % for patients treated between 1981 and 1986 to 88.1 % for patients treated between 2007 and 2011. For rectal cancer patients, the respective 5-year CSS rates improved from 53.4 % in the first observation period to 89.8 % in the second one. The local recurrence rate for rectal cancer dropped from 34.2 % in the years 1981-1986 to 2.1 % in the years 2007-2011. In the last decade of observation, prognosis for rectal cancer was equal to that for colon cancer (CSS 88.6 vs. 86.7 %, p = 0.409). Survival of patients with colon and rectal cancer has continued to improve over the last three decades. After major changes in treatment strategy including introduction of total mesorectal excision and neoadjuvant (radio)chemotherapy, prognosis for stage II and III rectal cancer is at least as good as for stage II and III colonic cancer.
Article
A positive circumferential resection margin has been associated with a high risk of local recurrence and a decrease in survival in patients who have rectal cancer. The purpose of this study was to analyze the involvement of circumferential resection margin in local recurrence and survival in a multidisciplinary population-based setting by using tailored oncological therapy and surgery with total mesorectal excision. Data were collected in a prospective database and retrospectively analyzed. Between 1996 and 2009, 448 patients with rectal cancer underwent a curative bowel resection. Population-based data were collected at a single institution in the county of Västmanland, Sweden. Preoperative radiotherapy was delivered to 334 patients (74%); it was delivered to 35 patients (8%) concomitantly with preoperative chemotherapy. In 70 patients (16%), en bloc resections of the prostate and vagina were performed. Intraoperative perforations were seen in 7 patients (1.6%). The mesorectal fascia was assessed as complete in 117/118 cases. In 32 cases (7%), the circumferential resection margin was 1 mm or less. After a median follow-up of 68 months, 5 (1.1%) patients developed a local recurrence; one of them had circumferential resection margin involvement. The 5-year overall survival was 77%. In the multivariate analysis, the circumferential resection margin was not an independent factor for disease-free survival. Mesorectal fascia was not assessed before 2007. The findings might be explained by a type II error but, from a clinical perspective, enough patients were included to motivate the conclusion of the study. Circumferential resection margin is an important measurement in rectal cancer pathology, but the correlation to local recurrence is much less than previously stated, probably because of oncological treatment and surgery that respects the mesorectal fascia and, when required, en bloc resections. Circumferential resection margin should not be used as a prognostic marker in the modern multidisciplinary management of rectal cancer.
Article
Objective: To review a single-center experience with 201 multivisceral resections for primary colorectal cancer to determine the accuracy of intraoperative prediction of potential curability, to identify prognostic factors, and to examine the effect of surgical experience on immediate outcome and long-term results. Summary Background Data: Locally advanced colorectal cancer may require an intraoperative decision for en bloc resection of surrounding organs or structures to achieve complete tumor removal. This decision must weigh the risk of complications and death of multivisceral resection against a potential survival benefit. Little is known about prognostic factors and the influence of surgical experience on the outcome of multivisceral resection for colorectal cancer. Methods: Patients undergoing multivisceral resection for primary colon or rectal cancer between 1982 and 1998 were identified from a prospective database. Patients were followed up according to a standard protocol. Results: Multivisceral resection was performed in 201 of 2,712 patients with a median age of 64 years. Postoperative rates of complications and death in 201 patients were 33% and 7.5%, respectively. A potentially curative resection was possible in 130 of 201 patients (65%) and histologic tumor infiltration was shown in 44% of patients with curative resection. Intraoperative assessment of curability was unreliable. After curative resection, the local recurrence rate was 11% and the overall 5-year survival rate was 51%. Multivariate analysis identified intraoperative blood loss (relative risk 1.7–6.4, P < .001), age 64 years or older (RR 3.7;P < .001), and UICC stage as independent prognostic factors (RR 2.0;P = .009). No prognostic significance was found for histologic tumor infiltration, the number of resected organs, or surgical experience. Conclusions: Multivisceral resection is safe, and long-term survival after curative resection is similar to that after standard resection. Because palliative resections cannot be predicted accurately at the time of surgery, every effort should be made to achieve complete tumor resection. Major blood loss but not surgical experience per se is an independent prognostic factor.
