[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.

[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.

[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.

[Palliative surgery in visceral medicine. Exemplified by colorectal and gastric cancer]. / Palliativchirurgie in der Viszeralmedizin. Am Beispiel des kolorektalen und des Magenkarzinoms.

BACKGROUND: The benefits of primary tumor resection in metastatic disease remains a matter of debate. Existing data are almost exclusively limited to results from retrospective analyses. Data from prospective, randomized trials are currently not available. AIM: The results from two prospective observational studies involving gastric and rectal cancer patients are presented and discussed in the context of the available literature. METHOD: Based on data collected within the prospective quality assurance studies on gastric and rectal cancer conducted by the Institute for Quality Assurance in Surgery at Otto von Guericke University, Magdeburg, Germany, the long-term outcome after palliative primary tumor resection in patients with International Union Against Cancer (UICC) stage IV rectal cancer (2005-2008, n = 2046) and metastatic gastric cancer (2007-2009, n = 687) was analyzed and compared to published data. RESULTS: The median survival time following palliative primary tumor resection of UICC stage IV rectal cancer in the patients analyzed was 20 months. In patients with hepatic metastases undergoing metastasectomy the median survival was 38 months. This increased to 58 months for patients with lymph node negative primary tumors. In metastatic gastric cancer patients undergoing palliative (R2) gastric resection and also patients not undergoing surgery showed a prognostic benefit from palliative chemotherapy; however, the median survival time was significantly prolonged if palliative chemotherapy was preceded by resection of the primary tumor (11 versus 7 months, p < 0.001). DISCUSSION: Together with previously published data, the results from the two observational studies on rectal and gastric cancer presented here suggest a prognostic benefit from palliative resection of the primary tumor in metastatic disease.

[Palliative treatment of advanced gastric cancer from surgical point of view]. / Palliative Behandlung des fortgeschrittenen Magenkarzinoms aus chirurgischer Sicht.

Data are available on two multicenter observational studies, the East German Gastric Cancer Study (EGGCS) '02 (surgical interventions only) and the German Gastric Cancer Study II (QCGC) from 2007 to 2009 (after inauguration of multimodal therapeutic concepts) with regard to palliative treatment of advanced gastric cancer. Through the first investigation period from January to December 2002 (EGGCS) overall 1139 patients with primary gastric cancer were registered and evaluated and then from 2007 to 2009 (QCGC) another 2897 patients were included. Comparing both time periods, there were no significant changes in the distribution of tumor sites and stages according to the Union Internationale Contre le Cancer (UICC) classification, in particular, there was no significant reduction of advanced tumor stages. From 2007 to 2009 in total 521 patients (18 %) received neoadjuvant therapy, 401 patients (13.9 %) out of the group with curative intention and 120 (4.1 %) out of the group of patients with palliative intention. The proportion of palliative patients who underwent chemotherapy (with neoadjuvant intention and/or postoperatively) was 32.5 % (n = 223). Thus, the rate of palliative treatment (rate of no R0 resection status 29.6 %, rate of patients who did not undergo surgical intervention at all 9.5 %) could be diminished from almost 40 % in 2002 to 24.5 % through the time period from 2007 to 2009. Taking all patients together (with curative and palliative intention) an increase of the 4-year survival probability from 40.0 % to 48.5 % was observed after inauguration of multimodal therapy. After a 5-year follow-up median survival time was 34 months during the investigation period from 2007 to 2009 considering all study subjects. Patients who had undergone palliative surgical interventions benefited from postoperative palliative chemotherapy; however, as expected this was of greater benefit to patients with resecting surgical interventions than those with non-resecting operations. Palliative tumor resection (even R2 resection status) should be part of a concept of multimodal palliative therapy in cases of acceptable perioperative risk.

[Treatment reality with respect to laparoscopic surgery of colonic cancer in Germany]. / Versorgungsrealität in der laparoskopischen Chirurgie des Kolonkarzinoms in Deutschland.

