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Orbach L, Gabay S, Montekio T, Chai AS, Kariv Y, Zemel M, Abu-Abeid A, Lahat G, Yuval JB. Comparison of perioperative outcomes of emergency hartmann resections performed by residents versus attending surgeons. Am J Surg 2025; 240:116084. [PMID: 39577121 DOI: 10.1016/j.amjsurg.2024.116084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2024] [Revised: 10/10/2024] [Accepted: 11/11/2024] [Indexed: 11/24/2024]
Abstract
OBJECTIVE The optimal level of resident autonomy in emergency colorectal surgery is unclear. This study assessed perioperative outcomes in patients undergoing emergency colectomy with end stoma based on the presence of an attending surgeon. PARTICIPANTS A retrospective analysis was conducted at a tertiary teaching hospital, including 360 patients who underwent emergency colectomy with end stoma between 2013 and 2023. The primary outcome was perioperative complications, including mortality. RESULTS Of the 360 patients, 36 (10 %) had surgery without an attending surgeon present. Baseline characteristics such as age (p = 0.34), Charlson Comorbidity Index (p = 0.313), and sex (p = 0.598) were similar across groups. Perioperative outcomes showed no significant differences in major complications (Clavien-Dindo ≥3, p = 0.176), 90-day complication rate (p = 0.698), or 90-day mortality (p = 0.389). Malignancy-related cases also did not differ in lymph node yield (p = 0.685) or overall survival (log-rank p = 0.574). CONCLUSION In this study, Hartmann resections performed by resident teams were not associated with worse perioperative or oncologic outcomes, suggesting that resident autonomy can be safely increased without compromising patient safety.
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Affiliation(s)
- Lior Orbach
- Division of Surgery, Tel Aviv Sourasky Medical Center and Tel Aviv University, Israel; Tel Aviv University, Faculty of Medical & Health Sciences, Israel.
| | - Shiran Gabay
- Division of Surgery, Tel Aviv Sourasky Medical Center and Tel Aviv University, Israel
| | - Tal Montekio
- Division of Surgery, Tel Aviv Sourasky Medical Center and Tel Aviv University, Israel
| | - Ariel S Chai
- Tel Aviv University, Faculty of Medical & Health Sciences, Israel
| | - Yehuda Kariv
- Division of Surgery, Tel Aviv Sourasky Medical Center and Tel Aviv University, Israel; Colorectal Service, Tel Aviv Sourasky Medical Center and Tel Aviv University, Israel; Tel Aviv University, Faculty of Medical & Health Sciences, Israel
| | - Meir Zemel
- Division of Surgery, Tel Aviv Sourasky Medical Center and Tel Aviv University, Israel; Colorectal Service, Tel Aviv Sourasky Medical Center and Tel Aviv University, Israel; Tel Aviv University, Faculty of Medical & Health Sciences, Israel
| | - Adam Abu-Abeid
- Division of Surgery, Tel Aviv Sourasky Medical Center and Tel Aviv University, Israel; Tel Aviv University, Faculty of Medical & Health Sciences, Israel
| | - Guy Lahat
- Division of Surgery, Tel Aviv Sourasky Medical Center and Tel Aviv University, Israel; Tel Aviv University, Faculty of Medical & Health Sciences, Israel
| | - Jonathan B Yuval
- Division of Surgery, Tel Aviv Sourasky Medical Center and Tel Aviv University, Israel; Colorectal Service, Tel Aviv Sourasky Medical Center and Tel Aviv University, Israel; Tel Aviv University, Faculty of Medical & Health Sciences, Israel
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Zhu DX, Chen M, Xu DH, He GD, Xu PP, Lin Q, Ren L, Xu JM. Pattern of colorectal surgery and long-term survival: 10-year experience from a single center. World J Gastrointest Oncol 2024; 16:4383-4391. [PMID: 39554737 PMCID: PMC11551632 DOI: 10.4251/wjgo.v16.i11.4383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/24/2024] [Accepted: 06/17/2024] [Indexed: 10/25/2024] Open
Abstract
BACKGROUND The incidence of colorectal cancer (CRC) has increased in recent decades, and ranks fourth among males and third among females in China. Surgical resection remains the most important treatment modality for curative intent in CRC. Several studies found that surgeon volumes and specialization appeared to be associated with improved overall survival (OS). Moreover, numerous reports have suggested that specialization and minimally invasive surgery have gained increased popularity in CRC surgery. However, few studies have specifically examined the role and long-term survival of all stage CRC in a real-world study. AIM To evaluate the effect of surgeon specialization on survival changes and minimally invasive surgery utilization in a real world study. METHODS A retrospective analysis on the association between surgeon specialization and OS between 2008 and 2013 in Zhongshan Hospital CRC database was performed. Standard demographic, clinicopathologic, surgical and follow-up data were obtained from the CRC database. Surgeon specialty was categorized as colorectal surgeon (CS) and general surgeon (GS). CRC patients who underwent primary surgical resection were enrolled. RESULTS A total of 5141 CRC patients who underwent primary surgical resection between 2008 and 2013 were evaluated, 1748 (34.0%) of these by CS. The percentage of minimally invasive procedures in the CS group showed an increasing trend. There was no benefit associated with surgeon specialization for stage I, II and IV patients. Surgeon specialization exhibited a significant association with OS solely among stage III patients, with 5-year OS rates of 76% and 67% for the CS and GS groups, respectively (P < 0.01). Further analyses found that surgeon specialization was significantly associated with survival only in stage III rectal patients, and the 5-year OS rate in the CS group and GS group was 80% and 67%, respectively (P < 0.01). CONCLUSION Surgeon specialization is associated with improved OS after primary surgery in stage III rectal patients. An appropriate surgical technique, perioperative program and adjuvant therapy may contribute to survival benefit in these patients.
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Affiliation(s)
- De-Xiang Zhu
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Miao Chen
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Dong-Hao Xu
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Guo-Dong He
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Ping-Ping Xu
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Qi Lin
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Li Ren
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Jian-Min Xu
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai 200032, China
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Jacobson CE, Harbaugh CM, Agbedinu K, Kwakye G. Colorectal Cancer Outcomes: A Comparative Review of Resource-Limited Settings in Low- and Middle-Income Countries and Rural America. Cancers (Basel) 2024; 16:3302. [PMID: 39409921 PMCID: PMC11475417 DOI: 10.3390/cancers16193302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2024] [Revised: 09/24/2024] [Accepted: 09/25/2024] [Indexed: 10/20/2024] Open
Abstract
Background/Objectives: Colorectal cancer remains a significant global health challenge, particularly in resource-limited settings where patient-centered outcomes following surgery are often suboptimal. Although more prevalent in low- and middle-income countries (LMICs), segments of the United States have similarly limited healthcare resources, resulting in stark inequities even within close geographic proximity. Methods: This review compares and contrasts colorectal cancer outcomes in LMICs with those in resource-constrained communities in rural America, utilizing an established implementation science framework to identify key determinants of practice for delivering high-quality colorectal cancer care. Results: Barriers and innovative, community-based strategies aimed at improving patient-centered outcomes for colorectal cancer patients in low resource settings are identified. We explore innovative approaches and community-based strategies aimed at improving patient-centered outcomes, highlighting the newly developed colorectal surgery fellowship in Sub-Saharan Africa as a model of innovation in this field. Conclusions: By exploring these diverse contexts, this paper proposes actionable solutions and strategies to enhance surgical care of colorectal cancer and patient outcomes, ultimately aiming to inform global health practices, inspire collaboration between LMIC and rural communities, and improve care delivery across various resource settings.
