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Friedrich-Alexander-Universität Erlangen-Nürnberg. Why do some achieve better results ? Is the surgeon or dedication crucial ?. Werner Hohenberger Chirurgische Universitätsklinik Erlangen. Colon Cancer Survival „No touch “ vs. “ Conventional “. Turnbull Conventional. - PowerPoint PPT Presentation
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Friedrich-Alexander-UniversitätErlangen-Nürnberg
Werner Hohenberger
Chirurgische Universitätsklinik Erlangen
Why do some achieve better results?Is the surgeon or dedication crucial?
Colon CancerSurvival
„No touch“ vs. “Conventional“
Rupert B.Turnbull 1967 and 1970
* age adjusted
all patients* 81,6%
Dukes C* 67,3%
observed all patients 68,85% 52,13%
Dukes C* 57,84% 28,06%
Turnbull Conventional
R. Turnbull 1967
R.Turnbull 1967
Surgery for Colon CancerOutcome Variations
all patients (n = 1157) 45,7 % (27 - 53 %)
R0, any stage (n = 732) 62,8 % (35 - 71 %)
Stage I (n = 150) 81,2 % (76 - 89 %)
II (n = 308) 70,1 % (36 - 89 %)
III (n = 245) 46,5 % (27 - 54 %)
IV (n = 29) 27,6 %
SGCRC, Hermanek 1994; observed survival at 5 years
UICC IIIT4 catecoryemergencies
Colon CancerQualtity of SurgeryThe Tough Cases
Colon CancerObserved Survival
° Kube et al 2009• Schrag et al 2010** Intact trial
UICC Stad. III
Middle Franconia 52,0 %1998 - 2007German Study Group° 52,7 %Colorectal Cancer
Chirurgische Klinik Erlangen 84,9 %1995 - 2002 **
SEERS pT1 N1 73,0 %1992 - 2004 pT3 N1 54,9 %
pT3 N2 38,1 %
USA„very high volume“ * 44,0 %
Sugihara/Tokyo 77,2 %
Why do some achieve better results? - case mix – patient`selection - stage migration - organisation, quality management - volume, centralisation, specialisation - standardisation - neo-/adjuvant treatment - special individual skill
Rectal Cancer Locoregional Recurrence
Factors Independent of Surgeon
case mix - lower third- stage- T-category (pT 3a,b / c,d)
treatment - abdomino-peranal resection- local excision- radiotherapy
definitions - rectum- R1-resection- all recurrencies / only first event
time of follow up
What is the definition of low and high volume?
volume median per 8 years
very low n = 1
low n = 4medium n = 7high n = 14
very high n = 22
study population: 6258 patientsBillingsley et al. 2008
Rectal Cancer German Patient Case Study
institution surgeon
local recurrence 10% - 37% 4% - 55%
observed 5-y-surv. 45% - 69% 46% - 79%
cancer-related 5-y-surv. 54% - 75% 54% - 85%
744 patientsKessler et al. 1998
Rectal Carcinom R0 M0
Patients with locoregional recurrenceobserved survival - logistic regression analysis
Significant factors p
1. Department 0.0017
2. Grading 0.0161
SGCRCSGCRC
Hermanek et al. 1995
Rectum CarcinomaNumber of Operations per Surgeon versus Locoregional Recurrence
SGCRCSGCRC
Operationsper surgeon
Spearman rank - correlationnot significant ( p ~ 0.40 )
Rate of locoregional recurrencesLF = Surgeons with low frequency of operations (≤15)
120
100
80
60
40
20
10 20 30 40 50 60%
LF
Kessler et al. 1998
Colorectal Cancer German Patient Care Study
Local Recurrence / Individual Surgeon, Hospital and OutcomeIntersurgeon variabilityodds ratio 95% c.i.
p
Institution A 0.31 0.18-0.54 0,001
others 1
Surgeon1,3-14 1low frequency surgeons ≤ 15 cases 1.71 1.02-2.86
0,04332 4.32 1.69-11.970,023
recruitment 08/1984 – 11/1986Kessler et al. 1998
Rectal Cancer Locoregional Recurrence Rate
60
50
40
30
20
10
0
% Dept. A Dept. B Dept. C
Individual surgeons with > 15 operations All surgeons with 15 operations
SGCRC, Hohenberger 1997
SurgeryQuality of Outcome
The Beginning
Set a Standard
Colorectal Cancer
Clinical Cancer Register Chirurgische Universitätsklinik Erlangen
Prospective Documentation Files
- History- Diagnosis- Staging- Neo- /adjuvant treatment- Surgery including individual surgeon- Pathology- Postop. Course- Follow - up
Clinical Cancer Register Chirurgische Universitätsklinik Erlangen
Objectives
- quality control (in part with external audit)
- identification of patient cohorts (biobank)
- scientific analysis of - prognostic factors - postop. complications
including mortality - ….
