Textbook outcome after rectal cancer surgery as a composite measure for quality of care: A population-based study

BackgroundTextbook outcome is a composite measure of combined outcome indicators, which has been suggested to be of additional value over single outcome parameters in clinical auditing of surgical treatment. This study aimed to assess textbook outcome after rectal cancer surgery as short-term marker for quality of care.Materials and methodsPatients who underwent elective rectal cancer surgery between 2012 and 2019 and registered in the Dutch ColoRectal Audit were included. Textbook outcome was achieved when the following criteria were met: 30-day and primary hospital admission survival, no reintervention, tumour-free margins, no postoperative complications, a hospital stay of less than 14 days and no readmission. Hospital variation was evaluated in case-mix corrected funnel-plots. A multilevel logistic regression analysis was performed to identify associated factors with textbook outcome.ResultsThe study population consisted of 20,521 patients who underwent primary rectal cancer surgery, of whom 56.3% achieved textbook outcome. Postoperative complications were the main contributor to not achieving textbook outcome. Case-mix corrected funnel plots demonstrated that underperforming hospitals in 2012–2015 were no underperformers in 2016–2019 anymore. Female sex, laparoscopic surgery, and rectal resection without defunctioning stoma creation were positively associated with textbook outcome.ConclusionTextbook outcome after rectal cancer resection is mainly driven by postoperative complications. Although textbook outcome showed some discriminating value for identifying underperforming hospitals, it does not fit the plan-do-check-act cycle of clinical auditing. In our opinion, textbook outcome has little added value to the current outcome indicators for rectal cancer surgery.     

Textbook outcome and survival after gastric cancer resection with curative intent: A population-based analysis

BackgroundThe concept of textbook outcome (TO) has been proposed for analyzing quality of surgical care. This study assessed the incidence of TO among patients undergoing curative gastric cancer resection, predictors for TO achievement, and the association of TO with survival.MethodAll patients with gastric and gastroesophageal junction cancers undergoing curative gastrectomy between January 2014–December 2017 were identified from a population-based database (Spanish EURECCA Registry). TO included: macroscopically complete resection at the time of operation, R0 resection, ≥15 lymph nodes removed and examined, no serious postoperative complications (Clavien-Dindo ≥II), no re-intervention, hospital stay ≤14 days, no 30-day readmissions and no 90-day mortality. Logistic regression was used to assess the adjusted achievement of TO. Cox survival regression was used to compare conditional adjusted survival across groups.ResultsIn total, 1293 patients were included, and TO was achieved in 541 patients (41.1%). Among the criteria, “macroscopically complete resection” had the highest compliance (96.5%) while “no serious complications” had the lowest compliance (63.7%). Age (OR 0.53 for the 65–74 years and OR 0.34 for the ≥75 years age group), Charlson comorbidity index ≥3 (OR 0.53, 95%CI 0.34–0.82), neoadjuvant chemoradiotherapy (OR 0.24, 95%CI 0.08–0.70), multivisceral resection (OR 0.55, 95%CI 0.33–0.91), and surgery performed in a community hospital (OR 0.65, CI95% 0.46–0.91) were independently associated with not achieving TO. TO was independently associated with conditional survival (HR 0.67, 95%CI 0.55–0.83).ConclusionTO was achieved in 41.1% of patients who underwent gastric cancer resection with curative intent and was associated with longer survival.     

A multi-institutional analysis of Textbook Outcomes among patients undergoing cytoreductive surgery for peritoneal surface malignancies