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Affiliation(s)
- Clare E. Jacobson
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Calista M. Harbaugh
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI 48109, USA
| | - Kwabena Agbedinu
- Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi 23321, Ghana
| | - Gifty Kwakye
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI 48109, USA
- Center for Global Surgery, University of Michigan, Ann Arbor, MI 48109, USA
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LeLeannec IC, Madoff RD, Jensen CC. Specialization Reduces Costs Associated With Colon Cancer Care: A Cost Analysis. Dis Colon Rectum 2023; 66:1185-1193. [PMID: 35522784 DOI: 10.1097/dcr.0000000000002370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Colorectal surgeons have been reported to have superior outcomes to general surgeons in the management of colon cancer, but it is unclear whether this leads to a difference in costs associated with cancer care. OBJECTIVE This study aimed to investigate whether colorectal surgeons versus general surgeons performing elective colectomies for colon cancer resulted in cost savings. DESIGN A decision analysis model was built to evaluate the cost of care. One-way and Monte Carlo sensitivity analyses were performed to test the assumptions of the model. SETTING Data for the model were taken from previously published studies. PATIENTS This study included a simulated cohort of patients undergoing elective colectomy for colon cancer. MAIN OUTCOME MEASURES Total cost of care from the societal and health care system perspectives. RESULTS In the base case scenario, from the societal perspective, colectomy performed by a colorectal surgeon costs $38,798 during the 5-year window versus $46,571 when performed by a general surgeon (net savings, $7773). From the health care system perspective, surgery performed by a colorectal surgeon costs $25,125 versus surgery performed by a general surgeon, which costs $29,790 (net savings, $4665). In probabilistic sensitivity analyses, surgeries performed by colorectal surgeons were cost saving or equivalent to those performed by general surgeons in 997 of 1000 simulations in the societal perspective and 989 of 1000 simulations in the health care system perspective. Overall, this finding was primarily driven by differences in reported overall recurrence rates and patient loss of productivity. LIMITATIONS The limitation of this study was reliance on published data, some of which included rectal cancer cases. CONCLUSIONS In our decision analysis model, elective colectomies for colon cancer had lower associated costs when performed by colorectal versus general surgeons. See Video Abstract at http://links.lww.com/DCR/B974 . LA ESPECIALIZACIN REDUCE LOS COSTOS ASOCIADOS CON LA ATENCIN DEL CNCER DE COLON UN ANLISIS DE COSTOS ANTECEDENTES: Se ha informado que los cirujanos colorrectales obtienen mejores resultados que los cirujanos generales en el tratamiento del cáncer de colon, pero no está claro si esto conduce a una diferencia en los costos asociados con la atención del cáncer.OBJETIVO: Investigar si los cirujanos colorrectales que realizan colectomías electivas para el cáncer de colon generaron ahorros de costos en comparación con los cirujanos generales.DISEÑO: Se construyó un modelo de análisis de decisiones para evaluar el costo de la atención. Se realizaron análisis de sensibilidad unidireccional y de Monte Carlo para probar los supuestos del modelo.AJUSTE: Los datos para el modelo se tomaron de estudios publicados previamente.PACIENTES: Una cohorte simulada de pacientes sometidos a colectomía electiva por cáncer de colon.PRINCIPALES MEDIDAS DE RESULTADO: Costo total de la atención y desde la perspectiva de la sociedad y del sistema de salud.RESULTADOS: El escenario del caso base incluyó suposiciones sobre las diferencias en los resultados, incluida la recurrencia general y local, el porcentaje de recurrencia operable, la mortalidad a los 30 días, la duración de la estadía, el porcentaje de cirugía mínimamente invasiva, las complicaciones y los costos asociados. En el escenario de caso base, desde la perspectiva social, la colectomía con un cirujano colorrectal costó $38 798 durante la ventana de cinco años, frente a $46 571 con un cirujano general (ahorros netos, $7 773). Desde la perspectiva del sistema de atención médica, la cirugía realizada por un cirujano colorrectal fue de $25 125 frente a $29 790 con la cirugía realizada por un cirujano general (ahorro neto, $4665). En los análisis de sensibilidad de probabilidad, los cirujanos colorrectales ahorraron costos o fueron equivalentes a los cirujanos generales en 997 de 1000 simulaciones en la perspectiva social y 989 de 1000 simulaciones en la perspectiva del sistema de salud. En general, este hallazgo se debió principalmente a las diferencias en las tasas de recurrencia generales informadas y la pérdida de productividad de los pacientes.LIMITACIONES: Dependencia de los datos publicados, algunos de los cuales incluyeron casos de cáncer de rectoCONCLUSIONES: En nuestro modelo de análisis de decisiones, las colectomías electivas por cáncer de colon tuvieron menores costos asociados cuando las realizaron cirujanos colorrectales versus generales. Consulte Video Resumen en http://links.lww.com/DCR/B974 . (Traducción-Dr Yolanda Colorado).
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Affiliation(s)
- Isabelle C LeLeannec
- Division of Colon and Rectal Surgery, Department of Surgery, NYU Grossman School of Medicine, New York, New York
| | - Robert D Madoff
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Christine C Jensen
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
- Colon and Rectal Surgery Associates, Minneapolis, Minnesota
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Castilho MJCD, Massago M, Arruda CE, Beltrame MHA, Strand E, Fontes CER, Nihei OK, Franco RDL, Staton CA, Pedroso RB, de Andrade L. Spatial distribution of mortality from colorectal cancer in the southern region of Brazil. PLoS One 2023; 18:e0288241. [PMID: 37418502 DOI: 10.1371/journal.pone.0288241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 06/22/2023] [Indexed: 07/09/2023] Open
Abstract
Colorectal cancer (CRC) is the leading cause of death due to cancer worldwide. In Brazil, it is the second most frequent cancer in men and women, with a mortality reaching 9.4% of those diagnosed. The aim of this study was to analyze the spatial heterogeneity of CRC deaths among municipalities in south Brazil, from 2015 to 2019, in different age groups (50-59 years, 60-69 years, 70-79 years, and 80 years old or more) and identify the associated variables. Global Spatial Autocorrelation (Moran's I) and Local Spatial Autocorrelation (LISA) analyses were used to evaluate the spatial correlation between municipalities and CRC mortality. Ordinary Least Squares (OLS) and Geographically Weighted Regression (GWR) were applied to evaluate global and local correlations between CRC deaths, sociodemographic, and coverage of health care services. For all age groups, our results found areas with high CRC rates surrounded by areas with similarly high rates mainly in the Rio Grande do Sul state. Even as factors associated with CRC mortality varied according to age group, our results suggested that improved access to specialized health centers, the presence of family health strategy teams, and higher rates of colonoscopies are protective factors against colorectal cancer mortality in southern Brazil.
