Quality Of Rectal Cancer Surgery Research Articles

Using Computed-Tomgraphy-Based Pelvimetry and Visceral Obesity Measurements to Predict Total Mesorectal Excision Quality for Patients Undergoing Rectal Cancer Surgery.

A complete total mesorectal excision is the gold standard in curative rectal cancer surgery. Ensuring quality is challenging in a narrow pelvis, and obesity amplifies technical difficulties. Pelvimetry is the measurement of pelvic dimensions, but its role in gauging preoperatively difficulty of proctectomy is largely unexplored. To determine pelvic structural factors associated with incomplete total mesorectal excision following curative proctectomy and build a predictive model for total mesorectal excision quality. Retrospective cohort study. A quaternary referral center database of patients diagnosed with rectal adenocarcinoma (2009-2017). Curative-intent proctectomy for rectal adenocarcinoma. All radiological measurements were obtained from preoperative CT-images using validated imaging processing software tools. Completeness of total mesorectal excision was obtained from histology reports. Ability of radiological pelvimetry and obesity measurements to predict total mesorectal excision quality. Of the 410 cases meeting inclusion criteria, 362 had a complete total mesorectal excision (88%). A multivariable regression identified a deeper sacral curve (per 100 mm2 [OR: 1.14, 95% CI: 1.06-1.23, p < 0.001]), and greater transverse distance of pelvic outlet (per 10 mm [OR:1.41, 95% CI: 1.08-1.84, p = 0.012]) as independently associated with incomplete total mesorectal excision. An increased area of pelvic inlet (per 10 cm2); OR: 0.85, [95% CI: 0.75-0.97, p = 0.02] was associated with a higher rate of complete mesorectal excision. No difference in visceral obesity ratio and visceral obesity (ratio >0.4 vs.<0.4) between body mass index (<30 vs. ≥30) or sex was identified. A model was built to predict mesorectal quality using variables: depth of sacral curve, area of pelvic inlet and transverse distance of pelvic outlet. Retrospective analysis not controlled for choice of surgical approach. Pelvimetry is predictive of total mesorectal excision quality in rectal cancer surgery and can alert surgeons preoperatively to cases of unusual difficulty. This predictive model may contribute to treatment strategy and aid in comparison of outcomes between traditional and novel techniques of total mesorectal excision. See Video Abstract.

Quality of rectal cancer surgery

Quality of rectal cancer surgery

1441 Real-World Comparison of Curative Open, Laparoscopic and Robotic Resections for Sigmoid and Rectal Cancer - Single Center Experience

Abstract Aim There is an increase in the utilization of robotic surgery in addition to traditional open or laparoscopic approaches. The aim of this study is to compare the short-term outcomes for open, laparoscopic, and robotic surgery for rectal and sigmoid cancer. Method One hundred and forty-seven patients (open n = 48, laparoscopic n = 49, robotic n = 50) undergoing curative resections by two surgeons, using a standardized technique, between 2013 and 2020 were included. Data analyzed included patient demographics, tumor characteristics, length of stay, post-operative outcomes, and pathologic surrogates of oncologic results, including total mesorectal excision (TME) quality, circumferential resection margin (CRM) involvement and lymph node (LN) yield. Results Median age of population was 68 years (IQR 59-73), majority (68%) were males. Median distance from anal verge in robotic surgery group was 8 cm, compared to 15 and 14.5 cm in the open and laparoscopic groups respectively, p = 0.029, (laparoscopic vs robotic, p = 0.005 and open vs robotic, p = 0.027). Proportion of patients who received neoadjuvant radiotherapy in robotic surgery group was higher, p = 0.04. In sub-group of tumors between 3 and 7 cm from anal verge more patients in the robotic surgery group had sphincter preservation, p = 0.006. Length of stay, maximum C-reactive protein, and white blood cell rise favored minimally invasive approaches compared to open surgery. There were no differences in post-operative complications, lymph node yield or CRM positivity rate between the three groups. Conclusions Robotic surgery approach is safe and allows sphincter preservation without compromising TME quality in rectal cancer surgery.

