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Friedrich-Alexander-Universität Erlangen-Nürnberg

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.

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Friedrich-Alexander-Universität Erlangen-Nürnberg

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  1. Friedrich-Alexander-Universität Erlangen-Nürnberg Why do someachievebetterresults? Isthesurgeonordedicationcrucial? Werner Hohenberger Chirurgische Universitätsklinik Erlangen

  2. Colon Cancer Survival „No touch“ vs. “Conventional“ Turnbull Conventional all patients* 81,6% Dukes C* 67,3% observed all patients 68,85% 52,13% Dukes C* 57,84% 28,06% * age adjusted Rupert B.Turnbull 1967 and 1970

  3. R. Turnbull 1967

  4. R.Turnbull 1967

  5. Surgery for Colon Cancer Outcome 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

  6. Colon Cancer Qualtity of Surgery The Tough Cases UICC III T4 catecory emergencies

  7. Colon Cancer Observed Survival UICC Stad. III Middle Franconia 52,0 % 1998 - 2007 German 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 % • ° Kube et al 2009 • Schrag et al 2010 • ** Intact trial

  8. 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

  9. 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

  10. What is the definition of low and high volume? volumemedian per 8 years very low n = 1 low n = 4 medium n = 7 high n = 14 very high n = 22 study population: 6258 patients Billingsley et al. 2008

  11. 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 patients Kessler et al. 1998

  12. Rectal Carcinom R0 M0 Patients with locoregional recurrence observed survival - logistic regression analysis Significant factors p 1. Department 0.0017 2. Grading 0.0161 Hermanek et al. 1995

  13. 120 100 80 60 40 20 Rectum Carcinoma Number of Operations per Surgeon versus Locoregional Recurrence Operations per surgeon Spearman rank - correlation not significant ( p ~ 0.40 ) LF 10 20 30 40 50 60% Rate of locoregional recurrences LF = Surgeons with low frequency of operations (≤15) Kessler et al. 1998

  14. Colorectal Cancer German Patient Care Study Local Recurrence / Individual Surgeon, Hospital and Outcome Intersurgeon variability odds ratio 95% c.i. p Institution A 0.31 0.18-0.54 0,001 others 1 Surgeon 1,3-14 1 low frequency surgeons ≤ 15 cases 1.71 1.02-2.86 0,0433 2 4.32 1.69-11.97 0,023 recruitment 08/1984 – 11/1986 Kessler et al. 1998

  15. Rectal Cancer Locoregional Recurrence Rate Dept. B Dept. A Dept. C % 60 50 40 30 20 10 0 Individual surgeons with > 15 operations All surgeons with  15 operations SGCRC, Hohenberger 1997

  16. Surgery Quality of Outcome The Beginning Set a Standard

  17. Colorectal Cancer

  18. Clinical Cancer Register Chirurgische Universitätsklinik Erlangen Prospective Documentation Files • History • Diagnosis • Staging • Neo- /adjuvant treatment • Surgery including individual surgeon • Pathology • Postop. Course • Follow - up

  19. 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

  20. Colorectal Cancer Outcome Differences • Surgeon Volume lower Sphincter LR Survival • third < 6cm pres. • 13 180 30,0% 86,1% 12,3 85,2 • 21 132 28,6% 79,5% 7,1 86,9 • 24 43 10,9% 69,0% 20,9 77,2 • 27 62 11,4% 78,0% 9,9 85,7 • others 121 19,1% 78,1% 8,7 81,4 Chir. Univ. - Klinik Erlangen R0, Stage I-III, solitary cancer

  21. Colon Cancer5 – Years‘ Survival best surgeon all UICC-Stage I 95,5% 100% II 90,4% 96,7% III 72,2% 80,4% R0, all Stages 86,6% 93,6% Chirurg. Univ.-Klinik Erlangen, 1995-2002 Cancer related, no adjuvant chemotherapy

  22. 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 Erlangen All stages

  23. Colorectal Cancer Postoperative Mortality Anastomotic Leak Rectal Cancer Colon Cancer 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

  24. Colorectal CancerPostop. Leaks Colon cancer Rectal cancer 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 - 2000 R0 - resections, stages I - III

  25. Rectal CancerPostop. LeaksSurgeon 13 1995-2001 2002-2005 ant. resection 0/16 0/13 Low ant. res. 16/116 (13,8 %) 1/84 (1 %) intersphinct. r. 1/20 (8 %) 0/7 all 17/125 (11,7) 1/104 (1 %) Chirurgische Universitätsklinik Erlangen 1995 - 2005 all stages

  26. Surgery for Colon Cancer Complete 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

  27. Colon Cancer Cancer related 5-Years Survival Related to Periods 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

  28. Colon Cancer Cancer related Survival o o o o o o Surg. Department Univ. Hosp. Erlangen postop. mortality excluded, 1995-2005

  29. Rectal Cancer High risk groups for local recurrence 3-J-LR all (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

  30. 15 12 9 30 days mortality (number of patients in %) 6 3 0 2 5 6 9 12 16 17 22 23 24 25 30 35 36 44 47 52 53 15 20 14 1 39 38 51 32 4 21 31 42 37 8 11 34 13 33 29 43 27 3 28 50 45 54 10 26 18 46 48 40 7 49 41 19 55 Anonym codes of hospitals involved German Oncologic Bowel Centres Benchmarking30 days mortality after elective operations (n=3.836) DOC Holding GmbH - Qualitätssicherung in der Onkologie

  31. Colorectal Cancer Surgery Outcome • - 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

  32. Seventh International • Symposium and Workshop • Advanced Course in • Colorectal Surgery • May, 21-22th 2012 • For further information and registration • please contact: • Susanne.Reed@uk-erlangen.de

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