Outcomes Of Colorectal Cancer Surgery Research Articles

Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Audit and Outcome Reporting.

Defining quality in colorectal cancer surgery is complex. Single metrics that describe safety or performance fail to adequately describe the complexity of colorectal care (Almoudaris et al., 2013). Meaningful performance measurement is dependent upon a) case-mix adjustment, b) an understanding of volume-outcome effects and c) reliable data sources. Old age and patient co-morbidity significantly increase the likelihood of peri-operative events and mortality. To enable comparison of surgical performance, adjustment must be made for case-mix differences between providers. Scoring systems, such as Charlson (Charlson et al., 1987) and Elixhauser (Elixhauser et al., 1998) are used widely to case-mix adjust models derived from large clinical datasets. Currently risk stratification models used for comparison of outcomes have limitations as they do not adjust for case mix, including BMI (body mass index) and socio-economic deprivation (Harris et al., 2009; Haydon et al., 2006). The main data sources in the United Kingdom are; The National Bowel Cancer Audit (NBOCA) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) delivered by the Health and Social Care Information Centre working in collaboration with the ACPGBI. The data are submitted from various NHS Trusts in the UK and the Republic of Ireland via the Open Exeter system. These data are used to examine variation in surgical practice, to describe outcome following colorectal resections for cancer and to derive predictive models of mortality (Tan et al., 2007; Tekkis et al., 2003; Tilney et al., 2009). Findings are disseminated in an annual report. These datasets are primarily collected for administrative purposes but are increasingly used for clinical performance benchmarking. The Hospital Episode Statistics (HES) represents the dataset for NHS England [www.hesonline.nhs.uk] and Information Services Division Scotland (ISD) for Scotland [www.isdscotland.org]. Such databases comprise of clinical codes that relate to diagnoses, procedures and demographic information. These data can be used to examine procedure volumes and basic clinical outcomes, including inpatient mortality rates, readmission rates and length of hospital stay. HES data have been linked to other national datasets such as the Office of National Statistics and the Cancer Registry for additional clinical and outcome information, such as out-of-hospital survival and tumour staging. The latter National Cancer Data Repository (NCDR) has recently been used in research studies to compare institutional mortality rates following colorectal surgery in England (Morris et al., 2011). The NCDR can also been linked to the national Radiotherapy Dataset (RTDS) to investigate patterns of management of rectal cancer across the English NHS (Morris et al., 2016). Surgeon level reporting of colorectal cancer surgery outcomes to the UK public was introduced in 2013. Capture of information on patients undergoing planned colorectal resection for cancer (excluding appendiceal neoplasms) are included in analyses. Surgeon level reporting has been spearheaded by Cardiac Surgeons but there are concerns amongst many surgeons that unit level reporting may be more appropriate. The ACPGBI agreed to participate in the process as the Department of Health stated that it would proceed with, or without the involvement of the ACPGBI. There are concerns regarding the quality of data and limitations of their interpretation. There are discrepancies in both information technology infrastructure and the availability of data capture personnel. As of 2013, NHS England (through the Healthcare Quality Improvement Partnership) has published 90-day risk-adjusted mortality figures for colorectal cancer patients undergoing planned surgery on a hospital and surgeon basis. This is based on data submitted to NBOCA. Monitoring of outcomes is required to define acceptable quality of care in elective colorectal cancer surgery. For the reasons already cited comparison can only be made when funnel plots are used to adjust for operative volumes, when data are reliable and when case-mix has been adjusted for. Outcomes for emergency surgery are generally less favourable. The following figures represent some published outcomes following elective colorectal cancer surgery: Surgeons and trusts must make provisions for the prospective collection of accurate clinical data for submission to the National Bowel Cancer Audit (NBOCA). Recommendation grade B Omar Faiz has no conflicts of interest to declare.