BACKGROUND: Prospective randomized studies and meta-analyses have shown that laparoscopic resection for colonic cancer is equivalent to open resection with respect to the oncological results and has short-term advantages in the early postoperative outcome. The aim of this study was to investigate whether laparoscopic colonic resection has become established as the standard in routine treatment. METHODS: Data from the multicenter observational study "Quality assurance colonic cancer (primary tumor)" from the time period from 1 January 2009 to 21 December 2011 were evaluated with respect to the total proportion of laparoscopic colonic cancer resections and tumor localization and specifically for laparoscopic sigmoid colon cancer resections. A comparison between low and high volume clinics (< 30 versus ≥ 30 colonic cancer resections/year) was carried out. RESULTS: Laparoscopic colonic cancer resections were carried out in 12 % versus 21.4 % of low and high volume clinics, respectively (p < 0.001) with a significant increase for low volume clinics (from 8.0 % to 15.6 %, p < 0.001) and a constant proportion in high volume clinics (from 21.7 % to 21.1 %, p = 0.905). For sigmoid colon cancer laparoscopic resection was carried out in 49.7 % versus 47.6 % (p = 0.584). Differences were found between low volume and high volume clinics in the conversion rates (17.3 % versus 6.6 %, p < 0.001), the length of the resected portion (Ø 23.6 cm versus 36.0 cm, p < 0.001) and the lymph node yield (Ø n = 15.7 versus 18.2, p = 0.008). There were no differences between the two groups of clinics regarding postoperative morbidity and mortality. The postoperative morbidity and length of stay were significantly lower for laparoscopic sigmoid resection than for conventional sigmoid resection. CONCLUSION: The laparoscopic access route for colonic cancer resection is not the standard approach in the participating clinics. The laparoscopic access route has the highest proportion for sigmoid colon resection. The differences in the conversion rates, length of the resected portion and the number of lymph nodes investigated between the low volume and high volume clinics must be viewed critically and must be interpreted in connection with the long-term oncological results.

[Iatrogenic splenic injuries in surgery of colorectal carcinoma: impact on the oncological long-term of outcome]. / Iatrogene Milzverletzungen in der kolorektalen Karzinomchirurgie: Einfluss auf das onkologische Langzeitergebnis.

INTRODUCTION: Iatrogenic lesions of the spleen during surgery of colorectal carcinoma is considered a significant risk factor for a worse early postoperative outcome. With regard to the impact of iatrogenic splenic lesions particularly associated with splenectomy on the oncological long-term outcome, only limited valid data are available. METHODS: Data obtained in a prospective multicenter observational study were analyzed. The study enrolled 45,265 patients with surgery for colorectal carcinoma in curative and palliative intentions during the study period from 01 January 2000 to 31 December 2004, with regard to the impact of iatrogenic splenic lesions on survival rates. RESULTS AND CONCLUSION: Follow-up data with corresponding informed consent were obtained from 564 patients with iatrogenic splenic lesions, resulting in a follow-up rate of 99.8 %. The median follow-up period was 50.2 months. The median 5-year overall survival was 4.8 years in group I (splenic lesion with splenectomy) and in group II (splenic lesion with organ preservation) 8.0 years (p = 0.009). Between group II (splenic lesion with organ preservation) and group III (control group with no splenic lesion) there were no significant differences with regard to long-term survival. Using multivariate Cox regression analysis, iatrogenic splenic lesions with splenectomy were identified as an independent risk factor for a worse oncological long-term outcome.

[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.

[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.

[Colorectal tumor surgery in the elderly: results of quality assurance]. / Kolorektale Tumorchirurgie beim Hochbetagten: Ergebnisse der Qualitätssicherung.

The age group ≥ 80 years has become of great importance in the surgical treatment of colorectal cancer due to the demographic changes over the years. To assess patient risk, early postoperative and oncologic long-term outcome 64,740 patients with colorectal cancer were enrolled in various nationwide multicenter observational studies through two study periods (2000-2004 and 2009-2011) and analyzed according to various age groups, in particular ≥ 80 years. The percentage of octogenarians increased from 2009 to 2011, which was associated with an increased patient risk. In 70  % of patients ≥ 80 years old the operative risk was preoperatively classified as ASA stages III and IV. There was a high age-independent resection rate of colon cancer; however, the rectal cancer resection rate in octogenarians was significantly lower. In the age group ≥ 80 years there was a relatively high rate of emergency surgical interventions because of an ileus due to tumor-induced lumen obstruction leading to a hospital mortality rate in both study periods of 18.8 % and 17.9 %, respectively. In the octogenarians there were more locally advanced colon cancer lesions of stage T3/4 but less tumor lesions with distant metastases. The age-corrected tumor-free 5-year survival rate of the octogenarians with colon cancer of tumor stage UICC I-III was identical to that of younger patients.

[Surgical treatment of gastric carcinoma. German multicenter observational studies]. / Chirurgische Therapie des Magenkarzinoms. Multizentrische Beobachtungsstudien.