Real-world comparison of curative open, laparoscopic and robotic resections for sigmoid and rectal cancer–single center experience

There has been an increase in the utilization of robotic surgery in addition to traditional open or laparoscopic approaches. Aim of this study is to compare the short-term outcomes for open, laparoscopic, and robotic surgery for rectal and sigmoid cancer. One hundred and forty-seven patients (open n = 48, laparoscopic n = 49, robotic n = 50) undergoing curative resections by two surgeons between 2013 and 2020 were included. Data analyzed included patient demographics, tumor characteristics, length of stay, post-operative outcomes, and pathologic surrogates of oncologic results, including total mesorectal excision (TME) quality, circumferential resection margin (CRM) involvement and lymph node (LN) yield. Median age of population was 68years (IQR 59-73), majority (68%) were males. Median distance from anal verge in the robotic surgery group was 8cm, compared to 15 and 14.5cm in the open and laparoscopic groups, respectively, p = 0.029, (laparoscopic vs robotic, p = 0.005 and open vs robotic, p = 0.027). Proportion of patients who received neoadjuvant radiotherapy in robotic surgery group was higher, p = 0.04. In sub-group of tumors between 3 and 7cm from anal verge more patients in the robotic surgery group had sphincter preservation, p = 0.006. Length of stay, maximum C-reactive protein, and white blood cell rise favored minimally invasive approaches compared to open surgery. There were no differences in post-operative complications, lymph node yield or CRM positivity rate between the three groups. Robotic surgery approach is safe and allows sphincter preservation without compromising TME quality in rectal cancer surgery.

A method to audit and score implementation of knowledge translation (KT) interventions in large health regions \u2013 an observational pilot study using rectal cancer surgery in Ontario

BackgroundAcross Ontario, since the year 2006 various knowledge translation (KT) interventions designed to improve the quality of rectal cancer surgery have been implemented by the provincial cancer agency or by individual researchers. Ontario is divided administratively into 14 health regions. We piloted a method to audit and score for each region of the province the KT interventions implemented to improve the quality of rectal cancer surgery.MethodsWe interviewed stakeholders to audit KT interventions used in respective regions over years 2006 to 2014. Results were summarized into narrative and visual forms. Using a modified Delphi approach, KT experts reviewed these data and then, for each region, scored implementation of KT interventions using a 20-item KT Signature Assessment Tool. Scores could range from 20 to 100 with higher scores commensurate with greater KT intervention implementation.ResultsThere were thirty interviews. KT experts produced scores for each region that were bimodally distributed, with an average score for 2 regions of 78 (range 73–83) and for 12 regions of 30.5 (range 22–38).ConclusionOur methods efficiently identified two groups with similar KT Signature scores. Two regions had relatively high scores reflecting numerous KT interventions and the use of sustained iterative approaches in addition to those encouraged by the provincial cancer agency, while 12 regions had relatively low scores reflecting minimal activities outside of those encouraged by the provincial cancer agency. These groupings will be used for future comparative quantitative analyses to help determine if higher KT signature scores correlate with improved measures for quality of rectal cancer surgery.

The development and future of the transanal total mesorectal excision

It is critical to ensure complete mesorectal excision for rectal cancer surgery. Different surgical approaches including laparoscopy and expensive robotic surgical system, are currently unable to achieve the same therapeutic effects as traditional open surgery. Transanal total mesorectal excision (TaTME) is a new technique in rectal cancer surgery in recent years, which can effectively solve the problems of traditional transabdominal approach due to poor operative vision caused by low pelvic anatomy. After nearly 10 years of development, TaTME has shown the potential to improve the quality of rectal cancer surgery. With the continued development of emerging surgical techniques, TaTME relies on extensive, continuous structured training and high-quality clinical researches. Key words: Rectal neoplasms; Rectal cancer; Transanal total mesorectal excision; Total mesorectal excision; Laparoscopy

Accreditation Readiness in US Multidisciplinary Rectal Cancer Care: A Survey of OSTRICH Member Institutions

This article presents a survey of 328 member health care centers by a consortium focused on improving quality in rectal cancer surgery.

Synoptic operative reports enhance documentation of best practices for rectal cancer.

