Oncological outcome after MRI-based selection for neoadjuvant chemoradiotherapy in the OCUM Rectal Cancer Trial.

BACKGROUND: It is not clear whether all patients with rectal cancer need chemoradiotherapy. A restrictive use of neoadjuvant chemoradiotherapy (nCRT) based on MRI findings for rectal cancer was investigated in this study. METHODS: This prospective multicentre observational study included patients with stage cT2-4 rectal cancer, with any cN and cM0 status. Carcinomas in the middle and lower third that were 1 mm or less from the mesorectal fascia, all cT4 tumours, and all cT3 tumours of the lower third were classified as high risk, and these patients received nCRT followed by total mesorectal excision (TME). All other carcinomas with a minimum distance of more than 1 mm from the mesorectal fascia and those in the upper third were classified as low risk; these patients underwent TME alone (no nCRT). Patients were followed for at least 3 years. Outcomes were the rates of local recurrence, distant metastasis and survival. RESULTS: Among 545 patients included, 428 were treated according to the study protocol: 254 (59·3 per cent) had TME alone and 174 (40·7 per cent) received nCRT and TME. Median follow-up was 60 months. The 3- and 5-year local recurrence rates were 1·3 and 2·7 per cent respectively, with no differences between the two treatment protocols. Patients with disease requiring nCRT had higher 3- and 5-year rates of distant metastasis (17·3 and 24·9 per cent respectively versus 8·9 and 14·4 per cent in patients who had TME alone; P = 0·005) and worse disease-free survival compared with that in patients who did not need nCRT (3- and 5-year rates 76·7 and 66·7 per cent, versus 84·9 and 76·0 per cent in the TME-alone group; P = 0·016). CONCLUSION: Restriction of nCRT to high-risk patients achieved good results.

[Quality of Mesorectal Excision ("Plane of Surgery") - Which Quality Targets are Adequate?]. / Qualität der Mesorektumexzision ("plane of surgery") - Welche Qualitätsziele sind angemessen?

Today, the examination of rectal cancer specimens includes the obligate macroscopic assessment of the quality of mesorectal excision by the pathologist reporting the plane of surgery. The frequency of operations in the muscularis propria plane of surgery (earlier described as incomplete mesorectal excision) is essential. The quality of mesorectal excision is important for the prognosis, especially as local recurrences are observed more frequently after operations in the muscularis propria plane of surgery. For the definition of quality targets, data of 13 studies published between 2006 and 2012, each with more than 100 patients and adequate specialisation and experience of the surgeons (5413 patients), data of the prospective multicentric observation study "Quality Assurance - Rectal Cancer" (at the Institute for Quality Assurance in Operative Medicine at the Otto-von-Guericke University at Magdeburg) from 2005 to 2010 (8044 patients) and data of the Department of Surgery, University Hospital Erlangen, from 1998 to 2011 (991 patients) were analysed. The total incidence of operations in the muscularis propria plane of surgery was 5.0 % (721/14 448). Even with adequate specialisation and experience of the surgeon, the frequency of operations in the muscularis propria plane of surgery is higher in abdominoperineal excisions than in sphincter-preserving surgery (8.4 vs. 2.8 %, p < 0.001). Thus, the quality target for the frequency of operations in the muscularis propria plane should be defined as < 5 % for sphincter-preserving procedures and as < 10 % for abdominoperineal excisions.

[Rectal cancer surgery in Germany - a 10-year-analysis based on the data of the "Institute of Quality Assurance in Operative Medicine" at the Otto-von-Guericke University Magdeburg]. / Rektumkarzinomchirurgie in Deutschland - eine 10-Jahres-Übersicht auf der Grundlage der Daten des AN-Instituts für Qualitätssicherung in der operativen Medizin gGmbH an der Otto-von-Guericke-Universität Magdeburg.

