Friedrich-Alexander-UniversitätErlangen-Nürnberg

Werner Hohenberger

Chirurgische Universitätsklinik Erlangen

Why do some achieve better results?Is the surgeon or dedication crucial?

Colon CancerSurvival

„No touch“ vs. “Conventional“

Rupert B.Turnbull 1967 and 1970

* age adjusted

all patients* 81,6%

Dukes C* 67,3%

observed all patients 68,85% 52,13%

Dukes C* 57,84% 28,06%

Turnbull Conventional

R. Turnbull 1967

R.Turnbull 1967

Surgery for Colon CancerOutcome Variations

all patients (n = 1157) 45,7 % (27 - 53 %)

R0, any stage (n = 732) 62,8 % (35 - 71 %)

Stage I (n = 150) 81,2 % (76 - 89 %)

II (n = 308) 70,1 % (36 - 89 %)

III (n = 245) 46,5 % (27 - 54 %)

IV (n = 29) 27,6 %

SGCRC, Hermanek 1994; observed survival at 5 years

UICC IIIT4 catecoryemergencies

Colon CancerQualtity of SurgeryThe Tough Cases

Colon CancerObserved Survival

° Kube et al 2009• Schrag et al 2010** Intact trial

UICC Stad. III

Middle Franconia 52,0 %1998 - 2007German Study Group° 52,7 %Colorectal Cancer

Chirurgische Klinik Erlangen 84,9 %1995 - 2002 **

SEERS pT1 N1 73,0 %1992 - 2004 pT3 N1 54,9 %

pT3 N2 38,1 %

USA„very high volume“ * 44,0 %

Sugihara/Tokyo 77,2 %

Why do some achieve better results? - case mix – patient`selection - stage migration - organisation, quality management - volume, centralisation, specialisation - standardisation - neo-/adjuvant treatment - special individual skill

Rectal Cancer Locoregional Recurrence

Factors Independent of Surgeon

case mix - lower third- stage- T-category (pT 3a,b / c,d)

treatment - abdomino-peranal resection- local excision- radiotherapy

definitions - rectum- R1-resection- all recurrencies / only first event

time of follow up

What is the definition of low and high volume?

volume median per 8 years

very low n = 1

low n = 4medium n = 7high n = 14

very high n = 22

study population: 6258 patientsBillingsley et al. 2008

Rectal Cancer German Patient Case Study

institution surgeon

local recurrence 10% - 37% 4% - 55%

observed 5-y-surv. 45% - 69% 46% - 79%

cancer-related 5-y-surv. 54% - 75% 54% - 85%

744 patientsKessler et al. 1998

Rectal Carcinom R0 M0

Patients with locoregional recurrenceobserved survival - logistic regression analysis

Significant factors p

1. Department 0.0017

2. Grading 0.0161

SGCRCSGCRC

Hermanek et al. 1995

Rectum CarcinomaNumber of Operations per Surgeon versus Locoregional Recurrence

SGCRCSGCRC

Operationsper surgeon

Spearman rank - correlationnot significant ( p ~ 0.40 )

Rate of locoregional recurrencesLF = Surgeons with low frequency of operations (≤15)

120

100

80

60

40

20

10 20 30 40 50 60%

LF

Kessler et al. 1998

Colorectal Cancer German Patient Care Study

Local Recurrence / Individual Surgeon, Hospital and OutcomeIntersurgeon variabilityodds ratio 95% c.i.

p

Institution A 0.31 0.18-0.54 0,001

others 1

Surgeon1,3-14 1low frequency surgeons ≤ 15 cases 1.71 1.02-2.86

0,04332 4.32 1.69-11.970,023

recruitment 08/1984 – 11/1986Kessler et al. 1998

Rectal Cancer Locoregional Recurrence Rate

60

50

40

30

20

10

0

% Dept. A Dept. B Dept. C

Individual surgeons with > 15 operations All surgeons with 15 operations

SGCRC, Hohenberger 1997

SurgeryQuality of Outcome

The Beginning

Set a Standard

Colorectal Cancer

Clinical Cancer Register Chirurgische Universitätsklinik Erlangen

Prospective Documentation Files

- History- Diagnosis- Staging- Neo- /adjuvant treatment- Surgery including individual surgeon- Pathology- Postop. Course- Follow - up

Clinical Cancer Register Chirurgische Universitätsklinik Erlangen

Objectives

- quality control (in part with external audit)

- identification of patient cohorts (biobank)

- scientific analysis of - prognostic factors - postop. complications

including mortality - ….

