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Colorectal surgery in a rural setting

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Abstract

Colorectal surgery is increasingly being concentrated in high-volume tertiary centers, whereas it has been demonstrated that it can be performed safely and effectively even in low-volume hospitals. We analyzed data of patients who underwent major colorectal surgery in 1 year in a “rural” hospital, located on a small island, where a dynamic colorectal multidisciplinary team (MDT) and an enhanced recovery programme have been implemented. Primary endpoints were rate of laparoscopic resections, morbidity, mortality and number of lymph nodes retrieved and examined. Secondary endpoints were rate of R0 resections and length of postoperative stay. Seventy-six patients had surgery for a severe colorectal condition. Fifty-five resections have been performed, 38 by laparoscopy (69.1 %). Conversion rate was 5 %. Morbidity for resections was 21.8 %. General leak rate was 1.8 %, no leaks in laparoscopic resections. There was no difference in morbidity between open and laparoscopic resections. Postoperative stay was significantly shorter in laparoscopic vs open operations and in elective vs emergency operations. Number of lymph nodes retrieved was higher in laparoscopic vs open resections, 85.4 % of patients had 12 or more lymph nodes examined. Overall rate of R0 resections was 80.5 %, higher in laparoscopic vs open resections. Major colorectal surgery can be performed safely and effectively also in low-volume hospitals in the presence of a trained high-volume surgeon, an effective MDT and an Enhanced Recovery Programme.

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References

  1. Begg CB, Cramer LD, Hoskins WJ, Brennan MF (1998) Impact of hospital volume on operative mortality for major cancer surgery. JAMA 280:1747–1751

    Article  CAS  PubMed  Google Scholar 

  2. Rogers SO, Wolf RE, Zaslavsky AM, Writh WE, Ayanian JZ (2006) Relation of surgeon and hospital volume to processes and outcomes of colorectal cancer surgery. Ann Surg 244:1003–1011

    Article  PubMed Central  PubMed  Google Scholar 

  3. Kuhry E, Bonjer HJ, Haglind E, Hop WC, Veldkamp R, Cuesta MA, Jeekel J, Pahlman L, Morino M, Lacy A, Delgado S, COLOR Study Group (2005) Impact of hospital case volume on short term outcome after laparoscopic operation for colonic cancer. Surg Endosc 19:687–692

    Article  CAS  PubMed  Google Scholar 

  4. Balentine CJ, Naik AD, Robinson CN, Petersen NJ, Chen GJ, Berger DH, Anaya DA (2014) Association of high-volume hospitals with greater likelihood of discharge to home following colorectal surgery. JAMA Surg 149:244–251

    Article  PubMed  Google Scholar 

  5. Grant AJ, Sedgwick DM (2011) Small can be beautiful: 10 years managing colorectal cancer in a rural general hospital. Scott Med J 56:26–29

    Article  CAS  PubMed  Google Scholar 

  6. Schittek A (2009) No anastomotic leaks after colorectal surgery in rural community hospitals. Arch Surg 144:978

    Article  PubMed  Google Scholar 

  7. Hoskins W, Taylor P, Jacob A, Wijeratne S, Campbell I (2013) Colectomies performed at a rural Australian Hospital: a 7-year analysis. Aust J Rural Health 21:279–284

    Article  PubMed  Google Scholar 

  8. National Institute for Health and Clinical Excellence. Colorectal cancer. The diagnosis and management of colorectal cancer. NICE clinical guideline 131, November 2011

  9. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications. A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  PubMed Central  PubMed  Google Scholar 

  10. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, fearon K, Ljungqvist O (2012) Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS) society recommendations. Clin Nutr 31:783–800

  11. Nygren J, Thacker J, Carli F, Fearon KCH, Nordeval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J (2012) Guidelines for perioperative care in elective rectal/pelvic surgery: enhanced recovery after surgery (ERAS) Society recommendations. Clin Nutr 31:801–816

    Article  CAS  PubMed  Google Scholar 

  12. Khan S, Gatt M, Horgan A, Anderson I, MacFie J (2009) Guidelines for implementation of enhanced recovery protocols. Association of Surgeons of Great Britain and Ireland, London

    Google Scholar 

  13. Heald RJ, Husband EM, Ryall RDH (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616

    Article  CAS  PubMed  Google Scholar 

  14. Archampong D, Borowski D, Wille-Jorgensen P, Iversen LH (2012) Workload and surgeon’s specialty for outcome after colorectal cancer surgery. Cochrane Database Syst Rev 3:CD005391

