Background: The circumferential resection margin (CRM) is a significant prognostic factor for local recurrence, distant metastasis, and survival after rectal cancer surgery. Therefore, availability of this parameter is essential. Although the Dutch total mesorectal excision trial raised awareness about CRM in the late 1990s, quality assurance on pathologic reporting was not available until the Dutch Surgical Colorectal Audit (DSCA) started in 2009. The present study describes the rates of CRM reporting and involvement since the start of the DSCA and analyzes whether improvement of these parameters can be attributed to the audit. Methods: Data from the DSCA (2009–2013) were analyzed. Reporting of CRM and CRM involvement was plotted for successive years, and variations of these parameters were analyzed in a funnelplot. Predictors of CRM involvement were determined in univariable analysis and the independent influence of year of registration on CRM involvement was analyzed in multivariable analysis. Results: A total of 12,669 patients were included for analysis. The mean percentage of patients with a reported CRM increased from 52.7% to 94.2% (2009–2013) and interhospital variation decreased. The percentage of patients with CRM involvement decreased from 14.2% to 5.6%. In multivariable analysis, the year of DSCA registration remained a significant predictor of CRM involvement. Conclusions: After the introduction of the DSCA, a dramatic improvement in CRM reporting and a major decrease of CRM involvement after rectal cancer surgery have occurred. This study suggests that a national quality assurance program has been the driving force behind these achievements.
Lieke Gietelink, Michel W.J.M. Wouters, Pieter J. Tanis, Marion M. Deken, Martijn G. ten Berge, Rob A.E.M. Tollenaar, J. Han van Krieken, Mirre E. de Noo and on behalf of the Dutch Surgical Colorectal Cancer Audit Group
Charlotte E.L. Klaver, Lieke Gietelink, Willem A. Bemelman, Michel W.J.M. Wouters, Theo Wiggers, Rob A.E.M. Tollenaar, Pieter J. Tanis and on behalf of the Dutch Surgical Colorectal Audit Group
Background: The goal of this study was to evaluate current clinical practice and treatment outcomes regarding locally advanced colon cancer (LACC) at the population level. Methods: Data were used from the Dutch Surgical Colorectal Audit from 2009 to 2014. A total of 34,527 patients underwent resection for non-LACC and 6,918 for LACC, which was defined as cT4 and/or pT4 stage. LACC was divided into those with multivisceral resection (LACC-MV; n=3,385) and without (LACC-noMV; n=1,595). Guideline adherence, treatment strategy, and short-term outcomes were evaluated. Results: Guideline adherence was >90% regarding preoperative imaging and ≥80% regarding preoperative multidisciplinary team (MDT) discussion. In the elective setting, neoadjuvant chemoradiotherapy (chemoRT) was applied in 6.2% of the cT4 cases, and neoadjuvant chemotherapy in 4.0%. R0 resection rates were 99%, 91%, and 87% in patients with non-LACC, LACC-noMV, and LACC-MV, respectively (P<.001). A postoperative complicated course occurred in 17%, 25%, and 29% of patients (P<.001), and the 30-day/in-hospital mortality rate was 3.6%, 6.0%, and 5.4% (P<.001) in the non-LACC, LACC-noMV, and LACC-MV groups, respectively. Discussion/Conclusions: This population-based study suggests that there is room for improvement in the treatment of LACC, with regard to short-term surgical outcomes and oncologic outcomes (ie, radicality of resection). Improvement might be expected from optimized preoperative imaging, routine MDT discussions, and further specialization and centralization of care. Optimized use of neoadjuvant treatment strategies based on already available and upcoming evidence is likely to result in a better margin status and thereby a better long-term prognosis. Furthermore, lower R0 resection rates in an emergency setting suggest a potential role for bridging strategies in order to enable optimal staging, neoadjuvant treatment, and elective surgery by a surgical team most optimally qualified for the procedure.
Daniëlle D. Huijts, Julia T. van Groningen, Onno R. Guicherit, Jan Willem T. Dekker, Leti van Bodegom-Vos, Esther Bastiaannet, Johannes A. Govaert, Michel W. Wouters and Perla J. Marang-van de Mheen
Background: It is unclear whether emergency weekend colon and rectal cancer surgery are associated with worse outcomes (ie, weekend effect) because previous studies mostly used administrative data, which may insufficiently adjust for case-mix. Materials and Methods: Prospectively collected data from the 2012–2015 Dutch ColoRectal Audit (n=5,224) was used to examine differences in 30-day mortality and severe complication and failure-to-rescue rates for emergency weekend (Saturday and Sunday) versus Monday surgery, stratified for colon and rectal cancer. Analyses were adjusted for age, sex, body mass index, Charlson comorbidity index, American Society of Anesthesiologists classification score, tumor stage, presence of metastasis, preoperative complication, additional resection for metastasis or locally advanced tumor, location primary colon tumor, type of rectal surgery (lower anterior resection or abdominal perineal resection), and type of neoadjuvant therapy (short-course radiotherapy or chemoradiotherapy). Results: A total of 5,052 patients undergoing colon cancer surgery and 172 undergoing rectal cancer surgery were included. Patients undergoing colon or rectal cancer surgery during weekends had significantly more preoperative tumor complications compared with those undergoing surgery on a weekday. Additionally, differences in year of surgery and location of primary tumor were found for colon cancer surgery. Emergency colon cancer surgery during the weekend was associated with increased 30-day mortality (odds ratio [OR], 1.66; 95% CI, 1.10–2.50) and severe complications (OR, 1.29; 95% CI, 1.03–1.63) compared with surgery on Monday. Estimates for emergency weekend rectal cancer surgery were similar but not statistically significant, likely explained by small numbers. Conclusions: Weekend emergency colon cancer surgery was associated with higher mortality and severe complication rates. More research is needed to understand which factors explain and contribute to these differences.
Daniëlle D. Huijts, Onno R. Guicherit, Jan Willem T. Dekker, Julia T. van Groningen, Leti van Bodegom-Vos, Esther Bastiaannet, Johannes A. Govaert, Michel W. Wouters and Perla J. Marang-van de Mheen
Background: Previous studies showing higher mortality after elective surgery performed on a Friday were based on administrative data, known for insufficient case-mix adjustment. The goal of this study was to investigate the risk of adverse events for patients with colon and rectal cancer by day of elective surgery using clinical data from the Dutch ColoRectal Audit. Patients and Methods: Prospectively collected data from the 2012–2015 Dutch ColoRectal Audit (n=36,616) were used to examine differences in mortality, severe complications, and failure to rescue by day of elective surgery (Monday through Friday). Monday was used as a reference, analyses were stratified for colon and rectal cancer, and case-mix adjustments were made for previously identified variables. Results: For both colon and rectal cancer, crude mortality, severe complications, and failure-to-rescue rates varied by day of elective surgery. After case-mix adjustment, lower severe complication risk was found for rectal cancer surgery performed on a Friday (odds ratio, 0.84; 95% CI, 0.72–0.97) versus Monday. No significant differences were found for colon cancer surgery performed on different weekdays. Conclusions: No weekday effect was found for elective colon and rectal cancer surgery in the Netherlands. Lower severe complication risk for elective rectal cancer surgery performed on a Friday may be caused by patient selection.