BackgroundWhile recent studies have introduced the composite measure of a textbook outcome (TO) for measuring postoperative outcomes, the incidence of a TO has not been characterized among patients undergoing cytoreductive surgery (CRS) for peritoneal surface malignancies (PSM).Study designAll patients who underwent CRS ± hyperthermic intraperitoneal chemotherapy (HIPEC) between 1999 and 2017 from 12 institutions were included. A TO was defined as the absence of any of the following criteria: completeness of cytoreduction >1, reoperation within 90-days, readmission within 90-days, mortality within 90-days, any grade ≥2 complication, hospital stay >75th percentile, and non-home discharge.ResultsAmong 1904 patients who underwent CRS, only 30.9% achieved a TO while 69.1% failed to achieve a TO most commonly because of postoperative complications. On multivariable analysis, factors associated with achieving a TO were age <65 years (OR: 1.5), albumin ≥3.5 g/dl (OR: 5.7), receipt of HIPEC (OR: 4.5), PCI ≤14 (OR: 2.2), intravenous fluid volume ≤10,000 ml (OR: 2.1), blood loss ≤1000 ml (OR: 4.2) and operative time <7 h (OR: 1.9); while receipt of neoadjuvant therapy (OR: 0.7) and liver resection (OR: 0.4) were associated with not achieving a TO (all p < 0.05). TO was associated with improved overall survival (median 159 months vs 56 months, p < 0.01) even after controlling for confounders on Cox regression (hazard ratio: 2.5, p < 0.01).ConclusionAmong patients undergoing CRS ± HIPEC for PSM, failure to achieve a TO is common and independently associated with worse overall survival.     

Waiting time to surgery and pancreatic cancer survival: A nationwide population-based cohort study

IntroductionThe effect of waiting time to surgery on survival in pancreatic cancer patients is unclear. We examined this association in a nationwide population-based cohort study.Materials and methodsA nationwide population-based cohort study of all patients undergoing surgery for pancreatic cancer (resection or a palliative procedure) registered in the Danish Pancreatic Cancer Database from May 2011 to May 2016. We defined waiting time to surgery in two ways: 1) from the date of entry into the National Cancer Pathway to the date of surgery and 2) from the date of the last preoperative computed tomography (CT) or positron emission tomography (PET-CT) scan to the date of surgery. Waiting time was grouped into three groups: <28 days (<4 weeks), 28–55 days (4–8 weeks), and ≥56 days (≥8 weeks). We calculated median survival with associated 95% confidence intervals (CIs) for patients undergoing resection and for patients undergoing a palliative procedure.ResultsWe included 873 patients. Mean age was 67 years (range: 35–86 years). Resection was performed in 701 patients (80%); the remaining 172 patients (20%) underwent an explorative laparotomy or palliative surgery. 652 patients (75%) had a registration in the National Cancer Pathway (median waiting time: 31 days, and 818 patients (94%) had registration of a preoperative CT or PET-CT scan (median waiting time: 32 days). We saw similar resection rates (∼80%) and median survival (∼22 months) in all thee groups.ConclusionIn this study, waiting time to surgery did not affect survival in patients undergoing surgery for pancreatic cancer.     

Completeness of lymph node dissection in patients undergoing minimally invasive- or open surgery for non-small cell lung cancer: A nationwide study

ObjectiveIn patients with NSCLC, lymph node metastases are an important prognostic factor. Despite an accurate pre-operative work up, for optimal staging an intrapulmonary- and mediastinal lymph node dissection (LND) as part of the operation is mandatory. The aim of this study is to assess the completeness of LND in patients undergoing an intended curative resection for NSCLC in the Netherlands and to compare performance between open surgery and minimally invasive surgery (MIS).Materials and methodsThe intraoperative LND was evaluated in 7460 patients who had undergone a lobectomy for clinically staged N0-1 NSCLC (2013–2018). The LND was considered complete, when three mediastinal (N2) lymph node stations, including station 7, were sampled or dissected, in addition to the lymph nodes from station 10 and 11. A comparison was made between open surgery and MIS.ResultsOf 5154 patients, who had MIS, a sufficient intrapulmonary LND was performed in 47.9% and a sufficient mediastinal LND in 58.6%. A complete LND was performed in 31.6%. For 2306 patients who had an open resection, these numbers were 45.0%, 59.0%, and 30.6%, respectively. The overall between-hospital variation in a complete LND ranged between 0 and 72.5%.ConclusionIn the Netherlands, a complete LND of both intrapulmonary- and mediastinal lymph nodes is performed only in a minority of patients with clinically staged N0-1 NSCLC, with substantial between-hospital variation. No differences were seen between open surgery and MIS. Because of poor performance, completeness of lymph node dissection will be recorded as a mandatory performance indicator in our national audit, to improve the quality of resection.     