BACKGROUND: The treatment of rectal cancer has undergone pronounced changes during the last two decades. There has been a significant improvement in local tumour control due to consequent use of neo-adjuvant therapy and total mesorectal excision in cases of distal rectal cancer. The presented analysis examines the realisation of the multimodal therapy for rectal cancer under the conditions of routine patient-centred care over a period of ten years. METHOD: The data acquired in the prospective multicentre observational study "Quality Assurance - Rectal Cancer" from the years 2000 to 2010 were analysed. N = 33,724 patients were documented. The resection rate was 95.2 %. The rate of curative resection was 84.2 %. RESULTS: No change was detected in perioperative total morbidity and lethality during the course of the study. The percentage of patients with neo-adjuvant treatment and curative resection rose from 5.6 % (2000) to 40.5 % (2012). The rate of performed TME in distal rectal cancer rose from 75.2 % (2000) to 95.3 % (2012). For patients who underwent curative resection in the years 2000/2001 the 5-year local recurrence rate was 11.7 %, while it was found to be 4.6 % for patients who were thus treated in the years 2005/2006 (p < 0.001). There was no improvement of total survival. CONCLUSION: While an increase in the use of neo-adjuvant treatment for rectal cancer and the establishment of TME in routine patient-centred care have led to a significant improvement in local tumour control with a constant total morbidity and lethality, there is no detectable influence on the patients' total survival.

[Quality indicators of diagnosis and therapy in MRI-based neoadjuvant radiochemotherapy for rectal cancer - interim analysis of a Prospective Multicentre Observational Study (OCUM)]. / Qualitätsindikaktoren der Diagnose und Therapie bei MRT-basierter neoadjuvanter Radiochemotherapie des Rektumkarzinoms - Interimsanalyse einer prospektiven, multizentrischen Beobachtungsstudie (OCUM).

BACKGROUND: The interim analysis of a prospective multicentre observational study of selective neoadjuvant chemoradiotherapy (OCUM) in patients with rectal cancer should evaluate the quality of diagnosis and therapy as a prerequisite for continuation of the study. PATIENTS AND METHODS: 230 patients with the clinical stage cT2 - 4, each cN, M0 with radical tumour resection were enrolled until now. The values of 13 quality indicators were compared with the target values formulated by the workflow of the Working Group rectal cancer II and the German Cancer Society and were also compared with the results of the certified bowel centres of Germany 2010. RESULTS: The target values were fulfilled to a high degree regardless of caseload. 83 % of parameters have been fully achieved and 14 % nearly achieved. In primary surgery the proportion of patients with 12 or more histologically examined lymph nodes was 99.2 %, after neoadjuvant chemoradiotherapy 90 %. A R0 resection was performed in 98.3 % and a resection of TME in muscularis propria plane only in 2.2 %. The rate of positive circumferential resection margins (pCRM + ) was 5.7 % only. CONCLUSIONS: The high quality of rectal surgery justifies the concept and the continuation of the study.

[Surgical treatment of carcinomas of the oesophagogastric junction - results achieved in multicentre studies]. / Multizentrische Ergebnisse der chirurgischen Therapie der Karzinome des ösophagogastralen Übergangs.

BACKGROUND: Adenocarcinomas of the oesophagogastric junction are increasingly being considered as a separated tumour entity. The prognosis is rather poorer compared with that for distal gastric cancer. Data from a multicentre study as part of research on clinical care aim to reflect the current situation in surgical treatment after inauguration of neoadjuvant modalities. PATIENTS AND METHOD: As part of the ongoing prospective multicentre observational study QCGC 2 (German Gastric Cancer Study 2), 544 adenocarcinomas of the oesophagogastric junction (AEG 1-3) were registered from 01/01/2007 to 12/31/2009. RESULTS: Patients underwent surgical intervention in 108 (76.6 %) of the 141 surgical departments which provided data to the study. In 391 patients (82.5 %), R0 resection was achieved. Almost 60 % of the carcinomas of the oesophagogastric junction were approached in departments with no more than 10 of these tumour lesions through the whole study period (3 years). Endoscopic ultrasonography was performed in 283 cases (53 %); the rate of neoadjuvant treatment was 34.4 % (n = 187). Intraoperative fresh frozen section was only included in intraoperative decision-making in 242 patients (60.8 %). In the revealed heterogeneous spectrum of surgical interventions, a limited number of transthoracic approaches (20 %) and a mediastinal lymphadenectomy rate of only 47 % were found. Hospital lethality was 6.6 %. In the adenocarcinomas of the oesophagogastric junction, a significantly lower median survival (25 months) compared with distal gastric cancer (38 months) was observed depending on the tumour stage. In addition, 5-year survival rate of AEG patients (33.1 %) was distinctly lower than for patients with distal gastric cancer (41.4 %). There was no significantly better survival by neoadjuvant treatment in the group of investigated patients. CONCLUSION: The results in the treatment of carcinomas of the oesophagogastric junction in the multicentre setting including surgical departments of each profile and region even after introduction of multimodal therapeutic concepts are not satisfying. In particular, modern diagnostic and surgical strategies need to be widely used or their percentage has to be increased. In this context, centralisation of the surgical care of this specific tumour entity appears reasonable.