Article
The study objective was to evaluate the influence of surgeon experience on outcomes in early-stage non-small cell lung cancer. In an institutional database, patients undergoing operations for pathologic stage I non-small cell lung cancer were categorized by surgeon experience: within 5 years of completion of training, the low experience group; with 5 to 15 years of experience, the moderate experience group; and with more than 15 years, the high experience group. From 2000 to 2012, 800 operations (638 lobectomies, 162 sublobar resection) were performed with the following distribution: low experience 178 (22.2%), moderate experience 224 (28.0%), and high experience 398 (49.8%). Patients in the groups were similar in age and comorbidities. The use of video-assisted thoracoscopic surgery was higher in the moderate experience group (low experience: 62/178 [34.8%], moderate experience: 151/224 [67.4%], and high experience: 133/398 [33.4%], P < .001), as was the mean number of mediastinal (N2) lymph node stations sampled (low experience: 2.8 ± 1.6, moderate experience: 3.5 ± 1.7, high experience: 2.3 ± 1.4, P < .001). The risk of perioperative morbidity was similar across all groups (low experience: 54/178 [30.3%], moderate experience: 51/224 [22.8%], and high experience: 115/398 [28.9%], P = .163). Five-year overall survival in the moderate experience group was 76.9% compared with 67.5% in the low experience group (P < .001) and 71.4% in the high experience group (P = .006). In a Cox proportional hazard model, increasing age, male gender, prior cancer, and R1 resection were associated with an elevated risk of mortality, whereas being operated on by surgeons with moderate experience and having a greater number of mediastinal (N2) lymph node stations sampled were protective. The experience of the surgeon does not affect perioperative outcomes after resection for pathologic stage I non-small cell lung cancer. At least moderate experience after fellowship is associated with improved long-term survival. Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.
Article
There has been increasing interest in the assessment of surgeon effects for survival data of post-operative cancer patients. In particular, the measurement of surgeon's surgical performance after eliminating significant risk variables is considered. The generalized linear mixed model approach, which assumes a log-normal-distributed surgeon effects in the hazard function, is adopted to assess the random surgeon effects of post-operative colorectal cancer patients data. The method extends the traditional Cox's proportional hazards regression model, by including a random component in the linear predictor. Estimation is accomplished by constructing an appropriate log-likelihood function in the spirit of the best linear unbiased predictor method and extends to obtain residual maximum likelihood estimates. As a result of the non-proportionality of the hazard of colon and rectal cancer, the data are analyzed separately according to these two kinds of cancer. Significant risk variables are identified. The 'predictions' of random surgeon effects are obtained and their association with the rank of surgeon is examined.
Article
Background Sphincter preservation (SP) is an important goal of rectal cancer surgery. We hypothesized that SP rates among veteran patients have increased and are comparable to national rates, and that a subset of patients with early disease still undergo non-SP procedures. Methods Patients with nonmetastatic primary rectal adenocarcinoma who underwent curative-intent rectal resection were identified from the Veterans Affairs Central Cancer Registry (VACCR) database (1995–2010). SP trends over time were described and compared to the Surveillance, Epidemiology, and End-Results (SEER) population. Subset analysis was performed in patients with nonirradiated, pathologic stage 0–I rectal cancers, a population that may qualify for novel SP strategies. Results Of 5,145 study patients, 3,509 (68 %) underwent SP surgery. The VACCR SP rate increased from 59.9 % in 1995–1999 to 79.3 % in 2005–2010, when it exceeded that of SEER (76.9 %, p = 0.023). On multivariate analysis, recent time period was independently associated with higher likelihood of SP (odds ratio [OR] 2.64, p
Article
Between 1980 and 1985, 694 patients with clinically resectable rectal adenocarcinoma entered a controlled clinical trial of radiotherapy (25 Gy over 5-7 days) prior to surgery, as compared with surgery alone. At a median follow-up time of 34 months, the incidence of pelvic recurrence among 545 patients operated on "for cure" was significantly reduced in the radiotherapy group (p less than 0.01). The relative reduction rate was similar among patients with Dukes' A, B, and C tumors. No significant differences between the treatment groups were observed with regard to frequency of distant metastasis or survival. The postoperative mortality--defined as death within 30 days of surgery--was 7% in the radiotherapy group as compared to 2% in the group randomized to surgery only (p less than 0.01). This mortality mainly occurred among patients aged above 75 years, and the difference between the groups may have been due to the fact that the irradiated volume was fairly large. In younger patients, there was no significantly increased mortality with radiotherapy.