Textbook Outcome as a measure of surgical quality assessment and prognosis in gastric neuroendocrine carcinoma: A large multicenter sample analysis

ObjectiveQuality assurance is crucial for oncological surgical treatment assessment. For rare diseases, single-quality indicators are not enough. We aim to develop a comprehensive and reproducible measurement, called the “Textbook Outcome” (TO), to assess the quality of surgical treatment and prognosis of gastric neuroendocrine carcinoma (G-NEC) patients.MethodsData from patients with primary diagnosed G-NEC included in 24 high-volume Chinese hospitals from October 2005 to September 2018 were analyzed. TO included receiving a curative resection, ≥15 lymph nodes examined, no severe postoperative complications, hospital stay ≤21 d, and no hospital readmission ≤30 d after discharge. Hospital variation in TO was analyzed using a case mix-adjusted funnel plot. Prognostic factors of survival and risk factors for non-Textbook Outcome (non-TO) were analyzed using Cox and logistic models, respectively.ResultsTO was achieved in 56.6% of 860 G-NEC patients. TO patients had better overall survival (OS), disease-free survival (DFS), and recurrence-free survival (RFS) than non-TO patients (P<0.05). Moreover, TO patients accounted for 60.3% of patients without recurrence. Multivariate Cox analysis revealed non-TO as an independent risk factor for OS, DFS, and RFS of G-NEC patients (P<0.05). Increasing TO rates were associated with improved OS for G-NEC patients, but not hospital volume. Multivariate logistic regression revealed that non-lower tumors, open surgery, and >200 mL blood loss were independent risk factors for non-TO patients (P<0.05).ConclusionsTO is strongly associated with multicenter surgical quality and prognosis for G-NEC patients. Factors predicting non-TO are identified, which may help guide strategies to optimize G-NEC outcomes.     

A radiofrequency-assisted device for bloodless rapid transection of the liver: A comparative study in a pig liver model

Background

Efficient and safe liver parenchymal transection is dependent on the ability to address both parenchymal division and hemostasis simultaneously. In this article we describe and compare with a saline-linked instrument a new radiofrequency (RF)-assisted device specifically designed for tissue thermocoagulation and division of the liver used on an in vivo pig liver model.

Methods

In total, 20 partial hepatectomies were performed on pigs through laparotomy. Two groups were studied: group A (n = 8) with hepatectomy performed using only the proposed RF-assisted device and group B (n = 8) with hepatectomy performed using only a saline-linked device. Main outcome measures were: transection time, blood loss during transection, transection area, transection speed and blood loss per transection area. Secondary measures were: risk of biliary leakage, tissue coagulation depth and the need for hemostatic stitches. Tissue viability was evaluated in selected samples by staining of tissue NADH.

Results

In group A both blood loss and blood loss per transection area were lower (p = 0.001) than in group B (70 ± 74 ml and 2 ± 2 ml/cm² vs. 527 ± 273 ml and 13 ± 6 ml/cm², for groups A and B, respectively). An increase in mean transection speed when using the proposed device over the saline-linked device group was also demonstrated (3 ± 0 and 2 ± 1 cm²/min for group A and B, respectively) (p = 0.002). Tissue coagulation depth was greater (p = 0.005) in group A than in group B (6 ± 2 mm and 3 ± 1 mm, for groups A and B, respectively). Neither macroscopic nor microscopic differences were encountered in transection surfaces between both groups.

Conclusions

The proposed RF-assisted device was shown to address parenchymal division and hemostasis simultaneously, with less blood loss and faster transection time than saline-linked technology in this experimental model.     

Safety and feasibility of robotic major hepatectomy for novice surgeons in robotic liver surgery: A prospective multicenter pilot study

