[Unicentre Results in Surgery of Primary Hyperparathyroidism with Postoperative Long-Term Follow-Up and Value of Intraoperative Quick Parathormone Test]. / Unizentrische Ergebnisse der Chirurgie des primären Hyperparathyreoidismus mit postoperativer Langzeitbeobachtung sowie Rolle des intraoperativen Quick-Parathormon-Tests.

BACKGROUND: The increasing use of focussed parathyroidectomy is attributed to introduction of intraoperative parathyroid hormone measurement (ioPTH) and novel preoperative imaging techniques. This study assesses the early postoperative and long-term outcomes of surgery and the value of standardised ioPTH in patients undergoing surgery for primary hyperparathyroidism (pHPT). METHODS: From 01/01/1996 to 09/30/2011, all consecutive patients undergoing surgery for pHPT were documented. Data of this observational study were retrospectively evaluated. Patients were subdivided into 2 groups: A.) use of Quick Intraoperative Intact PTH Assay (n = 142; "ioPTH group") vs. B.) control group ("CG", n = 44). For clinical long-term follow-up, also pre- and postoperative signs, symptoms and findings of the initial 43 patients obtained during the first 4 years of the study were semiquantitatively compared. RESULTS: 186 consecutive operations for pHPT were performed - in particular, 73 sole parathyroidectomies; 113 combined thyroid and parathyroid resections. Mean operation time was 87 (SD ± 48) min for parathyroidectomy and 120 (SD ± 49) min for combined resections. A persisting hypercalcaemia was found in 16 patients (8.6%) while postoperative elevation of serum calcium and parathormone occurred in 7 patients (3.8%). Postoperative hypocalcaemia was present in 35 patients (18.8%). Differences between both groups regarding hypocalcaemia (p = 1.0), hypercalcaemia (p = 0.67), hyperparathyrinaemia (p = 0.12) and rate of reintervention (p = 0.055) were not significant. Thirty nine of the initial 43 patients reported one or more signs of pHPT (90.7%). Most frequent symptoms were nephrolithiasis (41.9%), back pain (51.2%), discomfort in the upper abdomen (41.9%), fatigue (41.9%) and general weakness (61.1%). Follow-up investigations (mean, 4.7 [range, 3.2-6.5] years) revealed that 65 % of patients reported improvement of general condition, 27% had no change and 8% reported deterioration. CONCLUSIONS: IoPTH is now standard in parathyroid surgery. Value of ioPTH correlates directly with selected centre-specific intraoperative criteria. The stricter the criteria the more reliable is the exclusion of multiglandular disease. Surgery for pHPT was performed with a very low complication rate. Through the long-term follow-up, nearly two thirds of patients benefited from the operation.

Pancreatic remnant fate.

There is eternal discussion on the best surgical method of pancreatoduodenectomy and reconstruction method. Several different methods of pancreatic stump anastomosis exist. The most popular argument taken into account in the discussion is the frequency of early postoperative complications. Relatively fewer papers analyse the late functional outcome of pancreatic surgery and the method of anastomosis employed. Authors presented short series of 12 patients after pancreatic surgery with analysis of pancreatic remnant morphology and function. Pancreatic remnant volume, pancreatic duct distension and stool elastase-1 test were analysed. There was no correlation of pancreatic exo- or endocrine insufficiency with the volume of pancreatic remnant or the kind of surgery or anastomosis performed.

[Metastasized colonic cancer. When are there no indications for primary resection?]. / Metastasiertes Kolonkarzinom. Wann besteht keine Indikation zur primären Resektion?

The determination of an optimal treatment protocol for colonic cancer with synchronous incurable metastases remains a challenge, especially if the primary tumor is asymptomatic. Available data on whether resection of the primary tumor means a benefit or a danger to the patient are limited and inhomogeneous. A survival benefit could be shown only in retrospective studies with a bias against primary chemotherapy. The important question of the quality of life (QOL) remains completely unanswered in this respect. There are numerous groups and guidelines in favor of a primary palliative chemotherapy for these patients, possibly intensified by antibodies. The results of the currently ongoing randomized multicenter SYNCHRONUS study will deliver objective data facilitating the decision-making process with respect to the indications for resection of the primary tumor or primary chemotherapy.

International quality assurance project in colorectal cancer-unifying diagnostic and histopathological evaluation.