Factors influencing the quality of total mesorectal excision.

BACKGROUND: Total mesorectal excision (TME) has become the standard of care for rectal cancer. Incomplete TME may lead to local recurrence. METHODS: Data from the multicentre observational German Quality Assurance in Rectal Cancer Trial were used. Patients undergoing low anterior resection for rectal cancer between 1 January 2005 and 31 December 2009 were included. Multivariable analysis using a stepwise logistic regression model was performed to identify predictors of suboptimal TME. RESULTS: From a total of 6179 patients, complete data sets for 4606 patients were available for analysis. Pathological tumour category higher than T2 (pT3 versus pT1/2: odds ratio (OR) 1.22, 95 per cent confidence interval 1.01 to 1.47), tumour distance from the anal verge less than 8 cm (OR 1.27, 1.05 to 1.53), advanced age (65-80 years: OR 1.25, 1.03 to 1.52; over 80 years: OR 1.60, 1.15 to 2.22), presence of intraoperative complications (OR 1.63, 1.15 to 2.30), monopolar dissection technique (OR 1.43, 1.14 to 1.79) and low case volume (fewer than 20 procedures per year) of the operating surgeon (OR 1.20, 1.06 to 1.36) were independently associated with moderate or poor TME quality. CONCLUSION: TME quality was influenced by patient- and treatment-related factors.

Endorectal ultrasound in rectal carcinoma--do the literature results really correspond to the realities of routine clinical care?

BACKGROUND AND STUDY AIMS: This multicenter, prospective, country-wide quality-assurance study at more than 300 hospitals in Germany was designed to characterize and analyze the diagnostic accuracy of rectal endoscopic ultrasound (EUS) in the routine clinical staging of rectal carcinoma (depth of tumor infiltration). PATIENTS AND METHODS: Patients were surveyed between 1 January 2000 and 31 December 2008. Those who received neoadjuvant therapy after EUS were excluded. The correspondence between the EUS assessment of tumor depth (uT) and that determined by histology (pT) was calculated, and the influence of hospital volume upon the sensitivity, specificity, and positive and negative predictive values was investigated. RESULTS: At 384 hospitals providing care at all levels, 29 206 patients were included; of the 27 458 treated by surgical resection, EUS was performed for 12 235 (44.6 %). Of these, 7096 did not receive neoadjuvant radiochemotherapy, allowing a uT-pT comparison. The uT-pT correspondence was 64.7 % (95 % confidence interval [CI] 63.6 % - 65.8 %); the frequency of understaging was 18 % (95 %CI 17.1 % - 18.9 %) and that of overstaging was 17.3 % (95 %CI 16.4 % - 18.2 %). The kappa coefficient was greatest in the category T1 (κ = 0.591). For T3 tumors κ was 0.468. The poorest correspondence was found for T2 and T4 tumors (κ = 0.367 and 0.321, respectively). A breakdown by hospital volume showed that the uT-pT correspondence was 63.2 % (95 %CI 61.5 % - 64.9 %) for hospitals undertaking ≤ 10 EUS/year, 64.6 % (95 %CI 62.9 % - 66.2 %) for doing 11 - 30 EUS/year, and 73.1 % (95 %CI 69.4 % - 76.5 %) for those hospitals performing > 30 EUS/year. CONCLUSIONS: In clinical routine, the diagnostic accuracy of transrectal ultrasound in staging rectal carcinoma does not attain the very good results reported in the literature. Only in the hands of diagnosticians with a large case volume of rectal carcinoma patients can EUS lead to therapy-relevant decisions.