  15. Black J (1999) Has surgical subspecialization gone too far? Hosp Maed 60:206–209

    Article  CAS  Google Scholar 

  16. Taylor BL, Pilkington SN, Smith GB, McQuillan PJ (1996) Attitude of consultant physicians to Calman proposal. Who is responsible for quality of acute medical care? BMJ 312:443–444

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  17. Chowdhury MM, Dagash H, Pierro A (2007) A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg 94:145–161

    Article  CAS  PubMed  Google Scholar 

  18. Schrag D, Panageas KS, Riedel E, Cramer LD, Guillem JG, Bach PB, Begg CB (2002) Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection. Ann Surg 236:583–592

    Article  PubMed Central  PubMed  Google Scholar 

  19. Association of Coloproctology of Great Britain and Ireland. Individual Surgical Outcome for England 2013. http://www.acpgbi.org.uk/surgeon-outcomes/

  20. Oliphant R, Nicholson GA, Horgan PG, McMillan DC, Morrison DS. The impact of surgical specialization on survival following elective colon cancer surgery. Int J Colorectal Dis 2014 (Epub ahead of print)

  21. Burowski DW, Kelly SB, Bradburn DM, Wilson RG, Gunn A, Ratcliffe AA (2007) Northern Region Colorectal Cancer Audit Group. Impact of surgeon volume and specialization on short-term outcomes in colorectal cancer surgery. Br J Surg 94:880–889

    Article  Google Scholar 

  22. Hayanga AJ, Mukherjee D, Chang D, Kaiser H, Lee T, Gearhart S, Ahuja N, Freischlag J (2010) Teaching hospital status and operative mortality in the United States. Tipping point in the volume-outcome relationship following colon resections? Arch Surg 145:346–350

    Article  PubMed Central  PubMed  Google Scholar 

  23. Urbach DR, Baxter NN (2004) Does it matter what a hospital is “high volume” for? Specificity of hospital volume-outcome associations for surgical procedures: analysis of administrative data. BMJ 27(328):737–740

    Article  Google Scholar 

  24. Academy of Medical Royal Colleges (2012) The benefits of consultant-delivered care. London

  25. National Institute for Health and Clinical Excellence (2006) Laparoscopic surgery for colorectal cancer. NICE technology appraisal guidance 105

  26. National Institute for Health and Clinical Excellence (2004) Guidance on Cancer Services. Improving outcomes in colorectal cancers. Manual update. London

  27. Scoggins JF, Fedorenko CR, Donahue SM, Buchwald D, Blough DK, Ramsey SD (2012) Is distance to provider a barrier to care for Medicaid patients with breast, colorectal or lung cancer? J Rural Health 28:54–62

    Article  PubMed Central  PubMed  Google Scholar 

  28. Adamina M, Kehlet H, Tomlinson, Senagore AJ, Delaney CP (2011) Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 149:830–840

  29. Teeuwen PH, Bleichrodt RP, Strik C, Groenewould JJ, Brinkert W, van Laarhoven CJ, van Goor H, Bremers AJ (2010) Enhanced recovery after surgery (ERAS) versus conventional postoperative care in colorectal surgery. J Gastrointest Surg 14:88–95

    Article  PubMed Central  PubMed  Google Scholar 

  30. Kennedy RH, Francis EA, Wharton R, Blazeby JM, Quirke P, West NP, Dutton SJ (2014) Multicenter randomized controlled trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme: ENROL. J Clin Oncol 32:1804–1811

    Article  PubMed  Google Scholar 

  31. Wind J, Polle SW, Fung Kon Jin PH, Dejong CH, vonMeyenfeldt MF, Ubbink DT, Gouma DJ, Bemelman WA (2006) Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93:800–809

  32. National Bowel Cancer Audit Annual Report 2013 (2013) Health and Social Care Information Centre. London. http://www.hscic.gov.uk/catalogue/PUB11105/nati-clin-audi-supp-prog-bowe-canc-2013-rep1.pdf; http://www.hscic.gov.uk/catalogue/PUB11105/nati-clin-audi-supp-prog-bowe-canc-2013-rep2.pdf

  33. Caputo D, Caricato M, La Vaccara V, Capolupo GT, Coppola R (2014) Conversion in mini-invasive colorectal surgery: the effect of timing on short term outcome. Int J Surg 12:805–809

    Article  PubMed  Google Scholar 

  34. Gonzales R, Smith CD, Mason E, Duncan T, Wilson R, Miller J, Ramshaw BJ (2006) Consequences of conversion in laparoscopic colorectal surgery. Dis Colon Rectum 49:197–204

