[The Individual Surgeon is an Independent Risk Factor for Morbidity after Cholecystectomy. A Multivariate Analysis of 710 Patients Operated on by Experienced Surgeons]. / Der erfahrene Chirurg als unabhängiger Risikofaktor für die Morbidität nach Cholezystektomie. Eine multivariate Analyse von 710 Patienten.

BACKGROUND: In sophisticated surgical procedures, e. g. colectomy, cardiac surgery, arterial reconstruction and liver resection, the individual surgeon is a major influence on postoperative morbidity. For the everyday procedure of cholecystectomy, clear data on the morbidity related to the individual surgeon are lacking. AIMS: To assess the individual impact on the outcome of cholecystectomy in a cohort of experienced surgeons. METHODS: The analysis covered n = 710 consecutive patients who had received cholecystecomy between January 2014 and December 2018 - performed by experienced surgeons (> n = 300 cholecystectomies before entry in the study and > 5 years after specialty registration). In a univariate analysis, the influence of patient characteristics, laboratory findings and surgical data on postoperative morbidity were investigated. Variables with statistical significance were entered into a multivariate logistic regression. RESULTS: Mortality was 5/710 (0.7%), and morbidity was 58/710 (8.2%), including 37/710 patients with surgical morbidity and 21/710 patients with non-surgical morbidity. In a multivariable analysis the independent risk factors for overall morbidity were creatinine level (OR 1.29, CI 1.01-1.648, p = 0.042), GOT (OR 1.005, CI 1-1.01, p = 0.03), open/conversion surgery (OR 4.134, CI 1.587-10.768, p = 0.004) and the individual surgeon (OR up to 40.675, p = 0.001). In the analysis of surgical complications, open/conversion surgery (OR 8.104, CI 3.03-21.68, p < 0.001) and the individual surgeon (OR up to 79.69, p = 0.005) remained of significant influence. CONCLUSIONS: The individual surgeon is of major influence on the outcome after an everyday procedure such as cholecystectomy in a group of experienced surgeons with specialty registration. The individual outcome of each surgeon should be measured as a basis of targeted improvement programs.

[Why Certification of Colorectal Cancer Centres Does Not Improve Surgical Quality]. / Warum die Zertifizierung von Darmkrebszentren die chirurgische Ergebnisqualität nicht verbessert.

BACKGROUND: To improve treatment results, certification of colorectal cancer centres in Germany assures interdisciplinary treatment according to official treatment guidelines. The treatment results of certified colorectal cancer centres are published annually. Despite certification, the surgical quality indicators of anastomotic leakage, wound infection, and revision surgery have not improved between 2009 and 2015. PATIENTS AND METHODS: Patients with anastomotic leakage (AL) after colorectal resection of an adenocarcinoma were analyzed in a Morbidity and Mortality (M+M) conference structured according to the London Protocol. The results were compared to structure and process parameters that are part of the data entry form (DEF) of the Deutsche Krebsgesellschaft (DKG) used for the certification of colorectal cancer centres. RESULTS: Between 2015 and 2017, 387 colorectal resections were performed. Of these, 158 resections were performed due to the diagnosis of a colorectal carcinoma. For 13/149 resections with anastomosis, a leak was diagnosed (8.7%). All patients suffering from an AL were analysed in an M+M conference structured according to the London Protocol. For 10/13 patients, abnormalities in structural and procedural quality were found. As regards procedural quality, this included the application of standards (n = 6/10), communication (n = 3/10) and missing but needed results from examinations (n = 1/10). As regards structural quality, insufficient physical resources were predominant (n = 3/10). Only one of these abnormalities was identified using the DEF. CONCLUSION: For processes and structures to improve surgical quality, it is required that they have relevant influence on surgical quality. We found that only 1/13 abnormalities detected in the M+M conference structured according to the London Protocol was represented in the DEF. To improve the influence on surgical quality, extensions to the DEF of the Deutsche Krebsgesellschaft should be discussed.

[Patient-unrelated Risk Factors for the Development and Treatment Course of Anastomotic Failure in Colorectal Surgery - Results of Structured M+M Conferences]. / Nicht patientenbezogene Risikofaktoren für Entstehung und Behandlungsverlauf einer Anastomoseninsuffizienz nach Kolonresektion ­ Ergebnisse einer strukturierten M+M-Konferenz.

BACKGROUND: There are numerous published studies on patient-related risk factors for the development of anastomotic failure. We therefore investigated the influence of patient-unrelated risk factors for the development and course of treatment of anastomotic failure in colorectal surgery. PATIENT SAMPLE: From May 1, 2015, until December, 31, 2016, n = 179 post-colorectal surgery patients were analysed. Overall, n = 14 patients suffered from anastomotic failure. These patients' course of treatment was analysed in a Morbidity and Mortality Conference (M+M conference) structured according to the London Protocol. RESULTS: Irregularities in process quality were the most frequent analysis result (n = 8/14), followed by irregularities in post-treatment (n = 6/14). Irregularities in surgical technique (n = 2/14) and surgery procedure (n = 3/14) were less frequent. Future treatment approaches were identified for most patients (n = 11/14). On the basis of the analysis of data from four of these eleven patients, the strategy for future treatment was modified. CONCLUSION: Therapist- and environment-specific irregularities can be systematically identified in M+M conferences structured according to the London Protocol. This analysis is the prerequisite for quality improvement and must systematically complement the analysis of patient-related risk factors.