Implementation of best practices surgical checklists improves patient safety and outcomes. However, documenting performance of these practices can be challenging. The American Society of Colon and Rectal Surgeons developed a Best Practices for Rectal Cancer Checklist (RCC) to standardize and improve the quality of rectal cancer surgery. This study compared the degree to which synoptic (SR) and narrative (NR) operative reports document RCC items. Two reviewers independently reviewed a cohort of prospectively collected SR for rectal cancer surgery and a case-matched historical cohort of NR. Reports were reviewed for documentation of performance of operative items on the RCC. Abstraction time and inter-rater agreement were also measured. SR scored significantly higher than NR on the overall checklist score (mean adjusted score ± standard deviation 12.4 ± 0.9 vs. 5.7 ± 1.9, maximum possible score 18, P < 0.001). Reviewers abstracted data significantly faster from SR. Inter-rater agreement between reviewers was high for both types of reports. SR were associated with reliable and more complete and reliable documentation of items on the RCC. Use of an SR system standardizes operative reporting, providing the opportunity to enhance checklist compliance, and enable timely feedback to improve surgical outcomes for rectal cancer patients.

P-345 Temporary stoma rates as a marker of quality in rectal cancer surgery in a high volume UK hospital

Introduction: Permanent stoma rate continues to be one of the quality indicators for rectal cancer management. National Bowel Cancer Audit 2013 (United Kingdom) annual report quotes a non-closure rate 30% or more of “temporary” stomas in rectal cancer surgery. This is considered to be reflective of poor quality of rectal cancer care. Temporary defunctioning ileostomy can reduce the consequences of anastomotic leak following anterior resection. However some patients never have their ileostomy reversed and in other cases the time to reversal of ileostomy can be delayed.

Permanent stoma rates: a misleading marker of quality in rectal cancer surgery

The latest National Bowel Cancer Audit Programme (NBOCAP) audit identified our colorectal unit as an outlier with regard to the high permanent stoma rate. The aim of this study was to perform an audit of the rationale for stoma formation in patients undergoing rectal cancer resection in our unit. A review was conducted of all rectal cancer operations between April 2011 and March 2013. Preoperative staging investigations and operation reports were reviewed to identify the reasons for nonrestorative surgery. Postoperative histology reports were used to identify circumferential resection margin (CRM) involvement and tumour height. One-hundred and twenty-five patients underwent surgery for rectal cancer, of whom 102 underwent elective resection with curative intent. The permanent stoma rate was 63.2% when emergency and palliative procedures were included and 54.9% when only elective curative cases were considered. Tertiary referrals made up 31.4% of elective cases. The main reasons for nonrestorative surgery included multivisceral resection (n = 24) for locally advanced cancer and operations for lesions close to the anal sphincter (n = 21). The median length of stay was 8 days, the 90-day mortality was 2.9% and the rate of CRM involvement was 2.0%. Our unit provides multivisceral surgery for locally advanced rectal cancer and receives a substantial number of tertiary referrals. Many of the rectal cancers referred are locally advanced or threaten the anal sphincter. This study demonstrates that the complexity of a unit's case-mix can have a profound effect on the permanent stoma rate. Stoma rates taken at face value do not therefore provide an accurate representation of surgical quality. What does this paper add to the literature? The study reviews the practice of a colorectal surgical unit with an interest in multivisceral surgery with regard to the permanent stoma rate. The reasons for nonrestorative surgery are analysed, and the problems associated with the use of stoma rates as a marker of quality in colorectal surgery are highlighted.

Assessment of abdominoperineal resection rate as a surrogate marker of hospital quality in rectal cancer surgery

Rates of abdominoperineal resection (APR) have been suggested as a solitary surrogate marker for comparing overall hospital quality in rectal cancer surgery. This study investigated the value of this marker by examining the associations between hospital APR rates and other quality indicators. Hospital-level correlations between risk-adjusted APR rates for low rectal cancer and six risk-adjusted outcomes and six care processes were performed (such as 30-day mortality, complications, timely treatment). The ability of APR rates to discriminate between hospitals' performance was examined by means of hospital variance results in multilevel regression models and funnel plots. A linked population-based data set identified 1703 patients diagnosed in 2007 and 2008 who underwent surgery for rectal cancer. Some 15.9 (95 per cent confidence interval (c.i.) 14.2 to 17.6) per cent of these patients had an APR. Among 707 people with low rectal cancer, 38.2 (34.6 to 41.8) per cent underwent APR. Although risk-adjusted hospital rates of APR for low rectal cancer varied by up to 100 per cent, only one hospital (1 per cent) fell outside funnel plot limits and hospital variance in multilevel models was not very large. Lower hospital rates of APR for low rectal cancer did not correlate significantly with better hospital-level outcomes or process measures, except for recording of pathological stage (r = -0.55, P = 0.019). Patients were significantly more likely to undergo APR for low rectal cancer if they attended a non-tertiary metropolitan hospital (adjusted odds ratio 2.14, 95 per cent c.i. 1.11 to 4.15). APR rates do not appear to be a useful surrogate marker of overall hospital performance in rectal cancer surgery.