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Affiliation(s)
| | - Miyoko Massago
- Postgraduate Program in Health Sciences, State University of Maringa, Maringa, Parana, Brazil
| | - Carlos Eduardo Arruda
- Postgraduate Program in Management, Technology and Innovation in Urgency and Emergency, State University of Maringa, Maringa, Parana, Brazil
| | | | - Eleanor Strand
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | | | - Oscar Kenji Nihei
- Center of Education, Literature and Health, Western Paraná State University, Foz do Iguaçu, Parana, Brazil
| | - Rogério do Lago Franco
- Postgraduate Program in Health Sciences, State University of Maringa, Maringa, Parana, Brazil
| | - Catherine Ann Staton
- Postgraduate Program in Health Sciences, State University of Maringa, Maringa, Parana, Brazil
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Raissa Bocchi Pedroso
- Postgraduate Program in Health Sciences, State University of Maringa, Maringa, Parana, Brazil
| | - Luciano de Andrade
- Postgraduate Program in Health Sciences, State University of Maringa, Maringa, Parana, Brazil
- Department of Medicine at the State University of Maringa, Maringa, Parana, Brazil
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Haribhai S, Bhatia K, Shahmanesh M. Global elective breast- and colorectal cancer surgery performance backlogs, attributable mortality and implemented health system responses during the COVID-19 pandemic: A scoping review. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001413. [PMID: 37014874 PMCID: PMC10072489 DOI: 10.1371/journal.pgph.0001413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/07/2023] [Indexed: 04/05/2023]
Abstract
Globally, 28.4 million non-emergent ('elective') surgical procedures have been deferred during the COVID-19 pandemic. This study evaluated the impact of the COVID-19 pandemic on elective breast- or colorectal cancer (CRC) procedure backlogs and attributable mortality, globally. Further, we evaluated the interaction between procedure deferrals and health systems, internationally. Relevant articles from any country, published between December 2019-24 November 2022, were identified through searches of online databases (MEDLINE, EMBASE) and by examining the reference lists of retrieved articles. We organised health system-related findings thematically per the Structures-Processes-Outcomes conceptual model by Donabedian (1966). Of 337 identified articles, we included 50. Eleven (22.0%) were reviews. The majority of included studies originated from high-income countries (n = 38, 76.0%). An ecological, modelling study elucidated that global 12-week procedure cancellation rates ranged from 68.3%-73%; Europe and Central Asia accounted for the majority of cancellations (n = 8,430,348) and sub-Saharan Africa contributed the least (n = 520,459). The percentage reduction in global, institutional elective breast cancer surgery activity ranged from 5.68%-16.5%. For CRC, this ranged from 0%-70.9%. Significant evidence is presented on how insufficient pandemic preparedness necessitated procedure deferrals, internationally. We also outlined ancillary determinants of delayed surgery (e.g., patient-specific factors). The following global health system response themes are presented: Structural changes (i.e., hospital re-organisation), Process-related changes (i.e., adapted healthcare provision) and the utilisation of Outcomes (i.e., SARS-CoV-2 infection incidence among patients or healthcare personnel, postoperative pulmonary complication incidence, hospital readmission, length of hospital stay and tumour staging) as indicators of health system response efficacy. Evidence on procedure backlogs and attributable mortality was limited, partly due to insufficient, real-time surveillance of cancer outcomes, internationally. Elective surgery activity has decreased and cancer services have adapted rapidly, worldwide. Further research is needed to understand the impact of COVID-19 on cancer mortality and the efficacy of health system mitigation measures, globally.
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Affiliation(s)
- Sonia Haribhai
- Institute for Global Health, University College London, London, United Kingdom
- Africa Health Research Institute, Durban, South Africa
| | - Komal Bhatia
- Institute for Global Health, University College London, London, United Kingdom
| | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, United Kingdom
- Africa Health Research Institute, Durban, South Africa
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Hao S, Meyer D, Klose C, Irish W, Honaker MD. Association of distance traveled on receipt of surgery in patients with locally advanced rectal cancer. Int J Colorectal Dis 2023; 38:8. [PMID: 36629973 DOI: 10.1007/s00384-022-04300-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE Studies have shown patients residing in rural settings have worse cancer-related outcomes than those in urban settings. Specifically, rural patients with colorectal cancer have lower rates of screening and longer time to treatment. However, physical distance traveled has not been as well studied. This study sought to determine disparities in receipt of surgery in patients by distance traveled for care. METHODS A retrospective cohort study of patients with AJCC stage II/III rectal adenocarcinoma was identified within the National Cancer Database (2004-2017). Primary outcome was correlation of distance traveled to receipt of surgery. Multi-variable logistic regression was used to adjust for confounding factors. RESULTS 65,234 patients were included in the analysis. 94.6% resided in urban-metro areas while 2.2% resided in rural areas. Patients were predominantly non-Hispanic White (NHW) (75.2%) with an overall median age at diagnosis of 61 (IQR 52-71). Overall, 82.6% of patients received surgery. NHW patients were more likely to receive surgery than non-Hispanic Black patients (OR 0.67; 95% CI 0.61-0.73, p < 0.001), as were patients who were privately insured (OR 1.90, 95% CI 1.67-2.15, p < 0.001) or had Medicare (OR 1.68, 95% CI 1.47-1.92, p < 0.001) compared to uninsured patients. Patients traveling distances in the 4th quartile (median 47.9 miles) were more likely to receive surgery than those traveling the shortest distances (1st quartile: median 2.5 miles) (OR 1.37, 95% CI 1.24-1.50, p < 0.001). CONCLUSION Patients traveling farther distances were more likely to receive surgery than those traveling shorter distances. Shorter distance traveled does not appear to be associated with higher rates of surgical resection in patients with stage II/III rectal cancer.
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Affiliation(s)
- Scarlett Hao
- Division of Surgical Oncology, Department of Surgery, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - David Meyer
- East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Charles Klose
- East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - William Irish
- Division of Surgical Oncology, Department of Surgery, East Carolina University Brody School of Medicine, Greenville, NC, USA
- Division of Surgical Reseach, Department of Surgery, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Michael D Honaker
- Division of Surgical Oncology, Department of Surgery, East Carolina University Brody School of Medicine, Greenville, NC, USA.
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Arnarson Ö, Syk I, Butt ST. Who should operate patients presenting with emergent colon cancer? A comparison of short- and long-term outcome depending on surgical sub-specialization. World J Emerg Surg 2023; 18:3. [PMID: 36624451 PMCID: PMC9830814 DOI: 10.1186/s13017-023-00474-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/01/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Colorectal cancer presents as emergencies in 20% of the cases. Emergency resection is associated with high postoperative morbidity and mortality. The specialization of the operating team in the emergency settings differs from the elective setting, which may have an impact on outcome. The aim of this study was to evaluate short- and long-term outcomes following emergent colon cancer surgery depending on sub-specialization of the operating team. METHODS This is a retrospective population study based on data from the Swedish Colorectal Cancer Registry (SCRCR). In total, 656 patients undergoing emergent surgery for colon cancer between 2011 and 2016 were included. The cohort was divided in groups according to specialization of the operating team: (1) colorectal team (CRT); (2) emergency surgical team (EST); (3) general surgical team (GST). The impact of specialization on short- and long-term outcomes was analyzed. RESULTS No statistically significant difference in 5-year overall survival (CRT 48.3%; EST 45.7%; GST 42.5%; p = 0.60) or 3-year recurrence-free survival (CRT 80.7%; EST 84.1%; GST 77.7%21.1%; p = 0.44) was noted between the groups. Neither was any significant difference in 30-day mortality (4.4%; 8.1%; 5.5%, p = 0.20), 90-day mortality (8.8; 11.9; 7.9%, p = 0.37) or postoperative complication rate (35.5%, 35.9 30.7, p = 0.52) noted between the groups. Multivariate analysis adjusted for case-mix showed no difference in hazard ratios for long-term survival or postoperative complications. The rate of permanent stoma after 3 years was higher in the EST group compared to the CRT and GST groups (34.5% vs. 24.3% and 23.9%, respectively; p < 0.0.5). CONCLUSION Surgical sub-specialization did not significantly affect postoperative complication rate, nor short- or long-term survival after emergent operation for colon cancer. Patients operated by emergency surgical teams were more likely to have a permanent stoma after 3 years.