Article
From 1980 to 1987, 849 patients with clinically resectable rectal adenocarcinoma were randomized into a controlled clinical trial of radiation therapy (2500 cGy over 5 to 7 days) before surgery versus surgery alone. At a median follow-up time of 53 months (range, 8 to 90) the incidence of pelvic recurrence among 679 curatively operated upon patients was significantly lower among those allocated to radiation therapy (P < 0.01). A reduction was observed in all Dukes' stages. No significant difference between the treatment groups was observed with regard to frequency of distant metastases or overall survival. Among all randomized patients as well as the radically operated patients the recurrence-free interval, i.e., time to local recurrence or distant metastasis, was significantly prolonged in the preoperatively irradiated group. The radically operated patients also had a significantly prolonged survival related to rectal cancer (P = 0.05) The postoperative morbidity, however, was significantly higher among irradiated patients. The postoperative mortality was 8% in the radiation therapy group compared to 2% in the surgery alone group (P < 0.01).
Article
A randomized clinical trial was conducted by the European Organization for Research and Treatment for Cancer (EORTC) Gastrointestinal Cancer Cooperative Group to study the effectiveness of irradiation therapy administered in a dosage of 34.5 Gy, divided into 15 daily doses of 2.3 Gy each before radical surgery for rectal cancer (T2, T3, T4, NX, MO). Four hundred sixty-six patients were entered in the clinical trial between June 1976 and September 1981. Tolerance and side effects of pre- operative irradiation were acceptable. The overall 5-year survival rates were similar in both groups. When considering only the 341 patients treated by surgery with a curative aim, the 5-year survival rates were 59.1% and 69.1% in the control group and in the combined modality group, respectively (p = 0.08). The local recurrence rates at 5 years were 30% and 15% in the control group and the adjuvant radiotherapy group, respectively (p = 0.003). Although this study did not show preoperative radiotherapy to have a statistically significant benefit on overall survival, it does have a clear effect on local control of rectal cancer. Therefore, before performing radical surgery, this adjuvant therapy should be administered to patients who have locally extended rectal cancer.
Article
In this paper I review the early descriptions of what I take to be Crohn's disease, to suggest by bibliography and quotations from some of the early papers, that it is not a new disease of the twentieth century.
Article
Background. From 1980 to 1987, 849 patients with clinically resectable rectal adenocarcinoma were randomized into a controlled clinical trial to evaluate the role of preoperative radiotherapy.Methods. Patients were given either 25 Gy during 5 to 7 days before surgery or underwent surgery alone.Results. At a median follow-up time of 107 months (range, 62-144 months) the incidence of pelvic recurrence among 684 “curatively” operated patients was significantly lower among those who also received radiotherapy (P < 0.001) in all Dukes' stages. No significant difference was observed between the treatment groups with regard to frequency of distant metastases or overall survival. The time to local recurrence or distant metastasis and survival was significantly prolonged in the irradiated group. However, the postoperative mortality was 8% in the radiotherapy group compared with 2% in the surgery only group (P = 0.01).Conclusions. Preoperative short term radiotherapy reduced the incidence of pelvic recurrences and prolonged survival related to rectal cancer compared with surgery alone. The postoperative morbidity was significantly higher in the irradiated group.