A comparative study of short-term outcomes of colorectal cancer surgery in the elderly population

Background: Colorectal Cancer (CRC) is a disease of the elderly, and with an ageing population, oncological surgical procedures for CRC in the elderly is expected to increase. However, the balance between surgical benefits and risks associated with age and comorbidities in elderly patients is obscure.Materials and methods: A retrospective database of consecutive patients who received CRC surgery was used to compare short-term surgical and oncological outcomes between patients aged ≥75 and <75 years old undergoing CRC resection.Results: There were 54 patients (63.5%) in the <75 group and 31 patients (36.5%) in the ≥75 group. Overall, there were no differences between the <75 and ≥75 groups in postoperative HDU/ITU stay, median hospital LOS or 30-day mortality rates. Patients ≥75 had a higher preoperative performance status (25.9% versus 71.0%, p < .001), but no difference in ASA Grade and referral pattern, proportion of emergency operations, cancer staging, resection margins, achievement of curative resection or median lymph node yield. There was a significantly higher use of adjuvant chemotherapy in the <75 age group (48.1% versus 25.8%, p = .043).Conclusions: With adequate patient selection, CRC resection in elderly patients is not associated with higher postoperative mortality or worse short-term oncological benefits.

The Effect of Diabetes on the Perioperative Outcomes of Colorectal Cancer Surgery Patients.

There are approximately 1.3 million patients in Australia with diabetes. Conflicting reports exist in the literature as to the effect of diabetes on the outcomes of colorectal cancer patients. We hypothesized that patients with diabetes would have poorer perioperative outcomes, and that diabetes was an independent risk factor for both 30-day mortality and perioperative morbidity. The aim of this study was to assess the impact of diabetes on perioperative colorectal cancer surgery outcomes, as compared to a diabetes-free reference population, and to examine factors affecting perioperative risk. We conducted an analysis of a prospectively collected, clinician-led colorectal cancer database of patients from 2010–2015. Patients with diabetes were compared to patients without diabetes on a range of perioperative outcomes. Pearson χ-squared tests, Wilcoxon rank sum tests and t-tests were employed for univariate analyses. Confounding factors were controlled for by separate logistic and linear regression analyses. The Huber-White Sandwich Estimator was used to calculate robust standard errors. A total of 1725 patients were analysed over 1745 treatment episodes in the study period with 267 patients (268 episodes) with diabetes studied. Diabetes contributed to medical, surgical complications, and increased length of inpatient stay in univariate analyses. Multivariable analysis adjusted for variables independently associated with each outcome revealed that diabetes was an independent contributor to an increased risk of surgical complications, with no significant effect on medical complications, return to the operating room, 30-day mortality, or readmission within 30 days. In this study, where overall baseline morbidity and mortality levels are low, the effect of diabetes alone on perioperative surgical outcomes appears to be overstated with control of associated perioperative risk factors such as cardiac, renal and respiratory factors being more important.

Prior Bariatric Surgery Is Linked to Improved Colorectal Cancer Surgery Outcomes and Costs: A Propensity-Matched Analysis.

Morbid obesity is associated with worse colorectal cancer (CRC) perioperative outcomes. The impact of bariatric surgery on these outcomes is unknown. The National Inpatient Sample Database (2006-2012) was used to identify adults with prior bariatric surgery (divided into BMI ≤35kg/m2 and BMI >35kg/m2) or morbid obesity that underwent CRC surgery. Main outcomes were mortality, surgical complications and health care utilization. There were 1813 patients with prior bariatric surgery and 22,552 morbidly obese patients that underwent CRC surgery between 2006 and 2012. Prior bariatric surgery patients were younger, with fewer comorbidities, and had less emergency CRC surgery admissions (p<0.05). Multivariate analyses revealed no adverse association (OR 0.54, 95% CI=0.16 to 1.79) between prior bariatric surgery and CRC perioperative mortality. Notably, multivariate analysis revealed that bariatric surgery patients undergoing CRC surgery had fewer accidental surgical lacerations (OR 0.38, 95% CI=0.15 to 0.93), shorter hospitalizations (-1.85days, 95% CI=2.03 to 1.67), decreased total hospital costs (US$-5374, 95% CI=-5935 to -4813) and lower disposition to short-term rehabilitation facilities (OR 0.65, 95% CI=-0.43 to 0.97). Propensity score matched analysis validated these reductions in surgical complications and health care utilization in bariatric surgery patients, which were further more pronounced when bariatric surgery patients were restricted to BMI ≤35kg/m2. Analysis of national-level data demonstrates that prior bariatric surgery is associated with fewer colorectal cancer surgical complications and improved health care resource utilization compared to morbidly obese patients. These findings emphasize and extend the therapeutic effect of bariatric surgery to the colorectal cancer perioperative setting.