BackgroundRobotic liver resection has not yet been widely implemented. We aimed to evaluate the feasibility and safety of robotic major liver resection by performing a prospective multicenter study.MethodsFrom July 2017 to December 2018, five surgeons from five tertiary hospitals who were novices in robotic liver resection but experienced in open and laparoscopic liver resection performed 46 cases of robotic major anatomical liver resections. Perioperative clinical data and surgical data, including detailed procedure times were prospectively collected. All operations were performed according to a protocol for unify surgical techniques and instruments.ResultsTwenty-two cases of left hemihepatectomy, one case of extended left hemihepatectomy, 14 cases of right hemihepatectomy, two cases of right anterior sectionectomy, six cases of right posterior sectionectomy, and one case of central bisectionectomy were performed. The most common indications were hepatocellular carcinoma (21 cases) followed by intrahepatic duct stones (10 cases), intrahepatic cholangiocellular carcinoma (7 cases), liver metastases (3 cases), intraductal papillary neoplasms (2 cases), sarcoma (1 case), mucinous cystic neoplasm (1 case), and hemangioma (1 case). Surgical resection margins for all tumor cases were negative. The mean operation time was 378.58 ± 124.31 (190–696) minutes and the estimated intraoperative blood loss was 276.67 ± 397.41 mL (range, 10–2600 mL). Overall complications developed in 16 cases (34.8%). There were three cases of severe surgical complications (Clavien-Dindo classification of III or more). Only one of 46 cases was converted to conventional open left hemihepatectomy because of bleeding. The mean hospital stay was 7.3 ± 2.5 (4–18) days.ConclusionsThe results of this study indicate that robotic anatomic major liver resection can be safely performed by robotic beginners who are advanced open and laparoscopic liver surgeons.     

Selection for surgery and survival of synchronous colorectal liver metastases; a nationwide study

BackgroundResection of colorectal liver metastases (CRLM) is associated with improved survival but we currently have limited population-based data on selection for surgery.MethodsPatients in the Swedish Colorectal Cancer Register reported with liver metastases at diagnosis in 2007–2011 were identified. Clinical characteristics including American Society of Anesthesiologists classification, type of hospital and health care region were retrieved. Linkage to the National Patient Register and Statistics Sweden provided information on liver resection and socioeconomic variables.ResultsSynchronous CRLM was found in 4243/27,990 (15.2%) patients, of whom 1094 (25.8%) also had concurrent lung metastases. Of 3149 patients with liver-only metastases, 556 (17.8%) were subjected to liver resection. The resection rate varied by subsite; right-sided 11.7%, left-sided 19.7% and rectal cancer 22.7% (p = 0.001). It varied by type of hospital 14.1–23.6%, by region 11.5–22.7%, and was 19.8% in men and 14.9% in women (all p < 0.001).The adjusted odds were 0.74 (0.59–0.93) for females, 0.58 (0.46–0.74) for general district and 0.50 (0.37–0.68) for district hospital patients, and there were large regional differences. Patients >75 years were very unlikely to receive liver surgery 0.22 (0.15–0.32).In patients subjected to liver surgery, median survival was 57 months, 5-year survival rate was 45.4%, and those with left-sided colon cancer had the best outcome (48.8%; p = 0.02). Five-year hazard ratio for patients not subjected to liver surgery was 4.3 (3.7–5.0).ConclusionNationwide outcome after resection of synchronous CRLM was impressing but ambiguous selection mechanisms and inaccessibility need to be resolved. The implications of subsite deserve further attention.     

Curative rectal cancer surgery in a low-volume hospital: A quality assessment

Aims

Hospital volume or caseload is often used as a surrogate measure for quality of care in rectal cancer treatment. The aim of this study was to assess outcome in a low-volume hospital and secondly to examine the impact of surgeon volume on the results.

Methods

A retrospective review of 131 patients' charts identified 102 patients receiving apparently curative resections for rectal cancer in the period 1993–2002. Our study population did not differ significantly from the national average except for shift towards more advanced Dukes stage (p = 0.00) and a higher rate of node positive patients at time of diagnosis (p = 0.00).

Results

There were no significant differences from the national outcome results, neither in perioperative mortality or complications, nor 5-year survival or local recurrences. Thirteen different on-staff surgeons performed rectal cancer surgery in our hospital in the decade, and median annual caseload was four. We detect a difference in 5-year survival when grouping the surgeons by annual caseload, but the significance is inconclusive. It is, however, interesting that in 85% of the resections, two or more certified gastrointestinal surgeons with specific training were involved. A relatively high number (9%) of discrepancies between the Norwegian Rectal Cancer Registry (NRCR) database and the local hospital database were identified.

Conclusion

Adequate results for surgical outcome can be achieved in a low-volume hospital. Surgeon volume showed inconclusive impact for our results of outcome. A local quality initiative is justified in addition to national registries.     