Article
BACKGROUND Adjuvant preoperative radiotherapy of patients with primary rectal carcinoma improves local control and survival, but also may increase the risk of early postoperative morbidity and mortality. In addition, the possible late adverse effects of this treatment are largely unknown.METHODS The present study was based on 1027 curatively operated patients included in 2 prospective randomized trials of preoperative radiotherapy for rectal carcinoma patients (Stockholm I and Stockholm II Trials). The goal was to assess whether long term intercurrent morbidity and mortality were increased in patients allocated to the preoperative treatment. A computerized linkage of the randomized patients to a population-based registry of the Stockholm County Council was used to study hospital admissions for six groups of a priori defined diseases, putatively related to late adverse effects of the radiation.RESULTSPreoperative radiotherapy significantly increased the incidence of venous thromboembolism (P = 0.01), femoral neck and pelvic fractures (P = 0.03), intestinal obstruction (P = 0.02), and postoperative fistulas (P = 0.01). For arterial disease and genitourinary tract diseases, no difference in risk was found between irradiated and non irradiated patients. Radiotherapy significantly reduced rectal carcinoma deaths in both trials and also improved overall survival in the Stockholm II trial. The late intercurrent mortality was similar in irradiated and nonirradiated patients.CONCLUSIONS Although high dose, short term, preoperative radiotherapy can improve outcome after surgery for rectal carcinoma, there also may be an increased risk for long term morbidity. Refinement of the radiotherapy technique and a more accurate selection of patients suitable for the treatment will probably further improve the results, at least in regard to treatment-related complications. Cancer 1996;78:968-76.
Article
Background: A population based prospective randomized trial on preoperative radiotherapy in operable rectal cancer was conducted in Stockholm, Sweden. Five hundred fifty-seven patients from 12 institutions were included with histologically proven, clinically resectable rectal adenocarcinoma. Patients planned for local excision or previously irradiated to the pelvis were excluded. Methods: A total of 272 patients were allocated to preoperative irradiation with 25 Gy in five cycles during 5–7 days to the rectum and the pararectal tissues (RT+ group) and 285 patients were allocated to surgery only (RT− group). The median follow-up time was 50 months. No patient was lost to follow-up. Surgery was considered curative in 479 patients (86%). Results: Locoregional recurrence occurred in 10% of the patients in the RT+ group versus 21% in the RT− group (p<0.01). Among the curatively operated patients, distant metastases occurred in 19% in the RT+ group versus 26% in the RT− group (p=0.02). The overall survival was improved in the irradiated patients (p=0.02). Postoperative complications were more common after irradiation but were usually mild. The postoperative mortality was low in both groups. Conclusion: Preoperative short-term, high-dose radiotherapy as given in this trial reduces the risk of local and distant recurrence and improves survival after curative surgery for rectal carcinoma.
Article
PURPOSE: This study was designed to examine variations in operative mortality among surgical specialists who perform colorectal surgery. METHODS: Mortality rates were compared between six board-certified colorectal surgeons and 33 other institutional surgeons using comparable colorectal procedure codes and a validated database indicating patient severity of illness. Thirty-five ICD-9-CM procedure codes were used to identify 2,805 patients who underwent colorectal surgery as their principal procedure between July 1986 and April 1994. Atlas, a state-legislated outcome database, was used by the hospital's Quality Assurance Department to rank the Admission Severity Group (ASG) of 1,753 patients from January 1989 to April 1994 (higher ASG, 0 to 4, indicates increasing medical instability). RESULTS: Colorectal surgeons had an eight-year mean in-hospital mortality rate of 1.4 percent compared with 7.3 percent by other institutional surgeons (P=0.0001). There was a significantly lower mortality rate for colorectal surgeons compared with other institutional surgeons in ASG 2 (0.8 and 3.8 percent, respectively; P=0.026) and ASG 3 (5.7 and 16.4 percent, respectively; P=0.001). CONCLUSIONS: Board-certified colorectal surgeons had a lower in-hospital mortality rate than other institutional surgeons as patients' severity of illness increased.