Race/ethnicity and socio-economic differences in colorectal cancer surgery outcomes: analysis of the nationwide inpatient sample.

BackgroundThe purpose of this study was to examine racial and socio-economic differences in the receipt of laparoscopic or open surgery among patients with colorectal cancer, and to determine if racial and socio-economic differences exist in post-surgical complications, in-hospital mortality and hospital length of stay among patients who received surgery.MethodsWe conducted a cross-sectional analysis of hospitalized patients with a primary diagnosis of colorectal cancer between 2007 and 2011 using data from Nationwide Inpatient Sample. ICD-9 codes were used to capture primary diagnosis, surgical procedures, and health outcomes during hospitalization. We used logistic regression analysis to determine racial and socio-economic predictors of surgery type, post-surgical complications and mortality, and linear regression analysis to assess hospital length of stay.ResultsA total of 122,631 patients were admitted with a primary diagnosis of malignant colorectal cancer between 2007 and 2011. Of these, 17,327 (14.13 %) had laparoscopic surgery, 70,328 (57.35 %) received open surgery, while 34976 (28.52 %) did not receive any surgery. Black (36 %) and Hispanic (34 %) patients were more likely to receive no surgery compared with Whites (27 %) patients. However, among patients that received any surgery, there were no racial differences in which surgery was received (laparoscopic versus open, p = 0.2122), although socio-economic differences remained, with patients from lower residential income areas significantly less likely to receive laparoscopic surgery compared with patients from higher residential income areas (OR: 0.74, 95 % CI: 0.70-0.78). Among patients who received any surgery, Black patients (OR = 1.07, 95 % CI: 1.01-1.13), and patients with Medicare (OR = 1.16, 95 % CI: 1.11-1.22) and Medicaid (OR = 1.15, 95 % CI: 1.07-1.25) insurance experienced significantly higher post-surgical complications, in-hospital mortality (Black OR = 1.18, 95 % CI: 1.00-1.39), and longer hospital stay (Black β = 1.33, 95 % CI: 1.16-1.50) compared with White patients or patients with private insurance.ConclusionRacial and socio-economic differences were observed in the receipt of surgery and surgical outcomes among hospitalized patients with malignant colorectal cancer in the US.

Colorectal Cancer Surgery in the Very Elderly: Nonagenarians.

Surgery in the very elderly is a topic that has not been well studied, despite the steady rise in this population. With the rise in this population, there is now discussion on the safety of surgery in this cohort for colorectal cancer. The purpose of this study was to investigate elective and nonelective colorectal cancer surgery outcomes in patients aged ≥90 years at both private and public hospitals in Melbourne, Victoria, Australia. This was a retrospective analysis of patients aged ≥90 years who were included in the prospectively maintained Cabrini Monash University Department of Surgery colorectal neoplasia database for patients entered between January 2010 and February 2015. Comorbidity, ASA score, acuity of surgery, treatment, mortality, morbidity, and survival were analyzed. This study was conducted in a tertiary referral hospital. A total of 48 patients were identified from the database. The majority of these patients were women (58.0%), ASA score III to IV (91.7%), and treated in an elective setting (79.2%). The median age was 91.8 years. We measured 30-day mortality, 180-day mortality, and perioperative morbidity. Thirty-day mortality rate was 2.1%. The 180-day mortality rate was 10.4%. A total of 29.2% of patients had a perioperative complication. Median follow-up was 21 months (range, 13-54 months). In 180-day mortality, minimally invasive surgery was associated with a lower mortality rate vs open surgery (p = 0.043). Perioperative complications were associated with nonelective surgery (p = 0.045), open surgery procedures (p = 0.014), and higher stages of disease (p = 0.014). A total of 81.3% of patients were able to return home after surgery. This was a retrospective study with the usual limitations; however, these have been minimized with the use of a high-quality, prospective data collection database. The median follow-up was 21 months. Colorectal surgery was generally safe for nonagenarians in this study. This study demonstrates that excellent outcomes can be achieved in a selected group. Additional prospective studies with larger numbers and 5-year follow-up are recommended.

Impact of intraoperative blood loss on morbidity and survival after radical surgery for colorectal cancer patients aged 80 years or older.