Low-volume centre vs high-volume: the role of a quality assurance programme in colon cancer surgery.

AIM: The study aimed to determine whether hospitals within a quality assurance programme have outcomes of colon cancer surgery related to volume. METHOD: Data were used from an observational study to determine whether outcomes of colon cancer surgery are related to hospital volume. Hospitals were divided into three groups (low, medium and high) based on annual caseload. Cancer staging, resected lymph nodes, perioperative complications and follow up were monitored. Between 2000 and 2004, 345 hospitals entered 31,261 patients into the study: 202 hospitals (group I) were classified as low volume (<30 operations; 7760 patients; 24.8%), 111 (group II) as medium volume (30-60; 14,008 patients; 44.8%) and 32 (groups III) as high volume (>60; 9493 patients; 30.4%). RESULTS: High-volume centres treated more patients in UICC stages 0, I and IV, whereas low-volume centres treated more in stages II and III (P<0.001). There was no significant difference for intra-operative complications and anastomotic leakage. The difference in 30-day mortality between the low and high-volume groups was 0.8% (P=0.023).Local recurrence at 5 years was highest in the medium group. Overall survival was highest in the high-volume group; however, the difference was only significant between the medium and high-volume groups. For the low and high-volume groups, there was no significant difference in the 5-year overall survival rates. CONCLUSION: A definitive statement on outcome differences between low-volume and high-volume centres participating in a quality assurance programme cannot be made because of the heterogeneity of results and levels of significance. Studies on volume-outcome effects should be regarded critically.

Palliative stoma creation: comparison of laparoscopic vs conventional procedures.

BACKGROUND: The creation of a stoma is an established therapeutic concept for the palliation of non-resectable rectal carcinomas and advanced tumours infiltrating the pelvis. MATERIALS AND METHODS: In two prospective country-wide multicentre studies, each conducted over a similar period of time, the peri-operative course and postoperative short-term outcomes of laparoscopic vs laparotomy-based stoma construction were compared. RESULTS: A total of 90 patients underwent palliative laparoscopic construction; 550 patients received a stoma via a laparotomy. The intra-operative complication rate was lower after open surgery than after laparoscopic surgery (2.7 vs 5.6%; p = 0.15), although the difference was not significant. With regard to general (30.9 vs 15.6%; p = 0.003) and also specific postoperative complications (13.8 vs 5.6%; p = 0.029), however, a significant advantage of the laparoscopic approach was seen. Furthermore, mortality in the laparoscopic group was also significantly lower (4.4 vs 14.0%; p = 0.011). CONCLUSION: Palliative stoma done via laparoscopy had significantly better outcomes in terms of postoperative morbidity and mortality in comparison with the open surgical procedure.

[Investigations on in-hospital mortality in pancreatic surgery : Results of a multicenter observational study]. / Untersuchungen zur Hospitalletalität in der Pankreaschirurgie : Ergebnisse einer multizentrischen Beobachtungsstudie.