- TNM approval
Colorectal Cancer Outcome Differences
Surgeon Volume lower Sphincter LRSurvival
third < 6cm pres.
13 180 30,0% 86,1% 12,385,2
21 132 28,6% 79,5% 7,186,9
24 43 10,9% 69,0% 20,977,2
27 62 11,4% 78,0% 9,985,7
others 121 19,1% 78,1% 8,781,4
Chir. Univ. - Klinik ErlangenR0, Stage I-III, solitary cancer
Colon Cancer5 – Years‘ Survival
Chirurg. Univ.-Klinik Erlangen, 1995-2002Cancer related, no adjuvant chemotherapy
UICC-Stage I 95,5% 100%
II 90,4% 96,7%
III 72,2% 80,4%
R0, all Stages 86,6% 93,6%
all best surgeon
Rectal Resection for CancerPostop. Complications
- leaks n = 148 / 1871 (7,9%)
- intraabdominal sepsis n = 47 / 1871 (2,5%) without leak
- additional relevant n = 108 / 1871 (5,8%) general / extraabdominal complications
Chirurgische Universitätsklinik ErlangenAll stages
Colorectal CancerPostoperative Mortality
Anastomotic Leak
1978 - 1994 (29 / 148) 19,6 % (16 / 49) 32,7 %
1995 - 2000 (3 / 34) 8,8 % (2 / 17) 11,8 %
2001 - 2006 (0 / 20) (1 / 29) 3,4 %
Chirurgische Universitäts-Klinik Erlangen
Rectal Cancer Colon Cancer
Colorectal CancerPostop. Leaks
alle 9 / 334 (2,7%) 25 / 280 (8,9%)surgeon 13 1 / 121 (0,8% 12 / 96 (12,5%)surgeon 70 4 / 31 (3,0%)-Surgeon 21 - 4 / 69 (5,8%)
Chirurgische Universitätsklinik Erlangen 1995 - 2000R0 - resections, stages I - III
Colon cancer Rectal cancer
Rectal CancerPostop. LeaksSurgeon 13
ant. resection 0/16 0/13Low ant. res. 16/116 (13,8 %) 1/84 (1 %)intersphinct. r. 1/20 (8 %) 0/7all 17/125 (11,7)
1/104 (1 %)
Chirurgische Universitätsklinik Erlangen 1995 - 2005all stages
1995-2001 2002-2005
Surgery for Colon CancerComplete Mesocolic Excicion (CME)
Preservation of the mesocolic plane by sharp dissection off the parietal plane (turning embryology back)
Regional and central lymphnode dissection with high tie of suppling vesssels
2000-2004: 90,2%1995-1999: 87,2%1990-1994: 84,6%1985-1989: 83,6%1978-1984: 82,1%
Stages I-III, R0, Erlangen Registry 1978-2004
Colon CancerCancer related 5-Years Survival
Related to Periods
Colon CancerCancer related Survival
Surg. Department Univ. Hosp. Erlangenpostop. mortality excluded, 1995-2005
oooooo
Rectal Cancer High risk groups for local recurrence
3-J-LRall (n = 373) 8,8%T4 (n = 14) 23,4%pT3/4 pN2 (n = 39) 19,7%pN2 G3/4 (n = 18) 35,8%pN2 V1 extraminal (n = 10) 41,7%pN2 V1 G3/4 (n = 6) 46,7%
Chirurg. Univ.-Klinik Erlangen 1995-2000
UICC-Stage I-III, med. follow-up 53months
German Oncologic Bowel Centres Benchmarking
30 days mortality after elective operations (n=3.836)
DOC Holding GmbH - Qualitätssicherung in der Onkologie
0
3
6
9
12
15
2 5 6 9 1216172223242530353644475253152014 1 39385132 4 21314237 8 11341333294327 3 28504554102618464840 7 49411955
Anonym codes of hospitals involved
30 d
ays
mor
talit
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umbe
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atie
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in %
)
Colorectal Cancer Surgery
- the individual surgeon makes the difference
- needs a certain caseload
- this figure depends upon spectrum
- high volume does not guarantee high quality
- optimised standard controlled by a proper system
Outcome
Seventh International Symposium and Workshop
Advanced Course in Colorectal Surgery
May, 21-22th 2012
For further information and registration
please contact:[email protected]