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Affiliation(s)
- Örvar Arnarson
- Department of Surgery, Skane University Hospital Malmo, Lund University, Lund, Sweden.
| | - Ingvar Syk
- grid.4514.40000 0001 0930 2361Department of Surgery, Skane University Hospital Malmo, Lund University, Lund, Sweden
| | - Salma Tunå Butt
- grid.4514.40000 0001 0930 2361Department of Surgery, Skane University Hospital Malmo, Lund University, Lund, Sweden
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Survival Outcomes after Elective or Emergency Surgery for Synchronous Stage IV Colorectal Cancer. Biomedicines 2022; 10:biomedicines10123114. [PMID: 36551870 PMCID: PMC9775222 DOI: 10.3390/biomedicines10123114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/29/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
Patients with stage IV colorectal cancer (CRC) who have not undergone primary tumor resection (PTR) are at risk of sudden medical emergencies. Despite the ongoing controversy over the necessity and timing of PTR in patients with stage IV CRC, studies comparing the survival outcomes of elective and emergency surgery in this population are scarce. This is a retrospective study conducted at a single institute. The patients were divided into two groups: the elective surgery (ELS) group (n = 46) and the emergency surgery (EMS) group (n = 26). The primary outcome was 2-year overall survival (OS). During a median follow-up period of 27.0 months, the 2-year OS was significantly better in the ELS group (80% vs. 42.9%, p = 0.002). No significant differences were observed in the 2-year relapse-free survival and 30-day postoperative complication rates. Planning and performing elective surgery could help increase the survival rate of patients with synchronous stage IV CRC, especially those that undergo simultaneous or staged metastasectomy.
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Walther F, Schmitt J, Eberlein-Gonska M, Kuhlen R, Scriba P, Schoffer O, Roessler M. 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. BMJ Open 2022; 12:e058481. [PMID: 35879010 PMCID: PMC9328106 DOI: 10.1136/bmjopen-2021-058481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Felix Walther
- Quality and Medical Risk Management, University Hospital Carl Gustav Carus, Dresden, Germany
- Center for Evidence-based Healthcare, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Maria Eberlein-Gonska
- Quality and Medical Risk Management, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Ralf Kuhlen
- Initiative Qualitätsmedizin e.V, Berlin, Germany
| | - Peter Scriba
- Initiative Qualitätsmedizin e.V, Berlin, Germany
| | - Olaf Schoffer
- Center for Evidence-based Healthcare, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Martin Roessler
- Center for Evidence-based Healthcare, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany
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11
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Wirth K, Näpflin M, Graber SM, Blozik E. Does hospital volume affect outcomes after abdominal cancer surgery: an analysis of Swiss health insurance claims data. BMC Health Serv Res 2022; 22:262. [PMID: 35219332 PMCID: PMC8881861 DOI: 10.1186/s12913-022-07513-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 01/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background Medical treatment quality has been shown to be better in high volume than in low volume hospitals. However, this relationship has not yet been confirmed in abdominal cancer in Switzerland and is relevant for referral of patients and healthcare planning. Thus, the present study investigates the association between hospital volumes for surgical resections of colon, gastric, rectal, and pancreatic carcinomas and outcomes. Methods This retrospective analysis is based on anonymized claims data of patients with mandatory health insurance at Helsana Group, a leading health insurance in Switzerland. Outcome parameters were length of hospital stay, mortality and cost during the inpatient stay as well as at 1-year follow-up. Hospital volume information was derived from the Quality Indicators dataset provided by the Swiss Federal Office of Public Health. The impact of hospital volume on the different treatment outcomes was statistically tested using generalized estimating equations (GEE) models, taking into account the non-independence of observations from the same hospital. Results The studies included 2′859 resections in patients aged 18 years and older who were hospitalized for abdominal cancer surgery between 2014 and 2018. Colon resections were the most common procedures (n = 1′690), followed by rectal resections (n = 709). For rectal, colon and pancreatic resections, an increase in the mean number of interventions per hospital and a reduction of low volume hospitals could be observed. For the relationship between hospital volume and outcomes, we did not observe a clear dose-response relationship, as no significantly better outcomes were observed in the higher-volume category than in the lower-volume category. Even though a positive “routine effect” cannot be excluded, our results suggest that even hospitals with low volumes are able to achieve comparable treatment outcomes to larger hospitals. Conclusion In summary, this study increases transparency on the relationship between hospital volume and treatment success. It shows that simple measures such as defining a minimum number of procedures only might not lead to the intended effects if other factors such as infrastructure, the operating team or aggregation level of the available data are not taken into account. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07513-5.
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12
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Chioreso C, Gao X, Gribovskaja-Rupp I, Lin C, Ward MM, Schroeder MC, Lynch CF, Chrischilles EA, Charlton ME. Hospital and Surgeon Selection for Medicare Beneficiaries With Stage II/III Rectal Cancer: The Role of Rurality, Distance to Care, and Colonoscopy Provider. Ann Surg 2021; 274:e336-e344. [PMID: 31714306 PMCID: PMC7176526 DOI: 10.1097/sla.0000000000003673] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine factors associated with rectal cancer surgery performed at high-volume hospitals (HVHs) and by high-volume surgeons (HVSs), including the roles of rurality and diagnostic colonoscopy provider characteristics. SUMMARY OF BACKGROUND DATA Although higher-volume hospitals/surgeons often achieve superior surgical outcomes, many rectal cancer resections are performed by lower-volume hospitals/surgeons, especially among rural populations. METHODS Patients age 66+ diagnosed from 2007 to 2011 with stage II/III primary rectal adenocarcinoma were selected from surveillance, epidemiology, and end results-medicare data. Patient ZIP codes were used to classify rural status. Hierarchical logistic regression was used to determine factors associated with surgery by HVH and HVS. RESULTS Of 1601 patients, 22% were rural and 78% were urban. Fewer rural patients received surgery at a HVH compared to urban patients (44% vs 65%; P < 0.0001). Compared to urban patients, rural patients more often had colonoscopies performed by general surgeons (and less often from gastroenterologists or colorectal surgeons), and lived substantially further from HVHs; these factors were both associated with lower odds of surgery at a HVH or by a HVS. In addition, whereas over half of both rural and urban patients received their colonoscopy and surgery at the same hospital, rural patients who stayed at the same hospital were significantly less likely to receive surgery at a HVH or by a HVS compared to urban patients. CONCLUSIONS Rural rectal cancer patients are less likely to receive surgery from a HVH/HVS. The role of the colonoscopy provider has important implications for referral patterns and initiatives seeking to increase centralization.