The aim of the review is to compare the results of selected German multicenter observational studies on the surgical treatment of gastric carcinoma within the last two decades. Overall, 6,035 patients with gastric cancer who had been registered in numerous German comprehensive surgical clinics and departments in the time periods 1986-1989, January through December 2002 and 2007-2009 were enrolled in this analysis. In particular, the study aimed to investigate the most important criteria and factors with an impact on the perioperative and early postoperative outcome including the effects on oncological long-term results. In addition to the advances in diagnostic procedures and surgical techniques, the impact of multimodal therapeutic concepts which have been established particularly in the third investigation period is emphasized.

[Acute appendicitis - clinical health-service research on the current surgical therapy]. / Akute Appendizitis - Klinische Versorgungsforschung zur aktuellen chirurgischen Therapie.

INTRODUCTION: With about 135,000 operations every year appendectomy is one of the most frequent surgical operations in Germany. Acute appendicitis has shown changes in diagnosis and therapy with time. The status of the laparoscopic appendectomy has had to be redefined recently. The aim of this study was to make an analysis of the current surgical therapy for appendicitis and the individual procedures. PATIENTS AND METHODS: Three prospective multi-centre quality assurance studies (1988 / 89, 1996 / 97; 2008 / 09) of the "An-Institut" acquired 17,732 treatments from all supply levels of Germany. RESULTS: The average age of patients increased within of the three studies from 25.7 to 34.6 years. Within the studies in 1996 / 97 and in 2008 / 09 the share of laparoscopic appendectomy advanced from 33.1 to 85.8 percent. In the study from 2008 / 09 the laparoscopic appendectomy showed a significant advantage over the conventional technique in terms of wound-healing disturbances (p < 0.001) and a clinical duration of stay (p < 0.001). At no stage of the appendix inflammation did the laparoscopic appendectomy lead to a significant increase of intraabdominal abscesses. Compared with the conventional technique the operating time was shorter (46.6 min vs. 53.5 min). Currently the use of a stapler is the mostly frequently applied method of appendiceal stump closure (83.6 percent). CONCLUSION: The laparoscopic appendectomy is the most common method of current operative therapy. In comparison to former publications, there is no proof of any disadvantages of laparoscopic appendectomy.

[Local diagnostics for rectal cancer. What is realistic?]. / Lokale Diagnostik beim Rektumkarzinom. Wie sieht die Realität aus?

Accurate pretherapeutic staging of rectal cancer is crucial for further therapeutic management and important for prognosis. The most accurate diagnostic tools in the assessment of T and N categories of rectal cancer are endorectal ultrasound (EUS) and magnetic resonance imaging (MRI). Furthermore, MRI can accurately predict the distance of the tumor to the colorectal membrane (CRM) and computed tomography (CT) is more suitable for detecting distant metastases. In the routine care of rectal cancer EUS is the most frequently used diagnostic tool for local staging. The achieved accuracy for determining T category by EUS in routine clinical staging is lower than results reported in the literature. Furthermore, the accuracy of EUS depends on the experience of the examiner. Currently the frequency of using MRI for routine clinical staging of rectal cancer is low and in one out of five cases the local staging of rectal cancer is exclusively carried out by CT.

[Spleen injuries during colorectal carcinoma surgery. Effect on the early postoperative result]. / Milzverletzungen im Rahmen kolorektaler Karzinomchirurgie. Einfluss auf das frühpostoperative Ergebnis.

INTRODUCTION: Unlike gastric carcinomas, the consequences of spleen damage during operative treatment of colorectal carcinoma have barely been investigated, as splenectomy is not performed on these tumor patients to extend the radicality. In this context, the only interest is in the iatrogenic intraoperative spleen lesions, which make a splenectomy necessary or require reconstructive spleen preservation. METHODOLOGY: During the study period from January 2000 to the end of December 2004 the perioperative data of a prospective multicenter observational study of 46,682 Patients whose tumor had been removed with a curative or palliative intent were analyzed with respect to the early postoperative consequences of an iatrogenic spleen lesion. RESULTS: Of these 46,682 Patients, 640 (1.4%) suffered an iatrogenic spleen injury during the operative therapy. The spleens of 127 Patients (0.3%) were removed and the spleens of 513 Patients (1.1%) could be left in situ following repair. In more than 80% of the cases with an iatrogenic spleen injury, the tumor was localized in the left colon and in the rectum. Logistic regression analysis showed that the decisive risk factor for this organ lesion was the mobilization of the left colonic flexure with tumor localization in the left colon and rectum. Following spleen lesion a significantly higher morbidity rate was registered (47.2% following splenectomy, 48.5% following spleen repair) compared to patients without spleen injury (36.5%). Anastomotic leaks requiring surgery were most frequently observed following splenectomy (7.9%) but this was significantly lower following spleen preservation (3.3%, p = 0.003). The total hospital mortality was 3.1%. In patients with splenectomy the hospital mortality was 11.8% and subsequent repair with organ preservation was 4.7% (p < 0.0001). CONCLUSIONS: Iatrogenic spleen lesions during colorectal carcinoma surgery represent a significant risk factor for a poor early postoperative result. In particular, this concerns the high rate of anastomotic leaks and infectious septic complications. This also leads to a higher rate of total morbidity and hospital mortality. By comparison significantly worse postoperative results were found in the group of splenectomised patients compared to the group with organ preservation through repair of the injured spleen.