BACKGROUND: The rate of hospital mortality (in-hospital mortality) after complex pancreatic resections cannot be used as a decision-making criterion with no further analysis and specification. Such analysis has to provide a risk-adjusted benchmarking including a continuous evaluation taking into account the frequency of a surgical procedure and its competent perioperative management. MATERIAL AND METHODS: As part of the Prospective Evaluation study Elective Pancreatic surgery (PEEP), overall 2003 patients were enrolled over a 3-year time period from 01 January 2006 to 12 December 2008, who underwent elective pancreatic surgery in 27 surgical departments. Included in the study were only hospitals which perform pancreatic resections. In addition to the analysis of the current situation of the operative treatment of pancreatic diseases, the complex aspects of the in-hospital mortality as a main outcome parameter were investigated. RESULTS: Out of all enrolled patients (n = 2003), 75 patients (3.7%) died during the hospital stay. In the group of 1045 patients with partial pancreaticoduodenectomy (PD), 43 patients did not survive the hospital stay (4.1%). Similarly, such low in-hospital mortality rates were observed after total pancreatoduodenectomy (3.8%) and after left-sided resection of the pancreas (1.9%). With respect to a univariate risk stratification, advanced age and an American Society of Anaesthesiologists (ASA) score of 3 and 4 had a significant impact on in-hospital mortality. Multivariate regression analysis within the PD group revealed an increased need for blood transfusions and a delay in oral feeding as factors closely associated with specific complications with a significant impact on in-hospital mortality. Significant differences in the in-hospital mortality rates were found when comparing hospital volume groups, such as 10-20 vs. >20 cases/year for the 831 Kausch-Whipple procedures for adenocarcinoma and chronic pancreatitis. DISCUSSION: An adequate in-hospital mortality rate in the continuous benchmarking represents an acceptable quality level of structural and therapeutic predictions in pancreatic resections. The participation of surgical departments with complex oncosurgical interventions in clinical multicenter observational studies as a contribution to research on surgical care appears reasonable and recommendable since the results of such studies can provide a contribution to decision-making processes in daily surgical practice.

[Clinical value of laparoscopic surgery for colon cancer]. / Stellenwert der laparoskopischen Chirurgie des Kolonkarzinoms in der klinischen Routine.

BACKGROUND: Using data and analysis compiled in the nationwide German Colon/Rectal Cancer qualitative multicenter study, the aim of this study was to determine the value of laparoscopic surgery for colon cancer in clinical routine. METHODS: From 1 January 2000 to 31 December 2003, patients with colon cancer resections were evaluated for short-term postoperative and long-term oncologic results associated with operative approach (laparoscopic vs conversion vs open). RESULTS: Of 21,721 patients with colon cancer, 949 (4.4%) underwent laparoscopic resection. These patients were younger (P<0.001) with lower ASA risk factors (P<0.001) and earlier UICC tumor stages (P<0.001) than open resected patients. They also showed reduced overall morbidity (P<0.001), in-hospital mortality (P=0.001), and shorter hospital stays (P<0.001). The rates of intraoperative and specific complications remained unchanged. Nineteen percent of the patients had resections converted to open approaches. These had the highest overall morbidity and longest hospital stays. Their mortality was three times that of the group with complete laparoscopic resection. CONCLUSIONS: The open approach remained the standard of surgical care in colon cancer for the study duration. Laparoscopic surgery was used in only a small number of patients. By virtue of preferential patient selection, better early postoperative and long-term results could be achieved for the laparoscopic group than with the open approach. Conversions were shown to be associated with inferior results at the high rate of 19%. To ensure optimal results, laparoscopic surgery for colon carcinoma should be conducted by an experienced surgeon in an appropriately selected patient pool.

[Gender-specific differences of the early postoperative and oncosurgical long-term outcome in rectal cancer-data obtained in a prospective multicenter observational study]. / Genderspezifische Unterschiede im frühpostoperativen und onkochirurgischen Langzeitoutcome nach Rektumkarzinomresektion.

BACKGROUND: Gender-specific aspects have been increasingly considered in clinical medicine, also in oncological surgery. AIM: To analyze gender-specific differences of early postoperative and oncological outcomes after rectal cancer resection based on data obtained in a prospective multicenter observational study. PATIENTS AND METHODS: As part of the multicenter prospective observational study "Quality assurance in primary rectal cancer", data on tumor site, exogenic and endogenic risk factors, neoadjuvant treatment, surgical procedures, tumor stage, intraoperative and postoperative complications of patients with the histological diagnosis of rectal cancer were registered. Data from the years 2005-2006 and 2010-2011 were investigated with respect to gender-specific differences of postoperative morbidity, hospital mortality, local recurrency rate, disease-free and overall survival by univariable and multivariable analyses. RESULTS: Overall, data from 10,657 patients were evaluated: 60.9% of the patients were male, who were significantly younger (p < 0.001). Men had a significantly higher rate of alcohol (p < 0.001) and nicotine abuse (p < 0.001) as well as a trend to a higher body mass index (BMI) compared with women. Although, there was no significant difference in the distribution of various tumor stages comparing men and women, neoadjuvant radiochemotherapy was used significantly more often in male patients (p < 0.001). In addition, male patients underwent an abdominoperineal rectum exstirpation more often, whereas creation of an enterostoma and Hartmann's procedure were more frequently used in women (p < 0.001 each). Multivariate analysis revealed that male patients developed a higher overall morbidity (odds ratio, OR: 1.5; p < 0.001) during both study periods and from 2010-2011 a higher hospital mortality (OR: 1.8; p < 0.001). After a median follow-up period of 36 months, gender did not have a significant impact on overall survival, disease-free survival or on the local tumor recurrency. The 5­year overall survival was 60.5%, disease-free survival 63.8% and local recurrency rate was 5%. CONCLUSION: Independent of other variables, gender differences were found with respect to early postoperative outcome but not to oncological long-term results after surgery of rectal cancer.