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Affiliation(s)
- Catherine Chioreso
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - Xiang Gao
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Chi Lin
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Marcia M. Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
| | - Mary C. Schroeder
- Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, IA
| | - Charles F. Lynch
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
- Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, IA
| | | | - Mary E. Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
- Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, IA
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13
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The impact of the affordable care act on surgeon selection amongst colorectal surgery patients. Am J Surg 2021; 222:256-261. [DOI: 10.1016/j.amjsurg.2021.01.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 01/19/2021] [Accepted: 01/31/2021] [Indexed: 12/13/2022]
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14
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Koëter T, de Nes LCF, Wasowicz DK, Zimmerman DDE, Verhoeven RHA, Elferink MA, de Wilt JHW. Hospital variation in sphincter-preservation rates in rectal cancer treatment: results of a population-based study in the Netherlands. BJS Open 2021; 5:6325344. [PMID: 34291288 PMCID: PMC8295312 DOI: 10.1093/bjsopen/zrab065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/28/2021] [Indexed: 01/18/2023] Open
Abstract
Background This study aimed to examine the sphincter-preservation rate variations in rectal cancer surgery. The influence of hospital volume on sphincter-preservation rates and short-term outcomes (anastomotic leakage (AL), positive circumferential resection margin (CRM), 30- and 90-day mortality rates) were also analysed. Methods Non-metastasized rectal cancer patients treated between 2009 and 2016 were selected from the Netherlands Cancer Registry. Surgical procedures were divided into sphincter-preserving surgery and an end colostomy group. Multivariable logistic regression models were generated to estimate the probability of undergoing sphincter-preserving surgery according to the hospital of surgery and tumour height (low, 5 cm or less, mid, more than 5 cm to 10 cm, and high, more than 10 cm). The influence of annual hospital volume (less than 20, 20–39, more than 40 resections) on sphincter-preservation rate and short-term outcomes was also examined. Results A total of 20 959 patients were included (11 611 sphincter preservation and 8079 end colostomy) and the observed median sphincter-preservation rate in low, mid and high rectal cancer was 29.3, 75.6 and 87.9 per cent respectively. After case-mix adjustment, hospital of surgery was a significant factor for patients’ likelihood for sphincter preservation in all three subgroups (P < 0.001). In mid rectal cancer, borderline higher rates of sphincter preservation were associated with low-volume hospitals (odds ratio 1.20, 95 per cent c.i. 1.01 to 1.43). No significant association between annual hospital volume and sphincter-preservation rate in low and high rectal cancer nor short-term outcomes (AL, positive CRM rate and 30- and 90-day mortality rates) was identified. Conclusion This population-based study showed a significant hospital variation in sphincter-preservation rates in rectal surgery. The annual hospital volume, however, was not associated with sphincter-preservation rates in low, and high rectal cancer nor with other short-term outcomes.
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Affiliation(s)
- T Koëter
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - L C F de Nes
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Surgery, Maasziekenhuis Pantein, Boxmeer, The Netherlands
| | - D K Wasowicz
- Department of Surgery, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - D D E Zimmerman
- Department of Surgery, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - R H A Verhoeven
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - M A Elferink
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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15
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Dreifuss NH, Schlottmann F, Bun ME, Rotholtz NA. Emergent laparoscopic sigmoid resection for perforated diverticulitis: can it be safely performed by residents? Colorectal Dis 2020; 22:952-958. [PMID: 31955484 DOI: 10.1111/codi.14973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/19/2019] [Indexed: 12/21/2022]
Abstract
AIM Outcomes after resident involvement in emergent colectomies have rarely been studied. The aim of this study was to analyse the outcomes of laparoscopic sigmoidectomy for Hinchey III diverticulitis performed by residents. METHOD This study was a retrospective analysis of patients undergoing laparoscopic sigmoidectomy for diverticulitis. The sample was divided into two groups: patients operated on by a supervised resident (SR) or a senior surgeon (SS). Supervising surgeons and SSs could be general surgeons (GSs) or colorectal surgeons (CSs). A SR was considered the first surgeon if he/she completed at least three of five defined steps of the procedure. The primary end-points included length of hospital stay (LOS), morbidity and 30-day mortality. A sub-analysis of patients operated on by a SR assisted by either a CS or GS was performed. RESULTS Supervised residents and SSs operated on 59 and 42 patients, respectively. The presence of a CS was more frequent in the SS group (SR 41% vs SS 81%, P < 0.001). LOS (SR 9.4 days vs SS 6.4 days, P = 0.04) was higher in the SR group. Overall morbidity (SR 39% vs SS 43%, P = 0.69) and 30-day mortality (SR 5% vs SS 5%, P = 0.94) were also comparable among the groups. Procedures performed by SRs and supervised by a CS were associated with lower morbidity (GS 48% vs CS 25%, P = 0.06) and mortality (GS 8% vs CS 0%, P = 0.26). CONCLUSION Laparoscopic sigmoidectomy for Hinchey III diverticulitis has comparable outcomes when performed by a supervised SR or a SS. Procedures performed by residents assisted by a CS seem to have better outcomes than those assisted by a GS.
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Affiliation(s)
- N H Dreifuss
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - F Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - M E Bun
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
- Division of Colorectal Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - N A Rotholtz
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
- Division of Colorectal Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
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16
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Conticchio M, Papagni V, Notarnicola M, Delvecchio A, Riccelli U, Ammendola M, Currò G, Pessaux P, Silvestris N, Memeo R. Laparoscopic vs. open mesorectal excision for rectal cancer: Are these approaches still comparable? A systematic review and meta-analysis. PLoS One 2020; 15:e0235887. [PMID: 32722694 PMCID: PMC7386630 DOI: 10.1371/journal.pone.0235887] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 06/25/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND To analyze pathologic and perioperative outcomes of laparoscopic vs. open resections for rectal cancer performed over the last 10 years. METHODS A systematic literature search of the following databases was conducted: Cochrane Central Register of Controlled Trials, MEDLINE (through PubMed), EMBASE, and Scopus. Only articles published in English from January 1, 2008 to December 31, 2018 (i.e. the last 10 years), which met inclusion criteria were considered. The review only included articles which compared Laparoscopic rectal resection (LRR) and Open Rectal Resection (ORR) for rectal cancer and reported at least one of the outcomes of interest. The analyses followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement checklist. Only prospective randomized studies were considered. The body of evidence emerging from this study was evaluated using the Grading of Recommendations Assessment Development and Evaluation (GRADE) system. Outcome measures (mean and median values, standard deviations, and interquartile ranges) were extracted for each surgical treatment. Pooled estimates of the mean differences were calculated using random effects models to consider potential inter-study heterogeneity and to adopt a more conservative approach. The pooled effect was considered significant if p <0.05. RESULTS Five clinical trials were found eligible for the analyses. A positive involvement of CRM was found in 49 LRRs (8.5%) out of 574 patients and in 30 ORRs out of 557 patients (5.4%) RR was 1.55 (95% CI, 0.99-2.41; p = 0.05) with no heterogeneity (I2 = 0%). Incorrect mesorectal excision was observed in 56 out of 507 (11%) patients who underwent LRR and in 41 (8.4%) out of 484 patients who underwent ORR; RR was 1.30 (95% CI, 0.89-1.91; p = 0.18) with no heterogeneity (I2 = 0%). Regarding other pathologic outcomes, no significant difference between LRR and ORR was observed in the number of lymph nodes harvested or concerning the distance to the distal margin. As expected, a significant difference was found in the operating time for ORR with a mean difference of 41.99 (95% CI, 24.18, 59.81; p <0.00001; heterogeneity: I2 = 25%). However, no difference was found for blood loss. Additionally, no significant differences were found in postoperative outcomes such as postoperative hospital stay and postoperative complications. The overall quality of the evidence was rated as high. CONCLUSION Despite the spread of laparoscopy with dedicated surgeons and the development of even more precise surgical tools and technologies, the pathological results of laparoscopic surgery are still comparable to those of open ones. Additionally, concerning the pathological data (and particularly CRM), open surgery guarantees better results as compared to laparoscopic surgery. These results must be a starting point for future evaluations which consider the association between ''successful resection" and long-term oncologic outcomes. The introduction of other minimally invasive techniques for rectal cancer surgery, such as robotic resection or transanal TME (taTME), has revealed new scenarios and made open and even laparoscopic surgery obsolete.