    Article  Google Scholar 

  35. Paun BC, Cassie S, MacLean AR, Dixon E, Buie WD (2010) Postoperative complications following surgery for rectal cancer. Ann Surg 251:807–818

    Article  PubMed  Google Scholar 

  36. Ma Y, Yang Z, Qin H, Wang Y. A meta-analysis of laparoscopy compared with open resection for colorectal cancer. Med Oncol 2010 (online pub 11 May 2010)

  37. Van Der pas MH, Haglind E, Cuesta MA, Furst A, Lacy AM, Hop WC, Bonjer HJ; Colorectal cancer Laparoscopic or Open Resection II (COLOR II) Study Group (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short term outcome of a randomized, phase 3 trial. Lancet Oncol 14:210–218

  38. Gandy RC, Berney CR (2014) Safety of laparoscopic colorectal surgery in a low-volume setting: review of early and late outcome. Gastroenterol Res Pract 2014:581523. doi:10.1155/2014/581523 Epub 2014 Apr 3

    Article  PubMed Central  PubMed  Google Scholar 

  39. Kennedy RH, Jenkins I (2008) The case against mandatory mobilization of the splenic flexure in the left colonic and rectal malignancy. Ann R Coll Surg Engl 90:638–641

    Article  PubMed Central  PubMed  Google Scholar 

  40. Pezim ME, Nicholls RJ (1984) Survival after high or low ligation of the inferior mesenteric artery during curative surgery for rectal cancer. Ann Surg 200:729–733

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  41. Surtees P, Ritchies JK, Phillips RK (1990) High versus low ligation of the inferior mesenteric artery in rectal cancer. Br J Surg 77:618–621

    Article  CAS  PubMed  Google Scholar 

  42. Abraham NS, Young JM, Solomon MJ (2004) Meta-analysis of short term outcomes after laparoscopic resection for colorectal cancer. Br J Surg 91:1111–1124

    Article  CAS  PubMed  Google Scholar 

  43. King PM, Blazeby JM, Ewings P, Longman RJ, Kipling RM, Franks PJ, Sheffield JP, Evans LB, Soulsby M, Bulley SH, Kennedy RH (2006) The influence of an enhanced recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer. Colorectal Dis 8:506–513

    Article  CAS  PubMed  Google Scholar 

  44. Commission on Cancer, American College of Surgeons. At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. National Quality Forum Endorsed Measure 0225. http://www.qualityforum.org/QPS/0225

  45. Compton CC, Fielding LP, Burgart LJ, Conley B, Cooper HS, Hamilton SR, Hammond ME, Henson DE, Hutter RV, Nagle RB, Nielsen ML, Sargent DJ, Taylor CR, Welton M, Willett C (2000) Prognostic factors in colorectal cancer. College of American Pathologists Consensus Statement 1999. Arch Pathol Lab Med 124:979–994

    CAS  PubMed  Google Scholar 

  46. McDonald JR, Renehan AG, O’Dwyer ST, Hanoubi NY (2012) Lymph node harvest in colon and rectal cancer: current considerations. World J Gastrointest Surg 4:9–19

    Article  PubMed Central  PubMed  Google Scholar 

  47. Nelson H, Petrelli N, Carlin A, Couture J, Fleshman J, Guillem J, Miedema B, Ota D, Sargent D (2001) Guidelines 2000 for colon and rectal surgery. J Natl Cancer Inst 93:583–596

    Article  CAS  PubMed  Google Scholar 

  48. Moro-Valdezate D, Pla-Martí V, Martin-Arevalo J, Belenguer-Rodrigo J, Arago-Chofre P, Ruiz-Carmona MD, Checa-Ayet F (2013) Factors related to lymph node harvest: does a recovery of more than 12 improve the outcome of colorectal cancer? Colorectal Dis 15:1257–1266

    Article  CAS  PubMed  Google Scholar 

  49. Fielding LP, Aresnault PA, Chapuis PH, Dent O, Gathright B, Hardcastle JD, Hermanek P, Jass JR, Newland RC (1991) Clinicopathological staging for colorectal cancer: an internation documentation system (IDS) and an internation comprehensive anatomical terminology (ICAT). Working party report to the World Congress of Gastroenterology, Sidney 1990. J Gastroenterol Hepatol 6:325–344

    Article  CAS  PubMed  Google Scholar 

  50. DeCampos-Lobato LF, Stocchi L, DeSousa JB, Buta M, Lavery IC, Fazio VW, Dietz DW, Kalady MF (2013) Less than 12 nodes in the surgical specimen after total mesorectal excision following neoadjuvant chemoradiation: it means more than you think! Ann Surg Oncol 20:3398–3406