Impact of anastomotic leakage on oncological outcome after rectal cancer resection.

BACKGROUND: : Anastomotic leakage has a major impact on morbidity and mortality in rectal cancer surgery. Its relevance to oncological outcome is controversial. This observational study investigated the influence of anastomotic leakage on oncological outcome. METHODS: : Data for 1741 patients undergoing curative resection of rectal cancer (located less than 12 cm from the anal verge) with normal healing were compared with those for 303 patients who experienced anastomotic leakage. Morbidity, mortality and long-term oncological outcomes were analysed. RESULTS: : Median follow-up was 40 months. Patients with anastomotic leakage had a higher postoperative mortality rate than those with no leakage (4.3 versus 1.2 per cent; P < 0.001). Patients with leakage necessitating surgical treatment had a higher 5-year local recurrence rate (17.5 versus 10.1 per cent; P = 0.006) and a lower 5-year disease-free survival rate (70.9 versus 75.4 per cent; P = 0.020) than those without leakage. Patients with anastomotic leakage not requiring surgical intervention did not have a worse oncological outcome. CONCLUSION: : A negative prognostic impact of anastomotic leakage on local recurrence and disease-free survival was found only for patients with leakage needing surgical revision.

Influence of hospital volume on the frequency of abdominoperineal resection and long-term oncological outcomes in low rectal cancer.

AIM: Studies analysing the outcome after resection of low rectal cancer that has not infiltrated the anal sphincter reveal poorer long-term outcomes after abdominoperineal resections (APR) in comparison with low anterior resections (LAR). Further, a relationship between the frequency of APR and LAR for low rectal cancer and hospital volume is known. Our aim was to investigate the independent impact of hospital volume and type of resection on oncological outcomes after resection of low rectal cancer. METHOD: In a prospective multi-centre observational study of 1557 patients with low rectal cancer undergoing LAR or APR, the long-term oncological outcomes were analysed for their dependence on hospital volume and type of procedure. RESULTS: Univariate analysis revealed that patients undergoing APR had a higher local recurrence rate (p = 0.022) and shorter disease-free survival (p < 0.001) than patients undergoing LAR, while hospital volume showed merely a tendency to impact the local recurrence rate (p = 0.060). With regard to disease-free survival, no dependence on hospital volume was to be found (p = 0.201). The rate of APR was significantly associated with hospital volume (p < 0.001). Multivariate analysis revealed an independent impact of hospital volume on local recurrence rate, while disease-free survival was influenced by the type of surgical procedure performed. CONCLUSION: In the surgical treatment of low rectal cancer the hospital volume has a major impact on outcome. The type of procedure does not affect the local recurrence rate but the disease free survival.

Oldie but goldie: Bristow-Latarjet procedure for anterior shoulder instability.

PURPOSE: To analyse the functional and radiological outcomes of the Bristow-Latarjet procedure in patients with recurrent anterior glenohumeral instability. METHODS: Records of 29 patients were reviewed retrospectively. Date of first dislocation, injury mechanism, and number of recurring dislocations before and after surgery were recorded. The overall function and stability of the shoulder was evaluated. RESULTS: 24 (83%) of the glenohumeral instabilities were caused by trauma. The mean number of recurring dislocations was 8 (95% confidence interval [CI], 0-18); one patient had had 40 recurrences. No dislocation ensued postoperatively. The overall functional outcome was good, with a mean Rowe score of 90 points (95% CI, 78-100). Scores of 17 (59%) of the patients were excellent, 7 (24%) were good, 3 (10%) were fair, and 2 (7%) were poor. CONCLUSION: The Bristow-Latarjet procedure is a good surgical treatment for recurrent anterior-inferior instability of the glenohumeral joint.