This study aimed to assess the effect of intraoperative blood loss (IBL) on short- and long-term outcomes of colorectal cancer surgery for very elderly patients. We acquired the data of consecutive patients aged 80 years or older who underwent elective radical surgery for stage I to III colorectal cancer between January 2003 and December 2007 in 41 institutions. The patients were divided into high and low IBL groups, and the differences in postoperative morbidity and survival between the two groups were primarily assessed. Eleven factors were treated as potential confounders in multivariate analyses. A total of 1554 patients were eligible for this study, with an age range of 80-103 years. Median IBL was 71 ml (interquartile range, 25 to 200 ml), and 412 patients had IBL ≥200 ml. Morbidity was 46% among patients with IBL ≥200 ml, compared with 30 % among those with IBL <200 ml (p < 0.001). Patients with IBL ≥200 ml had worse overall survival rates and recurrence-free survival rates at 1, 3, and 5 years than those with IBL <200 ml. In multivariate analyses, IBL ≥200 ml was identified as an independent risk factor for postoperative adverse events (odds ratio (OR) 1.41, 95% confidence interval (CI) 1.08 to 1.86), overall survival (hazard ratio (HR) 1.34, 95% CI 1.04 to 1.72), and recurrence-free survival (HR 1.29, 95% CI 1.03 to 1.62). The degree of IBL is significantly associated with postoperative morbidity and survival in very elderly colorectal cancer patients.

Assessing measures of comorbidity and functional status for risk adjustment to compare hospital performance for colorectal cancer surgery: a retrospective data-linkage study.

BackgroundComparing outcomes between hospitals requires consideration of patient factors that could account for any observed differences. Adjusting for comorbid conditions is common when studying outcomes following cancer surgery, and a commonly used measure is the Charlson comorbidity index. Other measures of patient health include the ECOG performance status and the ASA physical status score. This study aimed to ascertain how frequently ECOG and ASA scores are recorded in population-based administrative data collections in New South Wales, Australia and to assess the contribution each makes in addition to the Charlson comorbidity index in risk adjustment models for comparative assessment of colorectal cancer surgery outcomes between hospitals.MethodsWe used linked administrative data to identify 6964 patients receiving surgery for colorectal cancer in 2007 and 2008. We summarised the frequency of missing data for Charlson comorbidity index, ECOG and ASA scores, and compared patient characteristics between those with and without these measures. The performance of ASA and ECOG in risk adjustment models that also included Charlson index was assessed for three binary outcomes: 12-month mortality, extended length of stay and 28-day readmission. Patient outcomes were compared between hospital peer groups using multilevel logistic regression analysis.ResultsThe Charlson comorbidity index could be derived for all patients, ASA score was recorded for 78 % of patients and ECOG performance status recorded for only 24 % of eligible patients. Including ASA or ECOG improved the predictive ability of models, but there was no consistently best combination. The addition of ASA or ECOG did not substantially change parameter estimates for hospital peer group after adjusting for Charlson comorbidity index.ConclusionsWhile predictive ability of regression models is maximised by inclusion of one or both of ASA score and ECOG performance status, there is little to be gained by adding ASA or ECOG to models containing the Charlson comorbidity index to address confounding. The Charlson comorbidity index has good performance and is an appropriate measure to use in risk adjustment to compare outcomes between hospitals.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-015-0175-1) contains supplementary material, which is available to authorized users.

Patient-reported care coordination and outcomes of colorectal cancer surgery.

6516 Background: Care coordination is an essential component of effective, patient-centered cancer care. Yet little is known about the impact of patient reported care coordination on clinical outco...

Influence of Individual Surgeon Volume on Oncological Outcome of Colorectal Cancer Surgery.

Background. Surgery performed by a high-volume surgeon improves short-term outcomes. However, not much is known about long-term effects. Therefore we performed the current study to evaluate the impact of high-volume colorectal surgeons on survival. Methods. We conducted a retrospective analysis of our prospectively collected colorectal cancer database between 2004 and 2011. Patients were divided into two groups: operated on by a high-volume surgeon (>25 cases/year) or by a low-volume surgeon (<25 cases/year). Perioperative data were collected as well as follow-up, recurrence rates, and survival data. Results. 774 patients underwent resection for colorectal malignancies. Thirteen low-volume surgeons operated on 453 patients and 4 high-volume surgeons operated on 321 patients. Groups showed an equal distribution for preoperative characteristics, except a higher ASA-classification in the low-volume group. A high-volume surgeon proved to be an independent prognostic factor for disease-free survival in the multivariate analysis (P = 0.04). Although overall survival did show a significant difference in the univariate analysis (P < 0.001) it failed to reach statistical significance in the multivariate analysis (P = 0.09). Conclusions. In our study, a higher number of colorectal cases performed per surgeon were associated with longer disease-free survival. Implementing high-volume surgery results in improved long-term outcome following colorectal cancer.