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Affiliation(s)
| | | | | | | | | | - Michele Ammendola
- Department of Health Sciences, General Surgery, Magna Græcia University, Medicine School of Germaneto, Catanzaro, Italy
| | - Giuseppe Currò
- Department of Health Sciences, General Surgery, Magna Græcia University, Medicine School of Germaneto, Catanzaro, Italy
| | - Patrick Pessaux
- IRCAD-IHU, General, Digestive, and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Nicola Silvestris
- Medical Oncology Unit, IRCCS Cancer Institute "Giovanni Paolo II", Bari, Italy
- Department of Biomedical Sciences and Human Oncology, University of Bari ‘Aldo Moro’, Bari, Italy
| | - Riccardo Memeo
- Department of Hepato-Pancreato-Biliary (HPB) Surgery, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
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17
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Ketelaers SHJ, Fahim M, Rutten HJT, Smits AB, Orsini RG. When and how should surgery be performed in senior colorectal cancer patients? Eur J Surg Oncol 2020; 46:326-332. [PMID: 31955993 DOI: 10.1016/j.ejso.2020.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 01/03/2020] [Indexed: 12/28/2022] Open
Abstract
Older studies reported high rates of postoperative morbidity and mortality in the senior population, which lead to a tendency to withhold curative surgery in the older population. However, more recent studies showed impressing developments in postoperative outcomes in seniors. Probably, these improvements are due to enhancements in both surgical and non-surgical aspects in the pre-, peri- and postoperative period, such as minimally invasive techniques and anesthesiological insights. The postoperative survival gap seen earlier between younger and older patients is fading. For optimal treatment in the older population, special awareness and care on several aspects is needed. As only a minority of the seniors are frail, a quick frailty assessment is crucial to distinguish the fit from the frail in the decision-making process. In addition, it could be valuable to improve the lacks in physical condition in the preoperative period with the use of prehabilitation programs. Furthermore, it is important to evolve an emergency to an elective setting by postponing emergency surgery to prevent any high-risk situation. In conclusion, based on modern insights, surgery is a valid option in the curative treatment of colorectal cancer in seniors, however individual attention and care is required.
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Affiliation(s)
- S H J Ketelaers
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands.
| | - M Fahim
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands; GROW: School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands
| | - A B Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - R G Orsini
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
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18
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Lavanchy JL, Vaisnora L, Haltmeier T, Zlobec I, Brügger LE, Candinas D, Schnüriger B. Oncologic long-term outcomes of emergency versus elective resection for colorectal cancer. Int J Colorectal Dis 2019; 34:2091-2099. [PMID: 31709491 DOI: 10.1007/s00384-019-03426-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Long-term outcomes in patients undergoing emergency versus elective resection for colorectal cancer (CRC) are discussed controversially. This study aims to assess long-term outcomes of emergency versus elective CRC surgery. METHODS Single-center retrospective cohort study. Patients undergoing emergency or elective CRC surgery from July 2002 to January 2013 were included. Primary outcome was 5-year survival, secondary outcomes were in-hospital mortality and local tumor recurrence. RESULTS Overall, 475 patients were included. Median age was 69.0 (IQR 59.0-77.0) years. A total of 141 patients (30%) were operated for rectal cancer and 334 patients (70%) for colon cancer. Median follow-up was 445 (IQR 67-1409) days. Emergency resection was performed in 105 patients (22%) due to obstruction, perforation, or bleeding. Stage IV tumors and ASA scores≥ 3 were significantly more frequent in the emergency than in the elective resection group (39.0% vs. 33.5%, p < 0.001; 75.5% vs. 61.3%, p = 0.003). The rate of patients with positive lymph nodes was similar in the two groups (46.2% vs. 46.3%, p = 1.000). In-hospital mortality was significantly higher in the emergency CRC versus the elective CRC group (8.4% vs. 3.0%, p = 0.023). Five-year survival (aHR 1.38; 95%CI 0.81-2.37, p = 0.237) or local tumor recurrence (aHR 1.48; 95%CI 0.47-4.66, p = 0.500) were not significantly different in patients undergoing emergency versus elective surgery for CRC. CONCLUSION In-hospital mortality was increased in emergency versus elective CRC resections. However, 5-year survival and local recurrence after surgery for CRC were determined by the tumor stage, and not by the emergency versus elective setting of surgical resection.
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Affiliation(s)
- Joël L Lavanchy
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas Vaisnora
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Haltmeier
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Inti Zlobec
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Lukas E Brügger
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Schnüriger
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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19
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Biondo S, Gálvez A, Ramírez E, Frago R, Kreisler E. Emergency surgery for obstructing and perforated colon cancer: patterns of recurrence and prognostic factors. Tech Coloproctol 2019; 23:1141-1161. [DOI: 10.1007/s10151-019-02110-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 11/02/2019] [Indexed: 02/07/2023]
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20
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Hung P, Deng S, Zahnd WE, Adams SA, Olatosi B, Crouch EL, Eberth JM. Geographic disparities in residential proximity to colorectal and cervical cancer care providers. Cancer 2019; 126:1068-1076. [PMID: 31702829 DOI: 10.1002/cncr.32594] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/15/2019] [Accepted: 10/04/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Persistent rural-urban disparities for colorectal and cervical cancers raise concerns regarding access to treatment providers. To the authors knowledge, little is known regarding rural-urban differences in residential proximity to cancer specialists. METHODS Using the 2018 Physician Compare data concerning physician practice locations and the 2012 to 2016 American Community Survey, the current study estimated the driving distance from each residential zip code tabulation area (ZCTA) centroid to the nearest cancer provider of the following medical specialties involved in treating patients with colorectal and cervical cancer: medical oncology, radiation oncology, surgical oncology, general surgery, gynecological oncology, and colorectal surgery. Using population-weighted multivariable logistic regression, the authors analyzed the associations between ZCTA-level characteristics and driving distances >60 miles to each type of specialist. ZCTA-level residential rurality was defined using rural-urban commuting area codes. RESULTS Nearly 1 in 5 rural Americans lives >60 miles from a medical oncologist. Rural-urban differences in travel distances to the nearest cancer care provider(s) increased substantially for cancer surgeons; greater than one-half of rural residents were required to travel 60 miles to reach a gynecological oncologist, compared with 8 miles for their urban counterparts. Individuals residing within ZCTAs with a higher poverty rate, those of American Indian/Alaska Native ethnicity, and/or were located in the South and West regions were more likely than their counterparts to be >60 miles away from any of the aforementioned providers. CONCLUSIONS The substantial travel distances required for rural, low-income residents to reach a cancer specialist should prompt a policy action to increase access to specialized cancer care for millions of rural residents.
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Affiliation(s)
- Peiyin Hung
- Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina.,Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Songyuan Deng
- Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina.,Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Whitney E Zahnd
- Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina.,Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Swann A Adams
- Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina.,College of Nursing, University of South Carolina, Columbia, South Carolina.,Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Bankole Olatosi
- Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina.,Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Elizabeth L Crouch
- Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina.,Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Jan M Eberth
- Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina.,Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
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21
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van Groningen JT, Marang-van de Mheen PJ, Henneman D, Beets GL, Wouters MWJM. Surgeon perceived most important factors to achieve the best hospital performance on colorectal cancer surgery: a Dutch modified Delphi method. BMJ Open 2019; 9:e025304. [PMID: 31551369 PMCID: PMC6773321 DOI: 10.1136/bmjopen-2018-025304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Hospital variation in risk-adjusted outcomes after colorectal cancer surgery has been shown. However, explanatory factors are not sufficiently clear. The objective of this study was to identify factors perceived by gastrointestinal surgeons as important to achieve excellent casemix-adjusted outcomes after colorectal cancer surgery. DESIGN Based on literature and experts' opinion, 86 factors associated with serious complications, failure to rescue and mortality were listed. These were presented to gastrointestinal surgeons through two web-based surveys and an expert meeting. Participants were asked to choose their top 10 of most important factors. PARTICIPANTS Dutch gastrointestinal surgeons (n=52) of different hospitals and different hospital types (general/teaching/academic). RESULTS Of 31 invited experts for the first survey and meeting, 71% responded. Of 130 invited surgeons, 34 responded to the second survey. Factors deemed important were: procedural hospital volume (46% in top 10), specialised surgeons performing surgery, (elective 87%, emergency 60% and reoperations 62% in top 10), accessibility of, and daily ward rounds by specialised surgeons (41% and 38% in top 10), preoperative screening for malnutrition (57% in top 10), a protocol for recognition of anastomotic leakage and rapid reintervention (54% and 49% in top 10). CONCLUSION Procedural hospital volume, specialisation of surgeons, screening for malnutrition, early recognition of complications followed by rapid action were perceived as most important factors to achieve good outcomes by gastrointestinal surgeons.
