Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial.

BACKGROUND: The TME trial investigated the value of preoperative short-term radiotherapy in combination with total mesorectal excision (TME). Long-term results are reported after a median follow-up of 12 years. METHODS: Between Jan 12, 1996, and Dec 31, 1999, 1861 patients with resectable rectal cancer without evidence of distant disease were randomly assigned to TME preceded by 5 × 5 Gy radiotherapy or TME alone (ratio 1:1). Randomisation was based on permuted blocks of six with stratification according to centre and expected type of surgery. The primary endpoint was local recurrence, analysed for all eligible patients who underwent a macroscopically complete local resection. FINDINGS: 10-year cumulative incidence of local recurrence was 5% in the group assigned to radiotherapy and surgery and 11% in the surgery-alone group (p<0·0001). The effect of radiotherapy became stronger as the distance from the anal verge increased. However, when patients with a positive circumferential resection margin were excluded, the relation between distance from the anal verge and the effect of radiotherapy disappeared. Patients assigned to radiotherapy had a lower overall recurrence and when operated with a negative circumferential resection margin, cancer-specific survival was higher. Overall survival did not differ between groups. For patients with TNM stage III cancer with a negative circumferential resection margin, 10-year survival was 50% in the preoperative radiotherapy group versus 40% in the surgery-alone group (p=0·032). INTERPRETATION: For all eligible patients, preoperative short-term radiotherapy reduced 10-year local recurrence by more than 50% relative to surgery alone without an overall survival benefit. For patients with a negative resection margin, the effect of radiotherapy was irrespective of the distance from the anal verge and led to an improved cancer-specific survival, which was nullified by an increase in other causes of death, resulting in an equal overall survival. Nevertheless, preoperative short-term radiotherapy significantly improved 10-year survival in patients with a negative circumferential margin and TNM stage III. Future staging techniques should offer possibilities to select patient groups for which the balance between benefits and side-effects will result in sufficiently large gains. FUNDING: The Dutch Cancer Society, the Dutch National Health Council, and the Swedish Cancer Society.

Nationwide outcome registrations to improve quality of care in rectal surgery. An initiative of the European Society of Surgical Oncology.

In recent years there have been significant improvements in rectal cancer treatment. New surgical techniques as well as effective neoadjuvant treatment regimens have contributed to these improvements. Key is to spread these advances towards every rectal cancer patient and to ensure that not only patients who are treated within the framework of clinical trials may benefit from these advancements. Throughout Europe there have been interesting quality programmes that have proved to facilitate the spread of up to date knowledge and skills among medical professionals resulting in improved treatment outcome. Despite these laudable efforts there is still a wide variation in treatment outcome between countries, regions and institutions, which calls for a European audit on cancer treatment outcome.

The surgeon's eye: a prospective analysis of the anteversion in the placement of hemiarthroplasties after a femoral neck fracture.

INTRODUCTION: Hip dislocation after hemiarthroplasty performed in elderly patients with a femoral neck fracture is associated with severe morbidity and costs. Optimal anteversion during the placement of the hemiarthroplasty might reduce the dislocation rate. We assessed the surgeons' intraoperative visual estimations of the femoral anteversion. METHODS: The postoperative femoral anteversion of 20 consecutively performed hemiarthroplasties was measured on computer tomography and compared to the intraoperative visual estimations of the surgeon. Furthermore, the femoral anteversion of the contralateral non-fractured hip, which was considered the 'ideal' anatomical reference, was recorded. RESULTS: The mean postoperative anteversion of the hemiarthroplasty was 20° (SD 8.7°). The mean femoral anteversion of the contralateral non operated femur was 14° (SD 9.5°).The average difference between the anteversion angle estimated by the surgeon and the CT-measured is 9° (1° to 18°). In 14 (70%) cases the measured angle was greater than desired. CONCLUSIONS: The current operation technique in which the anteversion angle is estimated by the surgeon's eye shows relatively good intraoperative precision.

A retrospective analysis of surgical site infections after chlorhexidine-alcohol versus iodine-alcohol for pre-operative antisepsis.