PP098-SUN: The Influence of Preoperative Nutritional Status on the Short-Term Outcomes of Colorectal Cancer Surgery Within an Enhanced Recovery Program

PP098-SUN: The Influence of Preoperative Nutritional Status on the Short-Term Outcomes of Colorectal Cancer Surgery Within an Enhanced Recovery Program

Hospital and geographic variability in two colorectal cancer surgery outcomes: complications and mortality after complications.

The purpose of this study was to describe hospital and geographic variation in 30-day risk of surgical complications and death among colorectal cancer (CRC) patients and the extent to which patient-, hospital-, and census-tract-level characteristics increased risk of these outcomes. We included patients at least 66years old with first primary stage I-III CRC from the 2000-2005 National Cancer Institute's Surveillance, Epidemiology, and End Results data linked with 1999-2005 Medicare claims. A multilevel, cross-classified logistic model was used to account for nesting of patients within hospitals and within residential census tracts. Outcomes were risk of complications and death after a complication within 30days of surgery. Data were analyzed for 35,946 patients undergoing surgery at 1,222 hospitals and residing in 12,187 census tracts; 27.2% of patients developed complications, and of these 13.4% died. Risk-adjusted variability in complications across hospitals and census tracts was similar. Variability in mortality was larger than variability in complications, across hospitals and across census tracts. Specific characteristics increased risk of complications (e.g., census-tract-poverty rate, emergency surgery, and being African-American). No hospital characteristics increased complication risk. Specific characteristics increased risk of death (e.g. census-tract-poverty rate, being diagnosed with colon (versus rectal) cancer, and emergency surgery), while hospitals with at least 500 beds showed reduced death risk. Large, unexplained variations exist in mortality after surgical complications in CRC across hospitals and geographic areas. The potential exists for quality improvement efforts targeted at the hospital and/or census-tract levels to prevent complications and augment hospitals' ability to reduce mortality risk.

Colorectal Cancer Surgery Outcomes for Vulnerable Patients in Safety-net versus Non-safety-net Hospitals

Extensive research documents disparities in health outcomes for vulnerable populations. Safety-net hospitals-those that serve a greater proportion of vulnerable patients with Medicaid or no insurance-may yield better outcomes for these vulnerable patients because of their expertise with this population. National Inpatient Sample data from 2005-2007 show that predicted rates of complications following colorectal cancer surgery are approximately 20% lower for vulnerable patients in safety-net than in non-safety-net hospitals (0.273 versus 0.340; 95% CI for the difference: -0.11, -0.001). Differences by safety-net status for Medicare and privately-insured patients were smaller and not statistically significant. The lower complication rates are not due to earlier discharge, as vulnerable patients had significantly longer stays at safety-net hospitals (1.79 days; 95% CI 0.13, 3.40). Additional research is needed to determine whether improvement in post-operative outcomes is due to the expertise of safety-net hospitals in caring for patients with Medicaid or no insurance.

高齢者（80歳以上）大腸癌に対する手術成績の検討

高齢者（80歳以上）大腸癌に対する手術成績の検討

Burden of Emergency and Non-emergency Colorectal Cancer Surgeries in West Virginia and the USA