Article
Current evidence would not support the notion that casevolume in itself is important for achieving good results in cancer surgery. It is, however, becoming increasingly clear that specialist interest is important, and it is not too difficult to guess at the reasons for this seeming paradox. In areas where surgical skill is paramount, such as in rectal cancer surgery, the specialist will be familiar with the relevant anatomy and techniques so that good results will be achieved, even though relatively small numbers of cancers may be treated. In conditions where a multi-disciplinary approach is vital, such as breast or ovarian cancer, the specialist surgeon will be acutely aware of the necessity for non-surgical forms of treatment. The generalist, on the other hand, may not appreciate the nuances of surgical technique or the availability of adjuvant therapy which are required to achieve the best results. Thus, despite a high case volume he or she might obtain suboptimal results, either through ignorance or through pure haste engendered by pressure of work.
Article
A retrospective study was conducted to determine the influence of subspecialty training in gynecologic oncology as well as several other covariates on the feasibility, operative mortality, and survival benefits of cytoreductive surgery for 263 patients with stages IIIC and IVA epithelial ovarian cancer. Covariates most predictive of an optimal (< or = 1 cm) cytoreductive outcome were the diameter of the largest metastases before cytoreduction (< or = 10 cm vs > 10 cm, P < 0.001) and the specialty training of the physicians present at surgery (gynecologic oncologists vs other, P < 0.001). Age influenced operative mortality most (< 60 vs > or = 60, P < 0.001). Covariates found to most significantly influence survival time include the specialty training of the physicians present at surgery (gynecologic oncologists vs other, P < 0.0001), cytoreductive outcome (complete vs optimal, P = 0.001, optimal vs suboptimal, P < 0.0001), grade of tumor (grade 1 vs grades 2 and 3, P = 0.01), and pelvic disease status (frozen pelvis vs mobile primary tumor, P = 0.03). We conclude that patients with advanced epithelial ovarian cancer should undergo aggressive cytoreductive surgery by gynecologic oncologists, with the objective to remove all macroscopic disease. Subsequent treatment with platinum-based chemotherapy offers the best chance for long-term survival or cure.
Article
A 7 1/2-year consecutive series is presented from a district hospital with a policy of referring all rectal carcinomas to one surgical firm. The performance of lower anterior resections has limited the rate of abdominoperineal excision with permanent colostomy to 11%. Of 115 patients in whom curative resection was attempted, 69 had anastomoses below 5 cm and 39 had mural resection margins of less than 2.5 cm. Surgical priority, however, was given to complete excision of the visceral rectal mesentery or mesorectum. At an average of 4.2 years postoperatively, three pelvic recurrences have developed but there have been no staple-line recurrences in patients who had "curative" surgery. The corrected cumulative probability of survival at 5 years is 87% and the tumour-free survival by Dukes stage is A 94%, B 87%, and C 58%. Patients with low tumours did no less well than those with high tumours, when treated by anterior resection. On this evidence, it is often safe to limit mural clearance and thus preserve the anal sphincters, provided that the mesorectum is excised intact with the cancer.