[Hospital volume effects in surgical treatment of gastric cancer : Results of a prospective multicenter observational study]. / "Hospital-volume"-Effekt in der operativen Behandlung des Magenkarzinoms : Ergebnisse einer prospektiven multizentrischen Beobachtungsstudie.

BACKGROUND: The impact of hospital and surgeon volume on the treatment outcome based on data obtained from cohort and register studies has been controversially discussed in the international literature. The results of large-scale prospective observational studies within the framework of clinical healthcare research may lead to relevant recommendations in this ongoing discussion. MATERIAL AND METHODS: Within the framework of the prospective multicenter German Gastric Cancer Study 2 (QCGC 2), from 1 January 2007 to 31 December 2009 a total of 2897 patients with the histological diagnosis of gastric cancer from 140 surgical departments were registered and analyzed. The departments were subdivided according to the number of cases into 4 volume groups: I) <5, II) 5-10, III) 11-20 and IV) >20 patients with surgical interventions per year. RESULTS: Overall 1163 patients (65.6 %) underwent surgical interventions in the departments of groups III and IV. Of the patients 521 (18 %) were scheduled for neoadjuvant treatment but with no significant differences among the various volume groups. In the departments of volume groups I and II subtotal gastric resection was performed significantly more often. Transthoracic extended surgical interventions in cases of a proximal tumor site were significantly more frequent in departments from volume group IV (p <0.001). The proportion of intraoperative fresh frozen sections correlated with the case volume: group I 23.2 % vs. group IV 61.2 %. Overall hospital mortality was 6.1 % and slightly higher in volume group I with 7.8 %. The median survival time and the 5­year survival rate showed no significant differences between the various volume groups independent of tumor stages. There was a tendency towards a longer median survival time in volume group IV only for proximal tumor sites, i.e. adenocarcinoma of the esophagogastric junction (AEG). Using Cox regression analysis hospital volume did not have an independent impact on long-term survival. CONCLUSION: Hospital volume effects could only be detected for the treatment of AEG. To improve oncological long-term outcome, centralization of treatment of proximal gastric cancer appears to be recommendable.

Feasibility and accuracy of TRUS in the pre-treatment staging for rectal carcinoma in general practice.

AIMS: Transrectal ultrasonography (TRUS) is the diagnostic tool of choice for local staging of rectal carcinoma. The accuracy in determining of tumour infiltration depth has been reported to reach 95% (on average, 85%). The aim of the study was to analyse the diagnostic accuracy of the TRUS in the clinical routine. PATIENTS AND METHODS: From 01/01/2000 to 12/31/2003, all patients with rectal carcinoma were enrolled in a prospective multicenter observational study. In case of complete findings of pre-operative TRUS and post-operative histological investigation of the surgical specimen on the tumour infiltration depth, overall accuracy of TRUS was determined. RESULTS: Overall, 13,610 patients with rectal carcinoma were enrolled in the study. Five thousand and fifty-six subjects (37%) underwent TRUS. In 3,501 patients, TRUS finding (uT-stage) could be compared with the result of the definitive histologic investigation (pT-stage). The accuracy of TRUS in all T-stages was 65.8%. The highest sensitivity was achieved in the T3-stage (74.9%), while in T2, T1, and T4, it was 59.6, 59.0 and 31.1%, respectively. In discriminating tumour growth limited to the rectal wall vs that through the rectal wall into the neighboring tissue, TRUS-associated accuracy was 76.5%. There were no differences between various tumour locations above the anocutaneous line. CONCLUSIONS: Diagnostic accuracy of TRUS in determining depth of tumour infiltration within or through the rectum wall in the routinuous diagnostic of rectal carcinoma does not reach the excellent published study results. A considerable improvement of the qualitative outcome in using this specific diagnostic tool appears to be recommendable to utilize its advantages such as high accuracy, efficacy, and practicability in the diagnostic process and deriving consequences for a possible neoadjuvant treatment as well as optimal planning of the surgical approach.