- TNM approval

Colorectal Cancer Outcome Differences

Surgeon Volume lower Sphincter LRSurvival

third < 6cm pres.

13 180 30,0% 86,1% 12,385,2

21 132 28,6% 79,5% 7,186,9

24 43 10,9% 69,0% 20,977,2

27 62 11,4% 78,0% 9,985,7

others 121 19,1% 78,1% 8,781,4

Chir. Univ. - Klinik ErlangenR0, Stage I-III, solitary cancer

Colon Cancer5 – Years‘ Survival

Chirurg. Univ.-Klinik Erlangen, 1995-2002Cancer related, no adjuvant chemotherapy

UICC-Stage I 95,5% 100%

II 90,4% 96,7%

III 72,2% 80,4%

R0, all Stages 86,6% 93,6%

all best surgeon

Rectal Resection for CancerPostop. Complications

- leaks n = 148 / 1871 (7,9%)

- intraabdominal sepsis n = 47 / 1871 (2,5%) without leak

- additional relevant n = 108 / 1871 (5,8%) general / extraabdominal complications

Chirurgische Universitätsklinik ErlangenAll stages

Colorectal CancerPostoperative Mortality

Anastomotic Leak

1978 - 1994 (29 / 148) 19,6 % (16 / 49) 32,7 %

1995 - 2000 (3 / 34) 8,8 % (2 / 17) 11,8 %

2001 - 2006 (0 / 20) (1 / 29) 3,4 %

Chirurgische Universitäts-Klinik Erlangen

Rectal Cancer Colon Cancer

Colorectal CancerPostop. Leaks

alle 9 / 334 (2,7%) 25 / 280 (8,9%)surgeon 13 1 / 121 (0,8% 12 / 96 (12,5%)surgeon 70 4 / 31 (3,0%)-Surgeon 21 - 4 / 69 (5,8%)

Chirurgische Universitätsklinik Erlangen 1995 - 2000R0 - resections, stages I - III

Colon cancer Rectal cancer

Rectal CancerPostop. LeaksSurgeon 13

ant. resection 0/16 0/13Low ant. res. 16/116 (13,8 %) 1/84 (1 %)intersphinct. r. 1/20 (8 %) 0/7all 17/125 (11,7)

1/104 (1 %)

Chirurgische Universitätsklinik Erlangen 1995 - 2005all stages

1995-2001 2002-2005

Surgery for Colon CancerComplete Mesocolic Excicion (CME)

Preservation of the mesocolic plane by sharp dissection off the parietal plane (turning embryology back)

Regional and central lymphnode dissection with high tie of suppling vesssels

2000-2004: 90,2%1995-1999: 87,2%1990-1994: 84,6%1985-1989: 83,6%1978-1984: 82,1%

Stages I-III, R0, Erlangen Registry 1978-2004

Colon CancerCancer related 5-Years Survival

Related to Periods

Colon CancerCancer related Survival

Surg. Department Univ. Hosp. Erlangenpostop. mortality excluded, 1995-2005

oooooo

Rectal Cancer High risk groups for local recurrence

3-J-LRall (n = 373) 8,8%T4 (n = 14) 23,4%pT3/4 pN2 (n = 39) 19,7%pN2 G3/4 (n = 18) 35,8%pN2 V1 extraminal (n = 10) 41,7%pN2 V1 G3/4 (n = 6) 46,7%

Chirurg. Univ.-Klinik Erlangen 1995-2000

UICC-Stage I-III, med. follow-up 53months

German Oncologic Bowel Centres Benchmarking

30 days mortality after elective operations (n=3.836)

DOC Holding GmbH - Qualitätssicherung in der Onkologie

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Anonym codes of hospitals involved

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Colorectal Cancer Surgery

- the individual surgeon makes the difference

- needs a certain caseload

- this figure depends upon spectrum

- high volume does not guarantee high quality

- optimised standard controlled by a proper system

Outcome

Seventh International Symposium and Workshop

Advanced Course in Colorectal Surgery

May, 21-22th 2012

For further information and registration

please contact:Susanne.Reed@uk-erlangen.de