Elective surgical resection is the curative treatment for colorectal cancer (CRC). Up to 30 % of patients present as surgical emergencies. The objective was to determine the association between presenting with an emergency condition and consequent outcomes of CRC surgery in the Appalachian state of West Virginia (WV) in comparison to the rest of the USA. Patients diagnosed with CRC who underwent a surgical procedure from January 1, 2003 to December 31, 2007 were selected, and those with a diagnosis requiring emergency surgery were identified. Primary outcome measures were length of stay (LOS), total hospital charges, and inpatient death. Mean LOS was higher for WV. Mean charges were higher for the USA than for WV. Inpatient deaths in WV were greater than the rest of the USA. Those undergoing emergency surgery spent 51.9 % (β=0.40) more days in the hospital than those who did not. For WV, LOS was 7.6 % (β=0.07) higher than that of the US. Hospital charges for those that underwent emergency resection were 68.3 % (β=0.52) higher than those who did not. The odds of in-hospital death were 1.68 (95 % CI=1.42-1.98) times greater in WV than in the USA. Those that underwent emergency surgery had a nearly four times (OR 3.88; 95 % CI=3.74-4.03) greater chance of in-hospital death. The study stresses the ongoing burden of emergency surgeries in many states around the nation and the need to increase awareness about CRC screening practices, especially in patients who are at increased risk of the disease.

Colorectal Cancer Surgery Outcomes Fall With Transfusions

Colorectal Cancer Surgery Outcomes Fall With Transfusions

Workload and surgeon´s specialty for outcome after colorectal cancer surgery

A large body of research has focused on investigating the effects of healthcare provider volume and specialization on patient outcomes including outcomes of colorectal cancer surgery. However there is conflicting evidence about the role of such healthcare provider characteristics in the management of colorectal cancer. To examine the available literature for the effects of hospital volume, surgeon caseload and specialization on the outcomes of colorectal, colon and rectal cancer surgery. We searched Cochrane Central Register of Controlled Trials (CENTRAL), and LILACS using free text search words (as well as MESH-terms). We also searched Medline (January 1990-September 2011), Embase (January 1990-September 2011) and registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. Non-randomised and observational studies that compared outcomes for colorectal cancer, colon cancer and rectal cancer surgery (overall 5-year survival, five year disease specific survival, operative mortality, 5-year local recurrence rate, anastomotic leak rate, permanent stoma rate and abdominoperineal excision of the rectum rate) between high volume/specialist hospitals and surgeons and low volume/specialist hospitals and surgeons. Two review authors independently abstracted data and assessed risk of bias in included studies. Results were pooled using the random effects model in unadjusted and case-mix adjusted meta-analyses. Overall five year survival was significantly improved for patients with colorectal cancer treated in high-volume hospitals (HR=0.90, 95% CI 0.85 to 0.96), by high-volume surgeons (HR=0.88, 95% CI 0.83 to 0.93) and colorectal specialists (HR=0.81, 95% CI 0.71 to 0.94). Operative mortality was significantly better for high-volume surgeons (OR=0.77, 95% CI 0.66 to 0.91) and specialists (OR=0.74, 95% CI 0.60 to 0.91), but there was no significant association with higher hospital caseload (OR=0.93, 95% CI 0.84 to 1.04) when only case-mix adjusted studies were included. There were differences in the effects of caseload depending on the level of case-mix adjustment and also whether the studies originated in the US or in other countries. For rectal cancer, there was a significant association between high-volume hospitals and improved 5-year survival (HR=0.85, 95% CI 0.77 to 0.93), but not with operative mortality (OR=0.97, 95% CI 0.70 to 1.33); surgeon caseload had no significant association with either 5-year survival (HR=0.99, 95% CI 0.86 to 1.14) or operative mortality (OR=0.86, 95% CI 0.62 to 1.19) when case-mix adjusted studies were reviewed. Higher hospital volume was associated with significantly lower rates of permanent stomas (OR=0.64, 95% CI 0.45 to 0.90) and APER (OR=0.55, 95% CI 0.42 to 0.72). High-volume surgeons and specialists also achieved lower rates of permanent stoma formation (0.75, 95% CI 0.64 to 0.88) and (0.70, 95% CI 0.53 to 0.94, respectively). The results confirm clearly the presence of a volume-outcome relationship in colorectal cancer surgery, based on hospital and surgeon caseload, and specialisation. The volume-outcome relationship appears somewhat stronger for the individual surgeon than for the hospital; particularly for overall 5-year survival and operative mortality, there were differences between US and non-US data, suggesting provider variability at hospital level between different countries, making it imperative that every country or healthcare system must establish audit systems to guide changes in the service provision based on local data, and facilitate centralisation of services as required. Overall quality of the evidence was low as all included studies were observational by design. In addition there were discrepancies in the definitions of caseload and colorectal specialist. However ethical challenges associated with the conception of randomised controlled trials addressing the volume outcome relationship makes this the best available evidence.