Survival of patients with colorectal peritoneal metastases is affected by treatment disparities among hospitals of diagnosis: A nationwide population-based study

BackgroundIn the Netherlands, surgery for peritoneal metastases of colorectal cancer (PMCRC) is centralised, whereas PMCRC is diagnosed in all hospitals. This study assessed whether hospital of diagnosis affects treatment selection and overall survival (OS).MethodsBetween 2005 and 2015, all patients with synchronous PMCRC without systemic metastases were selected from the Netherlands Cancer Registry. Treatment was classified as cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), systemic therapy or other/no treatment. Hospitals of diagnosis were classified as: (1) non-teaching or academic/teaching hospital and (2) HIPEC centre or referring hospital. Referring hospitals were further classified based on the frequency of CRS/HIPEC as high-, medium- or low-frequency hospital. Multivariable regression analyses were used to assess the independent influence of hospital categories on the likelihood of CRS/HIPEC and OS.ResultsA total of 2661 patients, diagnosed in 89 hospitals, were included. At individual hospital level, CRS/HIPEC and systemic therapy ranged from 0% to 50% and 6% to 67%, respectively. Hospital of diagnosis influenced the likelihood of CRS/HIPEC: 33% versus 13% for HIPEC centres versus referring hospitals (odds ratio (OR) 3.66 [2.40−5.58]) and 11% versus 17% for non-teaching hospitals versus academic/teaching hospitals (OR 0.60 [0.47–0.77]). Hospital of diagnosis affected median OS: 14.1 versus 9.6 months for HIPEC centres versus referring hospitals (hazard ratio (HR) 0.82 [0.67–0.99]) and 8.7 versus 11.5 months for non-teaching hospitals versus academic/teaching hospitals (HR 1.15 [1.06–1.26]). Compared with diagnosis in medium-frequency referring hospitals, median OS was increased in high-frequency referring hospitals (12.6 months, HR 0.82 [0.73−0.91]) and reduced in low-frequency referring hospitals (8.1 months, HR 1.12 [1.01–1.24]).ConclusionTreatment disparities among hospitals of diagnosis and their impact on survival indicate suboptimal treatment selection for PMCRC.     

Outcomes following synchronous liver resection,cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal liver and peritoneal metastases: A bi-institutional study

PurposeSynchronous liver resection, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal liver (CRLM) and peritoneal metastases (CRPM) has traditionally been contraindicated. However, latest practice promotes specialist, multidisciplinary-led consideration for select patients. This study aimed to evaluate the perioperative and oncological outcomes of synchronous resection in the management of CRLM and CRPM from two tertiary referral centres.MethodThis bi-institutional, retrospective, cohort study included patients undergoing simultaneous liver resection, CRS and HIPEC for metastatic colorectal cancer from 2013 to 2020. Patients treated with ablative liver techniques, staged operative approaches and extra abdominal disease were excluded. Overall survival (OS) and disease-free survival (DFS) rates were assessed. Univariate and multivariate analyses identified variables associated with survival and major morbidity (Clavien-Dindo grade III/IV).ResultsTwenty-three patients were included. The median peritoneal carcinomatosis index (PCI) was 9 (range 0–22). There were two major liver resections and 21 minor resections. CC-0 resections were achieved in all patients. Major morbidity occurred in 7 patients. There were no deaths at 90 days. PCI was independently associated with morbidity (p = 0.04). PCI >10 (p = 0.069), major morbidity (p = 0.083) and presence of KRAS mutation (p = 0.052) approached significance for poor OS. Median follow up was 21 months (4–54 months). Median OS was 37 months, 3-year survival 54%, and median DFS 18 months.ConclusionSynchronous liver resection, cytoreductive surgery and HIPEC is feasible in selected patients with low-volume CRPM and CRLM. Increasing PCI is associated with postoperative major morbidity, and should be considered during operative planning.     