Quality of rectal cancer surgery and its relationship to surgeon and hospital caseload: a population‐based study

A population-based audit of all rectal cancers diagnosed in Ireland in 2007 has shown an inconsistent relationship between surgeon and hospital caseload and a range of quality measures. Better outcome for rectal cancer has been associated with increasing surgeon and hospital caseload, but there is less evidence of how this may relate to quality of care. Our aim was to examine how measures of quality in rectal cancer surgery related to surgeon and hospital workload and to outcome. All colorectal surgeons in Ireland participated in an audit of rectal cancer based on an evidence-based instrument. Data were extracted from medical records by trained coders. Generalized linear mixed models were used to determine the relationship between surgeon or hospital caseload and measures of quality of care. Five hundred and eighty-one (95%) of the 614 rectal cancers diagnosed in Ireland in 2007 were audited; 49 hospitals and 86 surgeons participated. Ten (28%) hospitals treated fewer than five cases and seven fewer than three. A positive relationship between caseload and quality was seen for a few measures, more frequently for hospital than surgeon caseload. The relationship between caseload and quality of care was inconsistent, suggesting these measures do not represent a single dimension of quality. One-year survival was negatively associated with hospital caseload. There was no statistically significant relationship between survival and measures of quality of care. Quality of care was inconsistently influenced by surgeon and hospital caseload. Caseload may affect only one aspect of surgical management, such as the quality of preoperative workup, and is not necessarily related to the quality of other hospital care. Simple measures of outcome, such as survival, cannot represent the complexity of this relationship.

Assessment of the quality of mesorectumectomy in the surgery of rectal cancer

The quality of rectal cancer surgery was morphologically estimated during total mesorectumectomy (TME). Analysis of the findings has indicated that the type of an operation, the site of a tumor, and the depth of tumor invasion are major factors that influence the quality of TME. Macroscopic assessment of TME quality is an independent prognostic factor that identifies patients at high risk for a local recurrence, defines a postoperative management tactic, and serves as an indication for adjuvant therapy.

Abdominoperineal excision rate: a marker of quality in rectal cancer surgery

Colorectal DiseaseVolume 13, Issue 7 p. 731-731 Editorial Abdominoperineal excision rate: a marker of quality in rectal cancer surgery Ian Lindsey, Ian Lindsey Churchill Hospital, Headington, Oxford, UKSearch for more papers by this author Ian Lindsey, Ian Lindsey Churchill Hospital, Headington, Oxford, UKSearch for more papers by this author First published: 08 June 2011 https://doi.org/10.1111/j.1463-1318.2011.02663.xCitations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume13, Issue7July 2011Pages 731-731 RelatedInformation

TME quality in rectal cancer surgery

BackgroundThe concept of total mesorectal excision has revolutionised rectal cancer surgery. TME reduces the rate of local recurrence and tumour associated mortality. However, in clinical trials only 50% of the removed rectal tumours have an optimal TME quality. Patients: During a period of 36 months we performed 103 rectal resections. The majority of patients (76%; 78/103) received an anterior resection. The remaining patients underwent either abdominoperineal resection (16%; 17/103), Hartmann's procedure (6%; 6/103) or colectomy (2%; 2/103).ResultsIn 90% (93/103) TME quality control could be performed. 99% (92/93) of resected tumours had optimal TME quality. In 1% (1/93) the mesorectum was nearly complete. None of the removed tumours had an incomplete mesorectum. In 98% (91/93) the circumferential resection margin was negative. Major surgical complications occurred in 17% (18/103). 5% (4/78) of patients with anterior resection had anastomotic leakage. 17% (17/103) developed wound infections. Mortality after elective surgery was 4% (4/95).ConclusionOptimal TME quality results can be achieved in all stages of rectal cancer with a rate of morbidity and mortality comparable to the results from the literature. Future studies should evaluate outcome and local recurrence in accordance to the degree of TME quality.