BACKGROUND: Surgical site infection (SSI) is the most common hospital-acquired infection in the Netherlands. There is little evidence in regard to differences in the efficacy of pre-operative topical antisepsis with iodine-alcohol as compared with chlorhexidine-alcohol for preventing SSI. METHODS: We conducted a retrospective analysis at a single center, involving all patients who underwent breast, colon, or vascular surgery in 2010 and 2011, in which pre-operative disinfection of the skin was done with iodine-alcohol in 2010 and with chlorhexidine-alcohol in 2011. Demographic characteristics, surgical parameters, and rates of SSI were compared in the two groups of patients. Subgroup analyses were done for wound classification, wound type, and type of surgery performed. Associations of patient characteristics with SSI were also investigated. Data were analyzed with χ(2) tests, Student t-tests, and logistic regression analysis. RESULTS: No statistically significant difference was found in the rates of SSI in the two study groups, at 6.1% for the patients who underwent antisepsis with iodine-alcohol and 3.8% for those who underwent disinfection with chlorhexidine-alcohol (p=0.20). After multivariable analysis, an odds ratio (OR) of 0.68 (95% confidence interval [CI] 0.30-1.47) in favor of chlorhexidine-alcohol was found. Male gender, acute surgery, absence of antibiotic prophylaxis, and longer hospital length of stay (LOS) were all associated with SSI after pre-operative topical antisepsis. CONCLUSION: In this single-center study conducted over a course of one year with each of the preparations investigated, no difference in the rate of SSI was found after an instantaneous protocol change from iodine-alcohol to chlorhexidine-alcohol for pre-operative topical antisepsis.

The relationship between volume or surgeon specialty and outcome in the surgical treatment of lung cancer: a systematic review and meta-analysis.

BACKGROUND: Whether improvement of quality of surgical cancer care can be achieved by centralizing care in high-volume specialized centers is a subject of ongoing debate. We have conducted a meta-analysis of the literature on the effect of procedural volume or surgeon specialty on outcome of lung resections for cancer. METHODS: A systematic search of articles published between January 1, 1990 and January 20, 2011 on the effects of surgeon specialty and hospital or surgeon volume of lung resections on mortality and survival was conducted. After strict inclusion, meta-analysis assuming a random-effects model was performed. Meta-regression was used to identify volume cutoff values. Heterogeneity and the risk of publication bias were evaluated. RESULTS: Nineteen relevant studies were found. Studies were heterogeneous, especially in defining volume categories. The pooled estimated effect size was significant in favor of high-volume hospitals regarding postoperative mortality (odds ratio [OR] 0.71; confidence interval 0.62-0.81), but not for survival (OR 0.93; confidence interval 0.84-1.03). Surgeon volume showed no significant effect on outcome. General surgeons had significantly higher mortality risks than general thoracic (OR 0.78; 0.70-0.88) or cardiothoracic surgeons (OR 0.82; 0.69-0.96). A minimal annual volume of resections for lung cancer could not be identified. CONCLUSIONS: Hospital volume and surgeon specialty are important determinants of outcome in lung cancer resections, but evidence-based minimal-volume standards are lacking. Evaluation of individual institutions in a national audit program might help elucidate the influence of individual quality-of-care parameters, including hospital volume, on outcome.

A systematic review and meta-analysis of the relationship between hospital/surgeon volume and outcome for radical cystectomy: an update for the ongoing debate.

CONTEXT: There is an ongoing debate about centralisation of radical cystectomy (RC) procedures. OBJECTIVE: To conduct a systematic review of the literature on the volume-outcome relationship for RC for bladder cancer (BCa) with consideration for the methodologic quality of the available evidence and to perform a meta-analysis on the studies meeting predefined quality criteria. EVIDENCE ACQUISITION: A systematic search was performed to identify all articles examining the effects of procedure volume on clinical outcome for cystectomy. Reviews, opinion articles, and surveys were excluded. All articles were critically appraised for methodologic quality and risk of bias. Meta-analysis was performed to calculate the overall effect of higher surgeon or hospital volume on patient outcome. EVIDENCE SYNTHESIS: Ten studies of good methodologic quality were included for meta-analysis. Eight studies were based on administrative data, two studies on clinical data. The results showed a significant association between high-volume hospitals and low mortality. A meta-analysis of the seven studies on hospital mortality showed a pooled estimated effect of odds ratio (OR) 0.55 (range: 0.44-0.69). The result was moderate heterogeneity (I(2)=50). A large variation in cut-off points used was observed. Sensitivity analyses did not show different effects in any of the subgroup analyses. Also, no significant differences in effect sizes were observed for different cut-off points. The data were not suggestive for publication bias. One study showed a positive effect of hospital volume on survival (hazard ratio [HR]: 0.89; p=0.06). Two studies showed a beneficial effect of surgeon volume on mortality (OR: 0.55; OR: 0.64). Only one study on the impact of surgeon volume on survival was found; it showed no significant positive effect for higher volume (HR: 0.83; p=0.26). CONCLUSIONS: Postoperative mortality after cystectomy is significantly inversely associated with high-volume providers. However, additional quality criteria, such as infrastructure and level of specialisation, should be formulated to direct centralisation initiatives. The Dutch Association of Urology in 2010 implemented a national quality of care (QoC) registration programme for all patients treated by surgery for muscle-invasive BCa, including multiple parameters defining QoC.