Article
1988 patients with an adenocarcinoma of the rectum (1292; 65 per cent) or rectosigmoid (696; 35 per cent) have been studied. A resection (1700 patients) or polypectomy (124 patients) was performed in 1824 (92 per cent) and, of the former, 1376 patients either underwent abdominoperineal (AP) excision of the rectum (788 patients) or an anterior resection (598 patients). The in-hospital mortality was 63 patients (8 per cent) for AP and 44 (7 per cent) for anterior resection, and a curative resection had been performed in 504 (71 per cent) of those undergoing an AP, and 393 (71 per cent) of those undergoing an anterior resection. Follow-up information is available for 478 patients (95 per cent) who underwent an AP and 370 (94 per cent) who underwent an anterior resection. More patients have developed a local recurrence after an anterior resection (67; 18 per cent) than after AP (57; 12 per cent) (Logrank χ2 = 6.6, d.f.=1, P<0.02) (stratified for sex and Dukes' stage). This difference is not accounted for by a lesser margin of distal clearance after an anterior resection; firstly because the margin of clearance was not different in those who did and those who did not develop a local recurrence (AP: whole group = 4.4 cm, local recurrence = 4.5 cm; anterior resection: whole group = 3.0 cm, local recurrence = 3.1 cm) and secondly because for each centimetre of distal clearance there was a consistently greater probability of recurrence for anterior resection (Logrank χ2 = 9.1, d.f. = 1, P<0.01) (stratified for sex, Dukes' stage and distal clearance margin).
Article
Five cases are described where minute foci of adenocarcinoma have been demonstrated in the mesorectum several centimetres distal to the apparent lower edge of a rectal cancer. In 2 of these there was no other evidence of lymphatic spread of the tumour. In orthodox anterior resection much of this tissue remains in the pelvis, and its is suggested that these foci might lead to suture-line or pelvic recurrence. Total excision of the mesorectum has, therefore, been carried out as a part of over 100 consecutive anterior resections. Fifty of these, which were classified as 'curative' or 'conceivably curative' operations, have now been followed for over 2 years with no pelvic or staple-line recurrence.
Article
A prospective randomised multicentre trial compared pre-operative radiotherapy followed by surgery with surgery alone for rectal cancer < or = 12 cm from the anal verge. Of 468 patients (mean age 67 years, range 31-94, 273 males) who met the entry criteria, 228 were randomised to radiotherapy (3 x 5 Gy over 5 days within 2 days of operation) followed by surgery, and 239 to surgery alone. Randomisation was unknown in 1 patient. Follow-up to death or 5 years was achieved in 454 (97%) patients. 31 (7%) of the 468 patients died within 30 days of operation (radiotherapy and surgery 21 [9%], surgery alone 10 [4%]; P < 0.05). Cardiovascular and thromboembolic complications were more common after radiotherapy and surgery (30, 13%) than after surgery alone (8, 3%; P < 0.005). Of the 280 patients who had curative surgery, 52% of those who had radiotherapy and surgery and 56% of those who had surgery alone survived 5 years (P = 0.88). 395 patients attended outpatients clinics at least once. Local treatment failure was identified during follow-up in 82 patients [31/185 (17%) radiotherapy and surgery; 51/210 (24%) surgery alone; P < 0.05]. It occurred in 33 of the 258 patients who had a curative resection and attended outpatients [radiotherapy and surgery, 11/120 (9%), surgery alone, 22/138 (16%); P = 0.08]. Long-term survival was unaffected, but long-term local recurrence was reduced by the addition of low-dose radiotherapy to surgery. Peri-operative mortality was, however, increased.
Article
In order to lower unacceptably high local failure rates after surgery reported as curative for rectal cancer, perioperative radiotherapy has been extensively investigated. The collected information from a number of controlled trials indicates that the proportion of local recurrences is reduced to less than half when radiotherapy at moderately high doses is given preoperatively. This reduction in local failure rates is not seen after postoperative radiotherapy, even if higher doses have been used. Possibly, there is also a slight positive influence on survival from preoperative radiotherapy. Improved survival has been seen also in trials using postoperative radiotherapy, but then only when combined with chemotherapy. With proper dose planning, sufficiently high doses can be given preoperatively with little if any increase in postoperative mortality. Thus, although published knowledge is still rather limited, a properly planned preoperative radiotherapy seems to inflict small bowel and other complication rates, that are less than when radiotherapy of similar efficacy against the tumour is given postoperatively.