PURPOSE: Several European countries are undertaking quality control projects in colorectal cancer. These efforts have led to improvements in survival, but a comparison between different projects reveals questionable results. The aim of this study is the presentation of results from hospitals in three different European countries participating in the International Quality Assurance in Colorectal Cancer (IQACC) project. METHODS: For this publication, patients with cancer of the colon or rectum treated in 2009 and 2010 and recorded in the IQACC (Germany, Poland and Italy) were analysed. The comparison included number of patients, age, preoperative diagnostics (CT of the abdomen and thorax, MRI, colonoscopy, ultrasound, tumour markers), surgical approach, metastasis, height of rectal cancer and histopathological examination of a specimen (T stage, N stage and MERCURY classification for rectum resection). For short-term outcomes, general complications, wound dehiscence, tumour-free status at discharge, anastomotic leakage and in-hospital mortality were analysed. RESULTS: A total of 12,691 patients (6,756 with colon cancer, 5,935 with rectal cancer) were included in the analysis. Preoperative diagnostics differed significantly between countries. For pT and pN stages, several quality differences could be demonstrated, including missing stages (colon cancer: pT 5.7-12.5 %, pN 2.5-11.0 %; rectal cancer: pT 1.1-5.6 %, pN 1.1-15.5 %). The most relevant differences for short-term outcomes in colon cancer were found in general complications (4.2-22.8 %) and tumour-free status at discharge (74.5-91.7 %). In-hospital deaths ranged between 2.5 and 4.3 % and did not show significant differences. For rectal cancer, the country with the highest percentage of tumours localised less than 4 cm from the anal verge (16.0 %) showed the lowest frequency of amputation (8.5 %). Outcome differences were found for general complications (3.2-18.8 %), anastomotic leakage (0-4.3 %) and tumour-free status at discharge (72.9-87.6 %). In-hospital deaths ranged between 1.1 and 3.2 %. CONCLUSION: This study demonstrates the feasibility of an international quality assurance project in colorectal cancer. This concept ensures data analysis based on a comparable data input. Differences in preoperative diagnostics, completeness of histopathological evaluation and short-term outcomes for Germany, Poland and Italy might result from disparities in socioeconomic factors and implementation of existing guidelines. Further activities are necessary to warrant the use of common standards in outcome control.

Experts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: science, opinions and experiences from the experts of surgery.

The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process. Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer. Surgery is the cornerstone of curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?

[Quality assurance in colorectal cancer in Europe AD 2011]. / Qualitätssicherung beim kolorektalen Karzinom in Europa AD 2011.

INTRODUCTION: Malignant tumours are the second largest cause of death in Europe. Colorectal cancer takes second place within this group and is responsible for every eighth tumour-related death. CURRENT SITUATION: Surgical quality assurance requires a prospective observational study, any different type of study is not possible. A complete recording of all treated patients is a prerequisite for quality assurance. Currently, there are quality assurance programmes in Sweden, Norway, Denmark, Great Britain, Spain, Belgium, the Netherlands as well as the multinational study for patients from Germany, Poland and Italy. These projects deliver comprehensive information regarding the treatment of colorectal cancer. However, this information is deeply rooted in the organisation of the health-care system in the given country and is not easily transferable into international settings. Also, an interpretation of the collected data is often possible only within the given health-care system. FUTURE PERSPECTIVES: First, unified initial diagnostics is a prerequisite for quality assurance -  for the local extent and exclusion / confirmation of distant metastases. Until these criteria are unified, any comparison is limited, including a comparison of survival. Second, quality-of-life is not recorded in any of the current projects. Third, the main focus of a quality assurance project must be on therapy-dependent factors. The most sensible method of quality control remains within the connection of preoperative diagnostics (estimate of a best-case scenario), the surgical technique (the actual result) and a standardised pathological examination (evaluation of the actual result). These parameters can be recorded and compared within a quality assurance project regardless of the limitations of the national health-care systems. There is no alternative to a unified diagnostics model and unified histopathological evaluation, a complete picture of treatment quality is also not possible without systematic analysis of the quality of life.

Laparoscopy in the surgical treatment of rectal cancer in Germany 2000-2009.