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Affiliation(s)
- Julia Tessa van Groningen
- Department of Surgery, Leids Universitair Medisch Centrum, Leiden, The Netherlands
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Daniel Henneman
- Department of Surgery, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Geerard L Beets
- Department of Surgical Oncology, Antoni van Leeuwenhoek Nederlands Kanker Instituut, Amsterdam, The Netherlands
| | - Michel W J M Wouters
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
- Department of Surgical Oncology, Antoni van Leeuwenhoek Nederlands Kanker Instituut, Amsterdam, The Netherlands
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22
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Josey MJ, Odahowski CL, Zahnd WE, Schootman M, Eberth JM. Disparities in Utilization of Medical Specialists for Colonoscopy. Health Equity 2019; 3:464-471. [PMID: 31501806 PMCID: PMC6729104 DOI: 10.1089/heq.2019.0052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose: Colonoscopy is the preferred screening modality for colorectal cancer (CRC) prevention. The quality of the procedure varies although medical specialists such as gastroenterologists and colorectal surgeons tend to have better outcomes. We aimed to determine whether there are demographic and clinical differences between those who received a colonoscopy from a specialist versus those who received a colonoscopy from a nonspecialist. Methods: Using the population-based South Carolina Outpatient Ambulatory Surgery Database, we looked retrospectively to obtain patient-level endoscopy records from 2010 to 2014. We used multilevel logistic regression to model whether patients saw a specialist for their colonoscopy. The primary variables were patient race and insurance type, and an interaction by rurality was tested. Results: Of the 392,285 patients included in the analysis, 81% saw a specialist for their colonoscopy. County of residence explained 30% of the variability in the outcome. Non-Hispanic black (OR=0.65; confidence interval [95% CI]: 0.64–0.67) and Hispanic patients (OR=0.75; 95% CI: 0.67–0.84) were significantly less likely than non-Hispanic white patients to see a specialist. Compared with commercial/HMO insurance, all other types were less likely to see a specialist, and even more so for rural patients. The interaction of race by rurality was not significant. Conclusions: Specialists play a key role in CRC screening and can affect later downstream outcomes. This study has shown that ethnic minorities and adults with public or other insurance, particularly in rural areas, are most likely not to see a specialist. These results are consistent with disparities in CRC incidence, mortality, and survival.
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Affiliation(s)
- Michele J Josey
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina.,Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina
| | - Cassie L Odahowski
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina.,Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina
| | - Whitney E Zahnd
- Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina
| | - Mario Schootman
- Department of Clinical Analytics and Insights, Center for Clinical Excellence, SSM Health System, St. Louis, Missouri
| | - Jan M Eberth
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina.,Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina
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23
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Sparreboom CL, Lambrichts DPV, Menon AG, Kleinrensink GJ, Lingsma HF, Lange JF. Outcomes After Elective Colorectal Surgery by 2 Surgeons Versus 1 Surgeon in a Low-Volume Hospital. Surg Innov 2019; 26:753-759. [PMID: 31394977 DOI: 10.1177/1553350619868109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Improved patient outcomes after colorectal surgery in high-volume hospitals are leading to centralization of colorectal surgery. However, it is desirable to strive for optimal quality of colorectal surgery in low-volume hospitals. This study aimed to assess the effect of the number of surgeons involved in the surgical procedure on patient outcomes in a low-volume hospital. Methods. All patients who underwent elective colorectal surgery with construction of a primary anastomosis between January 1, 2007, and December 31, 2015, were included in this retrospective cohort. The propensity score was used to adjust for confounding. Results. A total of 429 patients were included. One hundred forty-three patients (33.3%) were operated by 1 surgeon and 286 patients (66.7%) were operated by 2 surgeons. Patients operated by 2 surgeons were younger, more often male, and had a higher body mass index. A multivariate analysis with propensity scores revealed that surgery with 2 surgeons was associated with fewer reoperations (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2-0.9, P = .038). Colorectal anastomotic leakage (OR = 0.6, 95% CI = 0.2-1.3, P = .204) and mortality (OR = 0.8, 95% CI = 0.2-3.7, P = .807) were not associated with the number of surgeons involved in the surgical procedure. Conclusion. The present study shows that elective colorectal surgery in a low-volume hospital performed by 2 surgeons resulted in fewer reoperations. This might positively influence patient outcomes and might be related to increased surgical quality as compared with procedures performed by only 1 surgeon.
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Affiliation(s)
| | | | - Anand G Menon
- Erasmus University Medical Center, Rotterdam, Netherlands.,Havenziekenhuis, Rotterdam, Netherlands.,IJsselland ziekenhuis, Capelle aan den IJssel, Netherlands
| | | | | | - Johan F Lange
- Erasmus University Medical Center, Rotterdam, Netherlands.,Havenziekenhuis, Rotterdam, Netherlands.,IJsselland ziekenhuis, Capelle aan den IJssel, Netherlands
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24
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Xie M, Li K, Li J, Lu D, Hu B. Association and diagnostic value of serum SPINK4 in colorectal cancer. PeerJ 2019; 7:e6679. [PMID: 30976466 PMCID: PMC6451835 DOI: 10.7717/peerj.6679] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 02/21/2019] [Indexed: 12/28/2022] Open
Abstract
The role of serum serine peptidase inhibitor, Kazal type 4 (SPINK4), in colorectal cancer (CRC) is largely unknown. This study aimed to explore the association and diagnostic value of serum SPINK4 in CRC. A total of 70 preoperative CRC patients, 30 postoperative CRC patients, 30 gastric cancer patients, and 30 healthy controls were enrolled. Using enzyme-linked immunosorbent assays, we found that the serum SPINK4 level was significantly increased in preoperative CRC compared with postoperative CRC patients, gastric cancer patients, and healthy controls (p < 0.05). The serum SPINK4 level was remarkably elevated in colon cancer compared with rectal cancer and was enhanced in the M1 stage compared with the M0 stage (p < 0.05). The area under the receiver operating characteristic curve of serum SPINK4 level in the diagnosis of CRC was 0.9186, with a sensitivity and specificity of 0.886 and 0.900, respectively, and a cut-off value of 2.065. There was no significant difference between high and low expression of serum SPINK4 regarding the overall survival time and disease-free survival (p > 0.05). This study demonstrated that the serum SPINK4 level increased in CRC and was associated with the location and distant metastasis of CRC. It had a high diagnostic value in CRC but was not associated with the survival of CRC patients.