    Article  Google Scholar 

  51. Persiani R, Biondi A, Gambacorta MA, Bertucci Zoccali M, vecchio FM, Tufo A, Coco C, Valentini V, Doglietto GB, D’Ugo D (2014) Prognostic implications of the lymph node count after neoadjuvant treatment for rectal cancer. Br J Surg 101:133–142

  52. Kuijpers CC, van Slooten HJ, Schreus WH, Moormann GR, Abtahi MA, Slappendel A, Cliteur V, van Diest PJ, Jiwa NM (2013) Better retrieval of lymph nodes in colorectal resection specimens by pathologists’ assistants. J Clin Pathol 66:18–23

    Article  CAS  PubMed  Google Scholar 

  53. Bamboat ZM, Deperalta D, Dursun A, Berger DL, Bordeianou L (2011) Factors affecting lymph node yield from patients undergoing colectomy for cancer. Int J Colorectal Dis 26:1163–1168

    Article  PubMed  Google Scholar 

  54. Mitchell PJ, Ravi S, Griffiths B, Reid F, Speake D, Midgley C, Mapstone N (2009) Multicentre review of lymph node harvest in colorectal cancer: are we understaging colorectal cancer patients? Int J Colorectal Dis 24:915–921

    Article  CAS  PubMed  Google Scholar 

  55. Moug SJ, Oliphant R, Balsitis M, Molloy RG, Morrison DS (2014) The lymph node ratio optimizes staging in patients with node positive colon cancer with implications for adjuvant chemotherapy. Int J Colorectal Dis 29:599–604

    Article  PubMed  Google Scholar 

  56. Onitilo AA, Stankowski RV, Engel JM, Doi SAR (2013) Adequate lymph node recovery improves survival in colorectal cancer patients. J Surg Oncol 107:828–834

    Article  PubMed  Google Scholar 

  57. Zhang B, Lv M, Chen T, Wei Q, Wang G, Tian J, Chen B (2013) The association between lymph node resection and postoperative survival in patients with colorectal cancer. Hepatogastroenterology 60:1922–1926

    PubMed  Google Scholar 

  58. Li Destri G, Di Carlo I, Scilletta R, Scilletta B, Puleo S (2014) Colorectal cancer and lymph nodes: the obsession with the number 12. World J Gastroenterol 20:1951–1960

    Article  PubMed Central  PubMed  Google Scholar 

  59. Verheijen PM, vd Ven AW, Davids PH, Pronk A (2013) More adequate lymph node dissection after laparoscopic colorectal surgery. Surg Laparosc Endosc Percutan Tech 23:498–501

    Article  PubMed  Google Scholar 

  60. Shia J, Wang H, Nash GM, Klimstra DS (2012) Lymph node staging in colorectal cancer: revisiting the benchmark of at least 12 lymph nodes in R0 resections. J Am Coll Surg 214:348–355

    Article  PubMed  Google Scholar 

  61. Horne J, Bateman AC, Carr NJ, Ryder I (2014) Lymph node revealing solutions in colorectal cancer: should they be used routinely? J Clin Pathol 67:383–388

    Article  PubMed  Google Scholar 

  62. Nagtegaal ID, Quirke P (2008) What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 26:303–312

    Article  PubMed  Google Scholar 

  63. Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94:232–238

    Article  CAS  PubMed  Google Scholar 

  64. Selvaggi F, Fucini C, Pellino G, Sciaudone G, Maretto I, Mondi I, Bartolini N, Caminati F, Pucciarelli S (2015) Outcome and prognostic factors of local recurrent rectal cancer: a pooled analysis of 150 patients. Tech Coloproctol 19(3):135–144

    Article  CAS  PubMed  Google Scholar 

  65. Georgiou PA, Bhangu A, Brown G, Rasheed S, Nicholls RJ, Tekkis PP (2015) Learning curve for the management of recurrent and locally advanced primary rectal cancer: a single team’s experience. Colorectal Dis 17(1):57–65

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Acknowledgments

The author is grateful to dr Adrian Dashfield, Consultant in Anaesthesia and Pain Management and Director of Medical Education at the Noble’s Hospital, Isle of Man, for reviewing the final draft of the manuscript and for his valuable suggestions.

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  1. Colorectal Surgery Unit, Division of Surgery, Noble’s Hospital, Strang, Isle of Man, IM4 4RJ, UK

    Giovanni Domenico Tebala

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Correspondence to Giovanni Domenico Tebala.

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Tebala, G.D. Colorectal surgery in a rural setting. Updates Surg 67, 407–419 (2015). https://doi.org/10.1007/s13304-015-0331-2

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