Article
Evidence regarding the relationship between outcome and the number (volume) of patients treated at individual hospitals or by individual surgeons is reviewed and the interplay of other factors such as hospital characteristics, population profiles and referral preferences examined. An inverse relationship between mortality rate and hospital volume has repeatedly been found and, while there have been similar findings for surgeon volume, these results have been less consistent. What is certain is that wide variation in outcome does occur. What is less clear is whether the relationship to volume is a causal one or whether it is due to other factors such as those mentioned above. Despite there being a great deal that we do not understand about these relationships, considerable action has been taken as a result of the studies reported here, in the USA in particular. This has taken the form of rationalization of services, publication of hospital mortality rates and the setting of minimum numbers of specific procedures that should be performed each year by individual surgeons. Understanding of this area should be much greater before rationalization is considered in the name of higher quality and before mortality rates according to hospital or surgeon are published.
Article
Concern about world wide local recurrence rates for rectal cancer of 20-45%, together with anxiety at the recent proliferation of adjuvant therapies, led us to review the efficacy of total mesorectal excision (TME) with which no adjuvant therapy had been combined. Precise, sharp dissection is undertaken around the integral mesentery of the hind gut, which envelopes the entire mid rectum. This procedure adds to operative time and complications but has been claimed to eliminate virtually all locally recurrent disease after "curative" surgery. Independent analysis (J. K. M.) of prospective follow-up data extended over a 13-year interval (1978-91; mean 7.5 years). The actuarial local recurrence rate after curative anterior resection at 5 years is 4% (95% Cl 0-7.5%) and the overall recurrence rate is 18% (10-25%). 10-year figures are 4% (0-11%) and 19% (7-32%). In view of the high-risk classification used for the North Central Cancer Treatment Group (NCCTG), which has led to a trend to chemoradiotherapy, a similar group of high-risk Basingstoke cases was constructed for comparison purposes. This group included 135 consecutive Dukes' B (B2) and Dukes' C cancer operations, both anterior resection and abdominal-perineal excision, for tumours below 12 cm from the anal verge. Results from TME alone are substantially superior to the best reported (NCCTG) from conventional surgery plus radiotherapy or combination chemoradiotherapy: 5% local recurrence at 5 years compared with 25% and 13.5%, respectively; and 22% overall recurrence compared with 62.7% and 41.5%, respectively (Dukes' B cases [B2], 15%; Dukes' C cases, 32%). Meticulous TME, which encompasses the whole field of tumour spread, can improve cure rates and reduce the variability of outcomes between surgeons. Far more genuine "cures" of rectal cancer are possible by surgery alone than have generally been believed or are currently accepted. Better surgical results are an essential background for the more selective use of adjuvant therapy in the future.
Article
An audit of treatment of gastric carcinoma was conducted in a major general hospital unit in the UK over a 5-year period. In all, 206 patients (114 men, 92 women) with a mean age of 68 years were treated. Operation was performed in 150 patients; 87 underwent gastrectomy with 31 procedures appearing potentially curative. Most tumours were advanced at diagnosis: 92 were stage IV and 34 stage IIIB, with 42 tumours at earlier stages. After the 87 gastrectomies anastomotic leakage occurred in 16 patients (18 per cent) and there were 14 deaths (16 per cent). The rates of resectability, inadequate resection, anastomotic leakage and postoperative mortality varied considerably between surgeons. The 5-year survival rate was 5 per cent overall, 11 per cent after gastrectomy and 32 per cent following curative resection. The results of treatment of gastric cancer by general surgeons are poor and show marked variation between operators. The declining incidence of the disease makes prospective audit difficult. Treatment by fewer surgeons specializing in this area might improve the outcome.