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.

[Advanced gastric cancer. Are there still indications for palliative surgical interventions?]. / Fortgeschrittenes Magenkarzinom. Gibt es noch Indikationen für Palliativeingriffe?

BACKGROUND AND METHODS: Based on data obtained in the prospective multicenter observational study on the surgical treatment of gastric cancer "East German Gastric Cancer Study 2002 (EGGCS)", the cohort of patients with gastric cancer who underwent palliative surgical interventions during the study period from 1(st) January to 31(st) December 2002 was investigated. RESULTS: Out of 1,139 documented patients with gastric cancer, 1,031 underwent a surgical intervention (operation rate 90.5%). In 70.4% (n=726) of the patients with surgical interventions, R0 resection status could be achieved whereas in 305 patients (29.6%), only a palliative (R1/2 resection status) result was possible using resection and non-resection procedures in 165 and 140 cases, respectively. The hospital mortality rate was 7.3% (n=53) in the group of curative R0 resection patients and was almost identical with 7.8% (n=13) in the group of R1/2 resection patients. The highest hospital mortality of 14.4% (n=20) was found in subjects who primarily underwent palliative surgical interventions (R2 resection or non-resection procedures). In the subgroup analysis the highest overall morbidity of 57.1% was found in the group of palliative (R2) resection patients. Curatively intended but palliatively operated patients (from the perspective of the final histopathological result) showed a significantly longer overall survival time (11 months) compared with patients who primarily underwent a surgical intervention with palliative intention (6.3 months). Even patients who underwent tumor resection with palliative intention were observed to have a longer survival time of 2.3 months (in total, 6.9 months) compared with patients with non-resection surgical intervention (4.6 months). In the group of R2 resection patients with a preoperatively detected pyloric stenosis/dysphagia, an increased overall morbidity (62.5% with stenosis versus 47.7% without stenosis) and an increased hospital mortality rate (25% versus 11.6%, respectively) were seen. This favors more interventional endoscopic procedures if possible considering the only marginal prolongation in survival time. In contrast, palliative resection in cases without stenosis is associated with an acceptable rate of postoperative complications (47.7%) and mortality (11.6%) resulting in the recommendation of a palliative resection under specific conditions considering the improved oncosurgical long-term outcome. CONCLUSION: Radical tumor resection with palliative intentions (if possible from a technical point of view) resulted in a prolongation of the median survival time of 3 months with an acceptable postoperative morbidity and mortality compared with non-resection procedures. According to the results of individual analysis of each tumor resection intervention, palliative gastrectomy showed a significant prolongation of survival time of 5 months compared with more limited subtotal resection (6 versus 11 months).

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.

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.

Colon carcinoma--classification into right and left sided cancer or according to colonic subsite?--Analysis of 29,568 patients.

BACKGROUND: It is common to distinguish between right and left colon cancer (RCC and LCC). But, little is known about the influence of its exact location on the tumor stage and characteristics when considering the colonic subsite within the right or left colon. METHODS: During a five-year period, 29,568 consecutive patients were evaluated by data from the German multi-centered observational study "Colon/Rectal Carcinoma". Patients were split into 7 groups, each group representing a colonic subsite. They were compared regarding demographic factors, tumor stage, metastatic spread and histopathological characteristics. RESULTS: Analysis of tumor differentiation and histological subtype revealed a linear correlation to the ileocecal valve, supporting the right and left side classification model. However, cancers arising from the RCC's cecum (52.3%) and LCC's splenic flexure (51.0%) showed the highest proportion of UICC stage III/IV tumors and lymphatic invasion, whereas the RCC's ascending colon (46.5%) and LCC's descending (44.7%) showed the lowest, which supports a more complex classification system, breaking down the right and left sides into colonic subsites. CONCLUSIONS: Age, tumor grade and histological subtype support the right and left side classification model. However, gender, UICC stage, metastatic spread, T and N status, and lymphatic invasion correlated with a specific colonic subsite, irrespective of the side. The classification of RCC or LCC provides a general understanding of the tumor, but identification of the colonic subsite provides additional prognostic information. This study shows that the standard right and left side classification model may be insufficient.