Short-term outcomes after elective colon cancer surgery: an observational study from the Norwegian registry for gastrointestinal and HPB surgery, NoRGast.

BACKGROUND: To describe the real burden of major complications after elective surgery for colon cancer in Norway, and to assess which predictors that are significantly associated with the short-term outcome. METHODS: An observational, multi-centre analysis of prospectively registered colon resections registered into the Norwegian Registry for Gastrointestinal Surgery, NoRGast, between January 2014 and December 2016. A propensity score-adjusted subgroup analysis for surgical access groups was attempted, with laparoscopic resections grouped as intention-to-treat. RESULTS: Out of 1812 resections, 14.0% of patients experienced a major complication within 30 days following surgery. The over-all reoperation rate was 8.7%, and rate of reoperation for anastomotic leak was 3.8%. Twenty patients (1.1%) died within 30 days after surgery. Higher age was not a significant predictor of major complications, including 30-day mortality. After correction for all co-variables, open access surgery was associated with higher rates of major complications (OR 1.67 (CI 1.22-2.29), p = 0.002), higher 30-day mortality (OR 4.39 (CI 1.19-16.13) p = 0.026) and longer length-of-stay (HR 0.58 (CI 0.52-0.65) p < 0.001). CONCLUSIONS: Our results indicate a low complication burden and high rate of uneventful patient journeys after elective surgery for colon cancer in Norway. Age was not associated with higher morbidity or mortality rates. Open access surgery was associated with an inferior short-term outcome.

The New National Registry for Gastrointestinal Surgery in Norway: NoRGast.

BACKGROUND AND AIMS: There is an increasing demand for high-quality data for the outcome of health care. Diseases of the gastro-intestinal tract involve large patient groups often presenting with serious or life-threatening conditions. Complications may affect treatment outcomes and lead to increased mortality or reduced quality of life. A continuous, risk-adjusted monitoring of major complications is important to improve the quality of health care to patients undergoing gastrointestinal resections. We present the development of the Norwegian Registry for Gastrointestinal Surgery, a national registry for colorectal, upper gastrointestinal, and hepato-pancreato-biliary resections in Norway. MATERIALS AND METHODS: A narrative and qualitative presentation of the development and current state of the registry. RESULTS: We present the variables and the analysis tools and provide examples for the potential in quality improvement and research. Core characteristics include a strictly limited set of variables to reflect important risk factors, the procedure performed, and the clinical outcomes. CONCLUSION: A registry with the potential to present complete national cohort data is a powerful tool for quality improvement and research.

Risk factors associated with poor lymph node harvest after colon cancer surgery in a national cohort.

AIM: Evaluation of ≥ 12 lymph nodes (LNs) is recommended after surgery for colon cancer. A harvest of ≤ 8 is considered poor, but few reports have evaluated risk factors associated with a poor harvest. This aims of this study were to analyse the clinical, surgical and pathological factors associated with poor LN harvest (LNH), the total number of examined nodes and the effect of LN number on stage. METHOD: All patients reported to the Norwegian Colorectal Cancer Registry during 2007 and 2008 who underwent curative resection for Stage I-III colon cancer were studied. Risk factors for poor LNH and the proportion of Stage III disease were analysed by univariate and multivariate analyses. RESULTS: A total of 2879 patients were included in the study. The median LNH was 14. Overall, 69.9% had ≥ 12 lymph nodes and 14.4% had ≤ 8 LN (poor harvest). Multivariate analysis showed that male sex, age > 75 years, sigmoid tumours, pT category 1-2, failure to use the pathology report template and distance of ≤ 5 cm from the bowel resection margin were all independent factors for poor LNH. Age < 65 years, pT category 3-4, and poor tumour differentiation were independent predictors of Stage III disease. An increased LNH did not increase the proportion of patients identified as being LN positive at the ≤ 8, 9-11 and ≥ 12 LN levels. CONCLUSION: Adequate LNH was achieved in the majority of curative colon cancer resections in this national cohort. Elderly, male patients with sigmoid cancers, and a short distal margin were at increased risk of a poor LNH.

Survival effect of implementing national treatment strategies for curatively resected colonic and rectal cancer.