Survival benefit from axillary surgery in patients aged 70 years or older with clinically node-negative breast cancer: A population-based propensity-score matched analysis

BackgroundOlder patients with breast cancer have good prognosis and most die from diseases other than breast cancer. Previous studies suggested that the surgical extent in older patients could be reduced. We aimed to compare survival outcomes in patients aged ≥70 years with clinically node-negative breast cancer, based on whether axillary surgery was performed.MethodsA total of 2,995 patients with breast cancer aged ≥70 years who underwent breast surgery were included in the Korean Breast Cancer Registry. Patients were classified into two groups according to the performance of axillary surgery. We used propensity score matching for demographic and treatment factors to minimize selection bias. We compared the 5-year overall survival (OS) and breast cancer-specific survival (BCSS).ResultsAmong 708 patients after 3:1 propensity score matching, 531 underwent breast surgery with axillary surgery and 177 underwent breast surgery alone. Of all patients, 51.7% had T1 stage, and 73.2% underwent mastectomy. Approximately 31.2% of patients received chemotherapy. Among patients who did not undergo axillary surgery, the 5-year OS and BCSS rates were 85.2% and 96.7%, respectively. The hazard ratio of axillary surgery for OS was 0.943 (95% confidence interval 0.652–1.365, p = 0.757), indicating no significant difference between two groups.ConclusionsOur study demonstrates that axillary surgery in a matched cohort of older patients with breast cancer and clinically negative nodes does not provide a survival benefit compared to patients undergoing breast surgery alone. These findings suggest that axillary surgery may be safely omitted in a select group of patients aged ≥70 years with clinically node-negative cancer. Further studies are needed to identify potential candidates for omitting axillary surgery.     

Uptake and survival effects of minimally invasive surgery for lung cancer: A population-based study

IntroductionDespite growing evidence supporting the safety of minimally invasive surgery (MIS) in the treatment of lung cancer, its uptake is still variable and its outcomes debated. This study examines the factors associated with MIS uptake and its effects on survival in patients with non-small cell lung cancer (NSCLC).MethodsAll patients in the Canadian province of Ontario with early stage NSCLC (stage I/II) from 2007 to 2017 were included. A logistic regression identified the predictors of MIS uptake, and a flexible parametric model was used to estimate survival rates based on MIS versus open resection.ResultsIn total, 8,988 patients underwent surgical resection; 53.6% had MIS. Year of diagnosis was associated with MIS uptake (OR = 1.33, p < 0.001); patients in later years were more likely to receive MIS. Rurality was a significant predictor of MIS, though distance from nearest regional cancer center did not predict MIS utilization. Patients with stage II disease were less likely to receive MIS compared to those with stage I disease (OR = 0.44, p < 0.001). MIS had a significantly higher 5-year survival compared to open resection for stage I and II disease. Patients >70 years had the greatest 5-year survival benefit from MIS.ConclusionsWe observed a substantial long-term survival benefit in patients undergoing MIS for early stage NSCLC. This difference was most pronounced in the oldest age group. These findings support the use of MIS in the treatment of lung cancer and challenge the notion that MIS compromises oncologic outcomes.     

Survival effects of time to surgery for Stage I lung cancer: A population-based study

ObjectivesTo examine the impact of time to surgery (TTS) on survival among patients with stage I non-small cell lung cancer (NSCLC).MethodsAll patients in the Canadian province of Ontario with stage I NSCLC from 2007 to 2017 were included. A logistic regression identified the predictors of TTS and a flexible parametric model estimated survival rates based on TTS.ResultsOver the study period, 6428 patients with stage I NSCLC undergoing surgical resection were identified, of which 62.5% had TTS >28 days. Less than half these patients (40.8%) underwent open resection, with 19.3% undergoing open sublobar and 21.5% undergoing open lobectomy. Adenocarcinoma and squamous cell carcinoma tumors accounted for 33.3% and 22.0% of cases, respectively. The majority (85.6%) of patients lived in urban areas within 50 km of a regional cancer center (76.9%). Variables that predicted TTS >28 days include age and extent of resection. After adjustment for VATS vs. open resection, age, sex, frailty, year of diagnosis, histology of tumor, and extent of resection, the hazard ratio for TTS >28 days was 1.26 (95%CI:1.13–1.40), indicating a 26% increased risk of all-cause mortality (p < 0.0001). The highest 5-year survival was observed for patients with stage I disease undergoing resection within 28 days.ConclusionsThe present study found age and extent of resection to be associated with increased TTS. Importantly, patients with TTS >28 days had reduced long-term survival.