APER Rate Has Multiple Limitations as an Indicator of Quality in Rectal Cancer Surgery

Tilney, Henry S. FRCS (Gen Surg); Purkayastha, Sanay BSc, MRCS; Darzi, Ara W. MD, FRCS; Tekkis, Paris P. MD, FRCS Author Information

APER Rate Has Multiple Limitations as an Indicator of Quality in Rectal Cancer Surgery

APER Rate Has Multiple Limitations as an Indicator of Quality in Rectal Cancer Surgery

Introduction of preoperative radiotherapy in the treatment of operable rectal cancer in the Southwest region of the Netherlands

Introduction After publication of the results of the Dutch TME-trial preoperative radiotherapy followed by TME-surgery was introduced in July 2001 in the region of the comprehensive cancer centre Rotterdam as standard treatment for rectal cancer. The aim of this study is to identify the compliance to a new standardized treatment protocol i.e. the introduction of preoperative radiotherapy and to analyze the results of rectal cancer treatment in the Cancer Centre Rotterdam Region. Patients and methods A total of 521 patients with adenocarcinoma of the rectum were included in the period from 2001 to 2003. All patients were treated with curative intent. Results There was a significant increase of preoperative radiotherapy for patients with a tumour in the lower two-third of the rectum (21% versus 69%, p < 0.001). Peri-operative mortality rate was 2.7% and overall anastomotic leakage rate was 10.3%. There was a significant increase in the occurrence of anastomotic leakage in end-to-end anastomoses ( p < 0.0001). Most anastomotic leakages occurred when patients were operated in between 4 and 8 days after the end of radiotherapy. Several aspects such as continence for urine and faeces and sexual functions were poorly registered. The total number of lymph nodes registered in pathology reports was low. The rate of reported circumferential margins increased from 37% to 70% after feedback to the regional pathology working group. Conclusion The regional quality of rectal cancer surgery is conform preset quality-demands. There was a significant increase in the percentage preoperative radiotherapy, but still about 25% of patients who qualified for radiotherapy did not receive radiation. Pathology reports improved during registration, which illustrates the importance of registration to assess and improve quality of rectal cancer treatment.

Staging of Rectal Cancer and the Pathologist's Role in Assessing the Quality of Rectal Cancer Surgery

Staging of Rectal Cancer and the Pathologist's Role in Assessing the Quality of Rectal Cancer Surgery

Impact of surgeon organization and specialization in rectal cancer outcome.

The present study was designed to assess the differences in the outcome of patients with rectal cancer treated by a group of surgeons before and after being organized as a Coloproctology Unit at the same University Department of Surgery. Comparison of two periods of rectal cancer surgery: I (1986-91) and II (1992-95). Period I: 94 patients were operated on by 14 general surgeons. Period II: 108 patients were operated on by only 4 surgeons of the same group organized as a Colorectal Surgery Unit after visiting referral centres abroad, adopting techniques such as total mesorectal excision (TME) for middle and low rectal cancer and washout of rectal stump. Mean follow-up during periods I and II was 69.1 and 42.0 months, respectively. A prospective data base analysis was used. Survival and local recurrence rates were calculated by the actuarial method. For comparison between groups the log rank method was used. The two groups were comparable with respect to mean age, gender, TNM and rectal tumour location. A significant increase in radical resectability and a decrease of the Abdominoperineal resection (APR)/Low anterior resection (LAR) ratio were observed in the second period. The overall pelvic recurrence rate was 25% in the first period and 11 in the second (P < 0.01). Significant differences were also found when the patients with LAR were compared between both periods, 30% vs 9% (P < 0.01) and specially when the 10 cm anal verge distance was considered to divide the LAR groups. No differences were found regarding the APR procedures in both periods. There was improved cancer-specific survival for the LAR group in the second period (P=0.03). Specialization and centralization influence the quality of rectal cancer surgery, mainly local recurrence rates and survival after low anterior resection.