Palliative stent implantation in the treatment of malignant colorectal obstruction.

BACKGROUND: Palliative surgical interventions for the management of colonic obstruction in cases of metastasized or locally irresectable colorectal carcinoma show remarkable morbidity and mortality rates for mostly older and multimorbid patients. For manifest obstruction, placement of a self-expanding metal stent (SEMS) is considered to be a suitable minimally invasive therapeutic option. This study aimed to investigate the efficacy of stent-based treatment for malignant large bowel obstruction. METHODS: From January 1999 to June 2005, consecutive patients who had undergone placement of a SEMS for malignant colorectal obstruction were enrolled and monitored. Manifest incontinence and rectum carcinoma within 5 cm above the anocutaneous line were contraindications for SEMS implantation. For all further locations of tumor-induced stenosis, a stent was implanted using endoscopy and fluoroscopy. This case series was characterized in terms of age, carcinoma localization, complications, morbidity and mortality, and the necessity for further interventions. RESULTS: For 44 of 48 patients (92%), stents were placed successfully and obstruction was abolished. The four remaining patients experienced stent dislocation. The median of age of the patients was 77.7 years (range, 47-96 years). The distribution of malignant stenoses was as follows: rectum (n = 16, 33.3%), sigmoideal colon (n = 21, 43.8%), descending colon (n = 4, 8.3%), splenic flexure (n = 2, 4.2%), transversal colon (n = 3, 6.2%), hepatic flexure (n = 1, 2.1%), and ascending colon (n = 1, 2.1%). There was no peri-interventional morbidity or mortality. The median in situ time for the stents was 251 days (mean, 422 days), with 13 of 44 patients treated with palliative therapy showing complications (29.5%). Six patients were treated endoscopically, and three individuals underwent surgical intervention. For four patients, no further intervention was required. Overall, there was no treatment-related mortality. CONCLUSIONS: For palliative treatment of malignancy-induced colorectal obstruction, SEMS is an efficient tool associated with low morbidity and minimal mortality. From a technical point of view, all tumor locations are accessible.

[Long-term oncological results after laparoscopic, converted and primary open procedures for rectal carcinoma. Results of a multicenter observational study]. / Operative Behandlung von Rektumkarzinomen im Vergleich. Onkologische Langzeitergebnisse einer multizentrischen Beobachtungsstudie nach laparoskopisch-assistierter, konvertierter und primär offener Operation.

BACKGROUND: The laparoscopic resection of rectal cancer shows morbidity and oncological safety comparable to the open approach, but morbidity increases after conversion to open resection. No oncological long-term results are available for the latter patients. METHODS: From 01/01/2000-31/12/2002, patients with curatively resected rectal cancer enrolled in a observational study were evaluated for morbidity, mortality, tumor- and local recurrence rate, paying attention to patients with conversion from laparoscopic to open resection. RESULTS: 237 (3.3%) of 7,189 patients underwent laparoscopic resection (ITT). These patients showed significantly more T1/2 tumors (P<0.001) in earlier UICC stages (P<0.001) than open resected patients. 35 (14.8%) of 237 laparoscopic procedures were converted. Compared with patients receiving complete laparoscopic or open resection, these patients showed significantly higher frequencies of intraoperative (P<0.001) and general postoperative complications (P=0.003) as well as the highest overall morbidity (P=0.031). After a median follow-up of 30.1 months, the highest 5-year local recurrence rate was found in the converted group (16.0%). The laparoscopically resected patients showed a local recurrence rate of 3.3%, patients with open resection of 12.4% (P=0.082). The disease-free survival rate did not differ between the groups (P=0.585). CONCLUSION: Laparoscopic resection of rectal cancer provides oncological results similar to open resection. After conversion, the short and oncological long-term outcomes were worse. Considering a conversion rate of 15%, only a strict indication for the laparoscopic approach can be allowed, and laparoscopic resection should be performed at centers.