AIM: The goal of this registry study was to compare open surgery with planned laparoscopy and then with laparoscopic to open conversion for rectal cancer surgery. METHOD: The study included 17,964 rectal cancer patients, operated on between 1 January 2000 and 31 December 2009, from 345 hospitals in Germany. All statistical tests were two-sided, with the χ(2) test (Pearson correlation) for patients and tumour characteristics. Fisher's exact test was used for complications and 30-day mortality. RESULTS: Of the 17,964 rectal cancer patients, 16,308 (90.8%) had an open procedure and 1656 (9.2%) were started with a laparoscopy. The 1455 patients with completed laparoscopic operations had fewer intra-operative and postoperative complications (5.4%vs 7.0%, P = 0.020, and 20.5%vs 25.8%, P < 0.001, respectively) and a lower 30-day mortality rate (1.1%vs 1.9%, P = 0.023). Of the 1656 planned laparoscopies, 201 (12.1%) were converted to open. The converted group suffered more intra-operative complications (18.9%vs 3.6% for completed laparoscopy and 7.0% for open surgery, P < 0.0001) and postoperative complications (32.3%vs 18.9% for completed laparoscopy and 25.8% for open operations, P < 0.0001). The converted group also had a higher 30-day mortality rate (2.0%vs 1.0% for completed laparoscopy and 1.9% for open surgery, P = 0.043). CONCLUSION: The more favourable patient profile provided justification for a laparoscopic procedure. For those converted to an open procedure, however, there were significantly more complications than planned open surgery patients. A move away from the standard open procedure for rectal cancer surgery and towards laparoscopy is not yet feasible.

The EURECCA project: Data items scored by European colorectal cancer audit registries.

AIMS: The EURECCA (European Registration of Cancer Care) consortium is currently formed by nine independently founded national colorectal audit registrations, of which most already run for many years. The cumulative experience of EURECCA's participants could be used to identify a 'core dataset' that covers all important aspects needed for high quality auditing and at the same time lacking needless data items that only consumes administrative effort. The aim of this study is to compare the data items used by the nine registries participating in EURECCA to identify a core dataset and explore options for future research. METHODS: All colorectal outcome registrations participating in the EURECCA project were asked to supply a list with all the data items they score. Items were scored 'present' if they appeared literally in a registration or in case they could be calculated using other items in the same registration. The definition of a 'shared data item' was that at least eight of the nine participating registries scored the item. RESULTS: The number of registered data items varied between 254 (Belgium) and 83 (Norway). Among the 45 variables were patient data, data about preoperative staging, surgical treatment, pre- or postoperative radio- and/or chemotherapy, and follow-up. Items about tumour recurrence or quality of life were scored too little to become shared data items. CONCLUSIONS: A total of 45 items were collected by 8 or more of the participating registries and subsequently met the criteria for a shared data item.

European quality assurance programme in rectal cancer--are we ready to launch?

AIM: There have been initiatives to create a European audit project. This paper addresses the issue of differences in data collected by different registries. METHOD: Patients with rectal cancer treated in 2008 and recorded in quality registries from Belgium, Germany/Poland, Spain and Sweden were analyzed. The comparison included number of patients, gender, age, American Society of Anesthesiology (ASA) classification, preoperative diagnostic and staging procedures, neoadjuvant therapy, surgical treatment and quality of surgery, postoperative complications and adjuvant treatment. RESULTS: The Belgian database consisted of 622 patients, the German/Polish database consisted of 3,393 patients, the Spanish database consisted of 1,641 patients and the Swedish database consisted of 1,826 patients. The percentage of patients in each ASA stage was highly variable. MRI use was highest in Spain and Sweden and very low in Germany/Poland. The percentage of cT4 stage tumours in Sweden was much higher than in all other countries. Sweden recorded the highest percentage of primary metastatic disease (20.3%) and Belgium recorded the lowest (10.2%). Neoadjuvant therapy in different protocols was administered to 41.2% patients in Germany/Poland, to 50.8% in Spain, to 55.2% in Belgium and to 62% in Sweden. Laparoscopic surgery (conversion rate) was performed for cure in 5% (28%) of patients in Sweden, in 20.8% (20.6%) in Spain, in 28.6% (15.2%) in Belgium and in 14.5% (8.9%) in Germany/Poland. The 30-day mortality for anterior resection, abdominoperineal excision and Hartmann's procedure in Sweden, Belgium and Spain was 2.0%, 2.3% and 3.1%, respectively. The German/Polish database reported an in-hospital mortality of 3.2%. CONCLUSION: A European quality assurance project in rectal cancer is possible only after data collection is standardized.

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.