BACKGROUND: The surgical management of rectal cancer has changed substantially over the past decade. There are limited data on the long-term outcome of implementing systematic management strategies. METHODS: Survival of a national cohort of patients treated surgically for colonic and rectal cancer over a 10-year interval was analysed. All 31 158 patients in Norway diagnosed with adenocarcinoma of the colon and rectum between 1994 and 2003 were identified from the Cancer Registry of Norway and the Norwegian Rectal Cancer Registry. Changes in 5-year relative survival were compared by age, stage and tumour location during the early and late years. RESULTS: The study population included 19 053 patients who had a curative resection. The relative 5-year survival rate significantly improved for both colonic cancer (73·8 versus 78·0 per cent; P < 0·001) and rectal cancer (72·1 versus 79·6 per cent; P < 0·001). The 5-year relative survival was significantly better for rectal than colonic cancer during the late period (P = 0·030). Improved 5-year relative survival was related to better outcomes in patients with positive lymph nodes (67·2 and 62·1 per cent for rectal and colonic cancer respectively; each P < 0·001 versus early period), but not for the subgroup aged over 75 years with lymph node-positive colonic cancer. CONCLUSION: In this national cohort, survival after curative surgery for colorectal cancer increased significantly after implementation of national management strategies. Improvements were most evident for rectal cancer and in lymph node-positive disease; they were less substantial for colonic cancer and elderly patients (over 75 years). Strategic treatment changes may be warranted for the latter group.

Locally recurrent rectal cancer in Norway.

BACKGROUND: The purpose of this study was to describe management and outcome in patients with locally recurrent rectal cancer based on data from the Norwegian Colorectal Cancer Registry. METHODS: This was a prospective national cohort study of 577 patients with local recurrence after major resection (R0/R1) for rectal cancer between November 1993 and December 2001 (initial cohort of 4504 patients). RESULTS: Of the 577 patients, 185 (32.1 per cent) had curative resections (R0/R1), 203 (35.2 per cent) had palliative radiotherapy with or without palliative surgery and chemotherapy, and 189 (32.8 per cent) received no treatment at all or only palliative surgery or chemotherapy. The overall 5-year survival rate was 14.9 per cent. Ninety-seven patients had an R0 resection, and 88 had an R1 resection, with 5-year overall survival of 55 and 20 per cent respectively. This outcome reflected surgical treatment in 33 different hospitals. Some 274 patients (47.5 per cent) had metastases. The 5-year survival rate after R0 resection was 62 per cent in patients without metastases. CONCLUSION: Obtaining an R0 resection is the most important prognostic factor in treating recurrent rectal cancer.

Impact of radiotherapy on local recurrence of rectal cancer in Norway.

BACKGROUND: The purpose of this study was to analyse the impact of radiotherapy on local recurrence of rectal cancer in Norway after the national implementation of total mesorectal excision (TME). METHODS: This was a prospective national cohort study of 4113 patients undergoing major resection of rectal carcinoma between November 1993 and December 2001. RESULTS: The proportion of patients who had radiotherapy before or after operation increased from 4.6 per cent in 1994 to 23.0 per cent in 2001. The cumulative 5-year local recurrence rate decreased from 16.2 to 10.7 per cent. Multivariable analysis showed that preoperative radiotherapy significantly reduced local recurrence (hazard ratio 0.59 (95 per cent confidence interval 0.39 to 0.87)). The use of preoperative radiotherapy in patients from a local hospital offering radiotherapy was 50 per cent higher than that for patients from a hospital without such services (P = 0.003); cumulative 5-year local recurrence rates for these patients were 10.6 and 15.8 per cent respectively (P < 0.001). CONCLUSION: Following national implementation of TME for rectal cancer, increased use of preoperative radiotherapy appeared to reduce recurrence rates further.

Surgical treatment of primary locally advanced rectal cancer in Norway.

