Inequalities in Implementation and Different Outcomes During the Growth of Laparoscopic Colorectal Cancer Surgery in England: A National Population-Based Study from 2002 to 2012.

AIM: Laparoscopic colorectal cancer surgery has developed from unproven technique to mainstay of treatment. This study examined the application and relative outcomes of laparoscopic and open colorectal cancer surgery over time, as laparoscopic uptake and experience have grown. METHODS: Adults undergoing elective laparoscopic and open colorectal cancer surgery in the English NHS during 2002-2012 were included. Age, sex, Charlson Comorbidity Index and Index of Multiple Deprivation were compared over time. Post-operative 30-day mortality, length of stay, failure to rescue reoperation and the associated mortality rate were examined. RESULTS: Laparoscopy rates rose from 1.1 to 50.8%. Patients undergoing laparoscopic surgery had lower comorbidity by 0.24 points (95% confidence intervals (CI) 0.20-0.27) and lower socioeconomic deprivation by 0.16 deciles (95% CI 0.12-0.20) than those having open procedures. Overall mortality fell by 48.0% from 2002-2003 to 2011-2002 and was 37.8% lower after laparoscopic surgery. Length of stay and mortality after surgical re-intervention also fell. However, re-intervention rates were higher after laparoscopic procedures by 7.8% (95% CI 0.9-15.2%). CONCLUSIONS: There was clear and persistent inequality in the application of laparoscopic colorectal cancer surgery during this study. Further work must explore and remedy inequalities to maximise patient benefit. Higher re-intervention rates after laparoscopy are unexplained and differ from randomized controlled trials. This may reflect differences in surgeons and practice between research and usual care settings and should be further investigated.

Population-based cohort study comparing 30- and 90-day institutional mortality rates after colorectal surgery.

BACKGROUND: Surgical mortality results are increasingly being reported and published in the public domain as indicators of surgical quality. This study examined how mortality outlier status at 90 days after colorectal surgery compares with mortality at 30 days and subsequent intervals in the first year after surgery. METHODS: All adults undergoing elective and emergency colorectal resection between April 2001 and February 2007 in English National Health Service (NHS) Trusts were identified from administrative data. Funnel plots of postoperative case mix-adjusted institutional mortality rate against caseload were created for 30, 90, 180 and 365 days. High- or low-mortality unit status of individual Trusts was defined as breaching upper or lower third standard deviation confidence limits on the funnel plot for 90-day mortality. RESULTS: A total of 171 688 patients from 153 NHS Trusts were included. Some 14 537 (8·5 per cent) died within 30 days of surgery, 19 466 (11·3 per cent) within 90 days, 23 942 (13·9 per cent) within 180 days and 31 782 (18·5 per cent) within 365 days. Eight institutions were identified as high-mortality units, including all four units with high outlying status at 30 days. Twelve units were low-mortality units, of which six were also low outliers at 30 days. Ninety-day mortality correlated strongly with later mortality results (rs = 0·957, P < 0·001 versus 180-day mortality; rs = 0·860, P < 0·001 versus 365-day mortality). CONCLUSION: Extending mortality reporting to 90 days identifies a greater number of mortality outliers when compared with the 30-day death rate. Ninety-day mortality is proposed as the preferred indicator of perioperative outcome for local analysis and public reporting.

Unselected rectal cancer patients undergoing low anterior resection with defunctioning ileostomy can be safely managed within an Enhanced Recovery Programme.

BACKGROUND: An increasing body of evidence supports the application of the Enhanced Recovery Programme (ERP) to colorectal surgery. Some institutions have reported an association between ERP failure and low rectal cancer surgery. We present the results that we achieved by applying the ERP to low anterior resections for tumours within 6 cm of the anal verge, with a view to determining the validity and safety of applying the ERP to this patient group. METHODS: A multimodal ERP, based on Kehlet's model, was introduced in January 2007 and applied to all patients undergoing elective resections. Patients having a low anterior resection for a rectal cancer less than 6 cm from the anal verge between January 2007 and August 2011 were retrospectively identified from a prospectively maintained database. Individual patient record review was performed. RESULTS: Twenty consecutive patients (12 males) were identified. Median total postoperative length of stay (LOS), including readmission, was 8 days (mean 10.7, range 4-47 days), with 2 readmissions and no deaths. When surgery was uncomplicated, median LOS was 5 days (mean 5.8, range 4-12 days, n = 11), whereas LOS increased when a complication occurred, with a median of 12 days (mean 16.6, range 8-47 days, n = 9) [p = 0.001]. CONCLUSIONS: The ERP can safely be applied to this high-risk patient group. When no complication occurs, LOS of 5 days can be expected. When a complication is encountered, LOS is prolonged (12 days), but this is acceptable compared with the current national median LOS in the United Kingdom of 11 days for all rectal cancer surgery (at any height) with a stoma.

The axillary nodal harvest in breast cancer surgery is unchanged by sentinel node biopsy or the timing of surgery.

Introduction. Patients with a positive sentinel lymph node biopsy may undergo delayed completion axillary dissection. Where intraoperative analysis is available, immediate completion axillary dissection can be performed. Alternatively, patients may undergo primary axillary dissection for breast cancer, historically or when preoperative assessment suggests axillary metastases. This study aims to determine if there is a difference in the total number of lymph nodes or the number of metastatic nodes harvested between the 3 possible approaches. Methods. Three consecutive comparable groups of 50 consecutive patients who underwent axillary dissection in each of the above contexts were identified from the Portsmouth Breast Unit Database. Patient demographics, clinicopathological variables, and surgical treatment were recorded. The total pathological nodal count and the number of metastatic nodes were compared between the groups. Results. There were no differences in clinico-pathological features between the three groups for all features studied with the exception of breast surgical procedure (P < 0.001). There were no differences in total nodal harvest (P = 0.822) or in the number of positive nodes harvested (P = 0.157) between the three groups. Conclusion. The three approaches to axillary clearance yield equivalent nodal harvests, suggesting oncological equivalence and robustness of surgical technique.

The incidence and outcome of brain metastases after liver resection for colorectal cancer metastases.

AIM: Brain metastases from colorectal cancer are rare, with an incidence of 0.6-4%. The risk and outcome of brain metastases after hepatic and pulmonary metastasectomy have not been previously described. This study aimed to determine the incidence, predictive factors, treatment and survival of patients developing colorectal brain metastases, who had previously undergone resection of hepatic metastases. METHOD: A retrospective review was carried out of a prospectively maintained database of patients undergoing liver resection for colorectal metastases. RESULTS: Fifty-two (4.0%) of 1304 patients were diagnosed with brain metastases. The annual incidence rate was 1.03% per person-year. In the majority of cases brain metastases were found as part of multifocal disease. Median survival was 3.2 months (95% CI: 2.3-4.1), but was best for six patients treated with potentially curative resection [median survival = 13.2 (range, 4.9-32.1) months]. Multivariate analysis showed that a lymph node-positive primary tumour [hazard ratio (HR) = 2.7, 95% CI: 1.8-6.19; P = 0.019], large liver metastases (> 6 cm) [HR = 2.23, 95% CI: 1.19-2.33; P = 0.012] and recurrent intrahepatic and extrahepatic disease [HR = 2.11, 95% CI: 1.2-4.62; P = 0.013] were independent predictors for the development of brain metastases. CONCLUSION: The annual risk of developing brain metastases following liver resection for colorectal metastases is low, but highest for patients presenting with a Dukes' C primary tumour, large liver metastases or who subsequently develop disseminated disease. The overall survival from colorectal brain metastases is poor, but resection with curative intent offers patients their best chance of medium-term survival.