Article
To compare survival outcome for patients with breast cancer cared for by specialist and non-specialist surgeons in a geographically defined area. Retrospective study of all female patients aged under 75 years in the area treated between 1980 and June 1988 (before breast screening began). Patients were identified from the cancer registry and from pathology records of all hospitals in the area. Specialist surgeons were identified by one author. All other surgeons caring for patients from the area were considered non-specialists. A geographically defined population in urban west of Scotland. 3786 patients with histologically verified breast cancer operated on between 1 January 1980 and 30 June 1988 and followed to 31 December 1993. Five and 10 year survival rates for specialists and non-specialists; relative hazard ratios derived from Cox's proportional hazards model adjusted for prognostic factors--age, socioeconomic status, tumour size, and nodal involvement. The five year survival rate was 9% higher and the 10 year survival 8% higher for patients cared for by specialist surgeons. A reduction in risk of dying of 16% (95% confidence interval 6% to 25%) was found after adjustment for age, tumour size, socioeconomic status, and nodal involvement. The benefit of specialist care was apparent for all age groups, for small and large tumours, and for tumours that did and did not affect the nodes and was consistent across all socioeconomic categories. Survival differences of the magnitude demonstrated have implications for the provision of services for the treatment of women with breast cancer. There is a need to improve equity in the treatment of breast cancer.
Article
Early results after rectal cancer surgery in a defined population were compared before and after the introduction of total mesorectal excision. In the first period (1984-1986) 211 cases of rectal cancer were diagnosed and in the second (1990-1992) 230. Of these, 134 patients in the first period (group 1) had anterior resection or abdominoperineal excision which was considered curative. In the second period 128 curative anterior resections and abdominoperineal excisions were performed by a limited number of surgeons familiar with total mesorectal excision (group 2). No differences between the groups were found in stage distribution, rate of curative operations, postoperative complications or postoperative mortality. Local recurrence had developed in 19 patients in group 1 and in eight in group 2, 1 year after the end of the study periods (P = 0.03). Local radicality was in doubt in 13 patients in group 1 and in eight in group 2. In the remaining 121 and 120 patients, 13 and four local recurrences respectively were present (P = 0.03). Actuarial analysis showed a significant reduction in local recurrence rate (P = 0.03) and an increase in crude survival (P = 0.03) at 4 years in group 2 compared with group 1. Total mesorectal excision reduces the local recurrence rate after excision of rectal cancer.
Article
A series of 103 consecutive rectal cancers was prospectively documented. Laparotomy was performed in 78 patients of whom five did not undergo resection. Resection was considered curative unless there were liver metastases or biopsy-proven residual disease. Nine patients had a palliative resection. Thus 64 patients underwent a curative resection, 52 (81 per cent) of whom had an anterior resection of which 26 (46 per cent) were performed by trainees. There were three deaths after operation. Eight (14 per cent) patients developed a clinical anastomotic leak. Thirty patients were available for a minimum follow-up of 24 (mean 33, range 24-49) months. Four (13 per cent) patients developed distant recurrence. There were no isolated pelvic or anastomotic recurrences. One patient with distal recurrence may have had pelvic disease. The cumulative recurrence-free survival rate at 24 months was 84 per cent. These results support the suggestion that mesorectal excision may reduce local recurrence.
Article
Adjuvant preoperative radiotherapy in patients with rectal cancer improves local control and possibly overall survival. However, an increased postoperative mortality rate after radiotherapy has been observed in some trials. This study was based on 1399 patients in two randomized trials of radiotherapy. It reviewed the causes of death after operation and attempted to identify risk factors for postoperative mortality in patients with rectal cancer treated with or without high-dose (5 x 5 Gy) preoperative radiotherapy. The majority of deaths were from cardiovascular disease or infection. The risk of postoperative mortality was significantly increased in patients irradiated with a two-portal technique to a relatively large volume compared with those not given radiotherapy, but not in those irradiated with a four-portal technique to a limited volume. Age, sex, tumour stage and coexistent cardiovascular disease were independent risk factors for postoperative mortality. The risk of postoperative death in patients with rectal cancer is related to the preoperative radiotherapy technique.
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