AIMS: Most reports on locally advanced rectal cancer come from specialized centres, with a selected patient material. The purpose of this study was to examine the results after surgical treatment of patients with locally advanced rectal cancer at a population level. METHODS: National cohort study of 896 patients undergoing surgery for a locally advanced primary adenocarcinoma of the rectum from November 1993 to December 2001. RESULTS: Surgery with resection was undertaken in 724 patients and 172 patients underwent palliative procedures. Of 557 patients treated for cure, a R0 resection was achieved in 342 (61%). In a multivariate analysis, pre-operative radiotherapy was the only factor with a positive association with R0 status (odds ratio 3.7, 95% confidence interval (CI) 2.1-6.4). Five-year local recurrence rates were 18% (CI 14-23) for R0 resections and 40% (CI 26-52) for R1 resections. Overall 5-year survival rate was 23%; for the group of patients with a R0 resection the survival rate was 49%. CONCLUSION: The radical resection rate and survival rates in this national study were similar to those reported from specialized centres.

Quality of life and functional outcome following anterior or abdominoperineal resection for rectal cancer.

AIMS: The aims of the study were (1) to evaluate quality of life (QoL) and functional outcome in patients following anterior resection (AR) or abdominoperineal resection (APR) for rectal cancer, and (2) whether these outcomes were dependent on the level of anastomosis. METHODS: Patients who were without recurrent or metastatic disease were identified from the Norwegian Rectal Cancer Registry. QoL was assessed by the EORTC questionnaires QLQ-C30 and QLQ-CR38, and rectal function by a short questionnaire. Of 319 patients studied, 229 had undergone AR and 90 APR. The median age was 73 years, and the median time since surgery was 64 months. RESULTS: Mean QoL scores for body image and male sexual problems were better following AR than APR (P<0.01), also in patients with a low (< or = 3 cm) anastomosis. Patients who had undergone AR had higher mean scores for constipation (P<0.001) and more often used anti-diarrhoeal medication (P=0.005), than patients who had undergone APR. Patients with a low anastomosis (< or = 3 cm) had more incontinence for gas and solid stools (P<0.05), and had more incontinence (P=0.006) compared with patients with higher anastomosis, but there was no difference in QoL. Subgroup analysis showed that irradiated patients (n=34) had worse rectal function in terms of frequency, urgency, and incontinence (P<0.01). CONCLUSIONS: Although rectal function was impaired in patients with low anastomosis, patients who had undergone AR had better QoL than patients who had undergone APR.

Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery at a national level.

BACKGROUND: The purpose of this prospective study was to examine the influence of hospital caseload on long-term outcome following standardization of rectal cancer surgery at a national level. METHODS: Data relating to all 3388 Norwegian patients with rectal cancer treated for cure between November 1993 and December 1999 were recorded in a national database. Treating hospitals were divided into four groups according to their annual caseload: hospitals in group 1 (n = 4) carried out 30 or more procedures, those in group 2 (n = 6) performed 20-29 procedures, group 3 (n = 16) 10-19 procedures and group 4 (n = 28) fewer than ten procedures. RESULTS: The 5-year local recurrence rates were 9.2, 14.7, 12.5 and 17.5 per cent (P = 0.003) and 5-year overall survival rates were 64.4, 64.0, 60.8 and 57.8 per cent (P = 0.105) respectively in the four hospital caseload groups. An annual hospital caseload of less than ten procedures increased the risk of local recurrence compared with that in hospitals where 30 or more procedures were performed each year (hazard ratio 1.9 (95 per cent confidence interval (c.i.) 1.3 to 2.7); P < 0.001). Overall survival was lower for patients treated at hospitals with an annual caseload of less than ten versus hospitals with 30 or more (hazard ratio 1.2 (95 per cent c.i. 1.0 to 1.5); P = 0.023). CONCLUSION: The rate of local recurrence was higher for hospitals with a low annual caseload of less than ten procedures than for hospitals with a high treatment volume of 30 or more. Patients treated in small hospitals also had a shorter long-term survival than those treated in large hospitals.

Anastomotic leakage following routine mesorectal excision for rectal cancer in a national cohort of patients.