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Affiliation(s)
- Mingzhi Xie
- Department of Chemotherapy, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, P.R. China
| | - Kezhi Li
- Department of Research, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, P.R. China
| | - Jilin Li
- Department of Research, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, P.R. China
| | - Dongcheng Lu
- Department of Research, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, P.R. China
| | - Bangli Hu
- Department of Research, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, P.R. China
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Abstract
BACKGROUND Relationships between high-volume surgeons and improved postoperative outcomes have been well documented. Colorectal procedures are often performed by general surgeons, particularly in emergent settings, and may form a large component of their practice. The influence of subspecialized training on outcomes after emergent colon surgery, however, is not well described. OBJECTIVE The purpose of this study was to determine whether subspecialty training in colorectal surgery is associated with differences in postoperative outcomes after emergency colectomy. DESIGN This was a retrospective cohort study. SETTINGS Three tertiary care hospitals participating in the National Surgical Quality Improvement Project were included. PATIENTS Patients undergoing emergent colon resections were identified at each institution and stratified by involvement of either a colorectal surgeon or a general or acute care surgeon. MAIN OUTCOME MEASURES Propensity score matching was used to isolate the effect of surgeon specialty on the primary outcomes, including postoperative morbidity, mortality, length of stay, and the need for unplanned major reoperation, in comparable cohorts of patients. RESULTS A total of 889 cases were identified, including 592 by colorectal and 297 by general/acute care surgeons. After propensity score matching, cases performed by colorectal surgeons were associated with significantly lower rates of 30-day mortality (6.7% vs 16.4%; p = 0.001), postoperative morbidity (45.0% vs 56.7%; p = 0.009), and unplanned major reoperation (9.7% vs 16.4%; p = 0.04). In addition, length of stay was ≈4.4 days longer among patients undergoing surgery by general/acute care surgeons (p < 0.001). LIMITATIONS This study was limited by its retrospective design, with potential selection bias attributed to referral patterns. CONCLUSIONS After controlling for underlying disease states and illness severity, emergent colon resections performed by colorectal surgeons were associated with significantly lower rates of postoperative morbidity and mortality when compared with noncolorectal surgeons. These findings may have implications for referral patterns for institutions. See Video Abstract at http://links.lww.com/DCR/A767.
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26
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Creavin B, Kelly ME, Ryan E, Winter DC. Meta-analysis of the impact of surgical approach on the grade of mesorectal excision in rectal cancer. Br J Surg 2017; 104:1609-1619. [PMID: 29044484 DOI: 10.1002/bjs.10664] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/17/2017] [Accepted: 07/07/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The subspecialization of colorectal surgeons, and improvements in the quality of mesorectal excision have revolutionized rectal cancer surgery. With the increasing use of minimally invasive techniques, the completeness of the mesorectal excision has been questioned. This study aimed to assess the pathological outcomes of open versus laparoscopic rectal resection. METHODS A meta-analysis of RCTs was undertaken. The primary endpoint was the adequacy of the mesorectal excision. Secondary endpoints included circumferential resection margin and distance to resection margins. RESULTS Four studies were included, reporting on 2319 patients; 972 (41·9 per cent) had open and 1347 (58·1 per cent) had laparoscopic resections. Meta-analysis of adequacy of the mesorectal excision showed a small difference in achieving an intact mesorectum in favour of open surgery (risk ratio (RR) 1·06, 95 per cent c.i. 1·02 to 1·10; P = 0·001). Superficial defects were more common in laparoscopic surgery (RR 0·70, 0·54 to 0·89; P = 0·004). Deep mesorectal defects (RR 0·78, 0·51 to 1·20; P = 0·256), circumferential margin (CRM) positivity (RR 0·85, 0·62 to 1·16; P = 0·310), and distance to radial (mean difference (MD) -0·06, 95 per cent c.i. -0·10 to 0·23; P = 0·443) and distal (MD 0·03, -0·06 to 0·12; P = 0·497) margins were all similar. A complete resection (intact mesorectum, negative CRM and distal margin) was achieved in 350 of 478 patients (73·2 per cent) in the laparoscopic group and 372 of 457 (81·4 per cent) in the open group (risk difference (RD) 8 (95 per cent c.i. 3 to 13) per cent; P = 0·003). However, an acceptable mesorectum (intact or superficial defects only) was present in 1254 of 1308 (95·9 per cent) and 916 of 949 (96·5 per cent) in the laparoscopic and open groups respectively (RD 1 (-1 to 3) per cent; P = 0·263). CONCLUSION Small differences in mesorectal quality were evident between open and laparoscopic rectal resections. This may be attributable to use of laparoscopic instruments; however, to date minor defects have not affected oncological outcomes.
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Affiliation(s)
- B Creavin
- Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - M E Kelly
- Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - E Ryan
- Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - D C Winter
- Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Link KH, Coy P, Roitman M, Link C, Kornmann M, Staib L. Minimum Volume Discussion in the Treatment of Colon and Rectal Cancer: A Review of the Current Status and Relevance of Surgeon and Hospital Volume regarding Result Quality and the Impact on Health Economics. Visc Med 2017; 33:140-147. [PMID: 28560230 PMCID: PMC5447170 DOI: 10.1159/000456044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND To answer the question whether minimum caseloads need to be stipulated in the German S3 (or any other) guidelines for colorectal cancer, we analyzed the current representative literature. The question is important regarding medical quality as well as health economics and policy. METHODS A literature research was conducted in PubMed for papers concerning 'colon cancer' (CC), 'rectal cancer' (RC), and 'colorectal cancer' (CRC), with 'results', 'quality', and 'mortality' between the years 2000 and 2016 being relevant factors. We graded the recommendations as 'pro', 'maybe', or 'contra' in terms of a significant correlation between hospital volume (HV) or surgeon volume (SV) and treatment quality. We also listed the recommended numbers suggested for HV or SV as minimum caseloads and calculated and discussed the socio-economic impact of setting minimum caseloads for CRC. RESULTS The correlations of caseloads of hospitals or surgeons turned out to be highly controversial concerning the influence of HV or SV on short- and long-term surgical treatment quality of CRC. Specialized statisticians made the point that the reports in the literature might not use the optimal biometrical analytical/reporting methods. A Dutch analysis showed that if a decision towards minimum caseloads, e.g. >50 for CRC resections, would be made, this would exclude a lot of hospitals with proven good treatment quality and include hospitals with a treatment quality below average. Our economic analysis envisioned that a yearly loss of EUR <830,000 might ensue for hospitals with volumes <50 per year. CONCLUSIONS Caseload (HV, SV) definitely is an inconsistent surrogate parameter for treatment quality in the surgery of CC, RC, or CRC. If used at all, the lowest tolerable numbers but the highest demands for structural, process and result quality in the surgical/interdisciplinary treatment of CC and RC must be imposed and independently controlled. Hospitals fulfilling these demands should be medically and socio-economically preferred concerning the treatment of CC and RC patients.
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Affiliation(s)
- Karl-Heinrich Link
- Department of Surgery, Asklepios Paulinen Klinik, Wiesbaden, Germany
- Forschungsgruppe Onkologie Gastrointestinale Tumoren (FOGT), University of Ulm, Ulm, Germany
| | - Peter Coy
- Department of Health Economics, RheinMain University of Applied Sciences, Wiesbaden, Germany
| | - Mark Roitman
- Department of Surgery, Asklepios Paulinen Klinik, Wiesbaden, Germany
| | - Carola Link
- Forschungsgruppe Onkologie Gastrointestinale Tumoren (FOGT), University of Ulm, Ulm, Germany
| | - Marko Kornmann
- Forschungsgruppe Onkologie Gastrointestinale Tumoren (FOGT), University of Ulm, Ulm, Germany
- Department of General and Visceral Surgery, University of Ulm, Ulm, Germany
| | - Ludger Staib
- Forschungsgruppe Onkologie Gastrointestinale Tumoren (FOGT), University of Ulm, Ulm, Germany
- Department of General and Visceral Surgery, Klinikum Esslingen, Esslingen, Germany
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