Surgeon and hospital-related risk factors in colorectal cancer surgery

The aim of this study was to identify surgeon and hospital-related factors in a well-defined population-based cohort; the results of this study could possibly be used to improve outcome in colorectal cancer. Data from the colonic (1997-2006) and rectal (1995-2006) cancer registers of the Uppsala/Örebro Regional Oncology Centre were used to assess 1697 patients with rectal and 2692 with colonic cancer. Putative risk factors and their impact on long-term survival were evaluated using the Cox proportional hazard model. The degree of specialization of the operating surgeon had no significant effect on long-term survival. When comparing the surgeons with the highest degree of specialization, noncolorectal surgeons demonstrated a slightly lower long-term survival for rectal cancer stage I and II (HR, 2.03; 95% CI, 1.05-3.92). Surgeons with a high case-load were not associated with better survival in any analysis model. Regional hospitals had a lower survival rate for rectal cancer stage III surgery (HR, 1.47; 95% CI, 1.08-2.00). Degree of specialization, surgeon case-load and hospital category could not be identified as important factors when determining outcome in colorectal cancer surgery in this study.

Colorectal cancer surgery in the elderly: limitations and drawbacks

The purpose of this study was to evaluate the outcomes of colorectal cancer surgery among the elderly. From March 2002 until February 2010, 434 patients who presented to our institution with the initial diagnosis of colorectal cancer and were submitted to open curative colorectal cancer resections or some kind of palliative procedure either elective or emergencies were retrospectively reviewed. A total of 286 of these patients (65.8%) were below 75 years (group A) and 148 (34.2%) above 75 years (group B). A procedure with curative intent was undertaken in 386 patients (88.9%), while forty-eight patients (11.1%) were submitted to a palliative procedure. Regarding the incidence of emergency operations, forty-five patients (15.7%) from group A and forty-four patients (29.7%) from group B were operated due to an emergency (obstructing, perforating or bleeding tumors; P < 0.001). Mean ASA score was 1.74 ± 0.84 and 2.32 ± 0.94 for groups A and B, respectively (P < 0.001). Mean TNM stage was 2.28 ± 1.00 and 2.74 ± 0.98 for groups A and B, respectively (P = 0.0001). Elderly patients exhibited increased incidence of post-operative complications and increased post-operative mortality compared with their younger counterparts (P = 0.002 and 0.001, respectively). Colorectal cancer surgery in the elderly is a challenging clinical scenario. Treatment decision adjusted to each individual case is the ideal practice in order to maintain an acceptable balance between curative cancer resections and palliative procedures.

Volume and outcome in colorectal cancer surgery

Aims There is a growing consensus to concentrate high-risk surgical procedures to high volume surgeons in high volume hospitals. However, there is fierce debate about centralizing more common malignancies such as colorectal cancer. The objective of this review is to conduct a meta-analysis using the best evidence available on the volume-outcome relationship for colorectal cancer treatment. Methods A systematic search was performed to identify all relevant articles studying the relation between hospital and/or surgeon volume and clinical outcomes for colorectal cancer. Using strict inclusion criteria, 23 articles were selected concerning colon cancer, rectal cancer or both diseases together as ‘colorectal cancer’. Pooled estimated effect sizes were calculated using the casemix adjusted outcomes of the highest volume group opposed to the lowest volume group. Results High volume hospitals have a significantly lower postoperative mortality in half of the pooled results. Non significant results show a trend in favour of high volume hospitals. All results showed a significantly better long term survival in high volume hospitals. High volume surgeons have a lower postoperative mortality, although evidence is sparse. All analyses showed a significantly better long term survival in favour of high volume surgeons. Conclusions The results show a clear and consistent relation between high volume providers and improved long term survival. This applies to both high volume hospitals and high volume surgeons. Most results show a relation between high volume providers and a reduced postoperative mortality, but evidence is less convincing. In the ideal world, extensive population based audit registrations with casemix adjusted feedback should make rigid minimal volume standards obsolete. Until then, using volume criteria for hospitals and surgeons treating colorectal cancer can improve mortality and especially long term survival.