OBJECTIVE: Mesorectal excision is successfully implemented as the standard surgical technique for rectal cancer resections in Norway. This technique has been associated with higher rates of anastomotic leakage (AL) and the purpose of this study was to examine AL in a large national cohort of patients. METHODS: This was a prospective national cohort study of 1958 patients undergoing rectal cancer surgery with anterior resection in Norway from November 1993 to December 1999. RESULTS: The overall rate of AL was 11.6% (228 of 1958 patients). In a multivariate analysis, the risk of AL was significantly higher in males (odds ratio (OR) 1.6, 95% confidence interval (CI) 1.1-2.2), in patients receiving pre-operative radiotherapy (OR 2.2, CI 1.0-4.7) and in low level (4-6 cm) (OR 3.5, CI 1.6-7.7) and ultra-low level (< or = 3 cm) anastomoses (OR 5.4, CI 2.3-12.9). The presence of a diverting stoma was associated with a 60% reduction in the risk of AL (OR 0.4, CI 0.3-0.7) for anastomoses 6 cm and below. 30-day mortality was significantly higher for the patients with AL (7.0%, CI 3.7-10.3) compared with no AL (2.4%, CI 1.7-3.2) AL had no significant effect on local recurrence rate (log rank P=0.608). CONCLUSION: Low anastomoses should be defunctioned to avoid AL and the associated high perioperative mortality. No effect of AL on local recurrence was found in this large cohort.

Inadvertent perforation during rectal cancer resection in Norway.

BACKGROUND: Inadvertent perforation of the bowel or tumour is a relatively common complication during resection of rectal cancer. The purpose of this study was to examine intraoperative perforation following the introduction of mesorectal excision as a standard surgical technique in Norway. METHODS: This was a prospective national cohort study of 2873 patients undergoing major resection of rectal carcinoma at 54 Norwegian hospitals from November 1993 to December 1999. RESULTS: The overall perforation rate was 8.1 per cent (234 of 2873 patients). In a multivariate analysis, the risk of perforation was significantly greater in patients undergoing abdominoperineal resection (odds ratio (OR) 5.6 (95 per cent confidence interval (c.i.) 3.5 to 8.8)) and in those aged 80 years or more (OR 2.0 (95 per cent c.i. 1.2 to 3.5)). The 5-year local recurrence rate was 28.8 per cent following perforation, compared with 9.9 per cent in patients with no perforation (P<0.001); survival rates were 41.5 and 67.1 per cent respectively (P<0.001). CONCLUSION: The risk of intraoperative perforation was significantly greater in patients with rectal cancer undergoing abdominoperineal resection and in those aged 80 years or more. The high local recurrence rates and reduced survival following perforation call for increased attention to avoid this complication.

Total mesorectal excision for rectal cancer--what can be achieved by a national audit?

OBJECTIVE: The results of rectal cancer surgery in Norway have been poor. In a national audit for the period 1986-88, 28% of the patients developed local recurrence (LR) following treatment with a curative intent. Five-year overall survival was 55% for patients younger than 75 years. The aim of this study is to report how an initiative focusing on better surgery can improve the prognosis for rectal cancer patients on a national level. METHODS: In 1994, the Norwegian Rectal Cancer Group was founded. The aim of this initiative was to improve the surgical standard by implementing total mesorectal excision (TME) on a national level and to evaluate the results. A number of courses were arranged to teach the surgeons the TME technique, and pathologists were trained to increase the standard of both macroscopic and microscopic assessment of specimens. A rectal cancer registry was established, and all surgical departments treating rectal cancer were invited to transfer their clinical data to this registry. Each department regularly receives its own results together with the national average for comparison and quality control. RESULTS: The Rectal Cancer Registry includes all patients with rectal cancer diagnosed since November 1993. From then until December 1999, 5382 patients had a tumour located within 16 cm from the anal verge, and 3432 patients underwent rectal resection with a curative intent. Of these, 9% had adjuvant radiotherapy, and 2% were given chemotherapy. There was a rapid implementation of the new technique, as 78% underwent TME in 1994, increasing to 96% in 1998. After 39 months mean follow-up the rate of local recurrence was 8%, and 5-year overall survival was 71% for patients younger than 75 years. CONCLUSIONS: An optimized surgical technique (TME) for rectal cancer can reduce the rate of local recurrence and increase overall survival. This improved surgical treatment can be implemented on a national level within a few years. Specialization of surgeons, feedback of results and a separate rectal cancer registry are thought to be major contributors to the improved treatment.