Advertisement

International Journal of Colorectal Disease

, Volume 28, Issue 2, pp 197–206 | Cite as

Volume and outcome in rectal cancer surgery: the importance of quality management

  • Werner Hohenberger
  • Susanne Merkel
  • Paul Hermanek
Original Article

Abstract

Purpose

For many years, the impact of the surgeon volume on short- and long-term outcome after rectal carcinoma surgery is controversially discussed. Literature and own department data were reviewed in order to clarify the impact of surgeon volume in the current era of total mesorectal excision surgery, multimodal therapy, quality management, and centralization of cancer care.

Methods

Uni- and multivariate analysis of data from 1,028 patients with solitary rectal carcinoma, treated between 1995 and 2010 at the Department of Surgery, University Hospital, Erlangen, Germany, was performed. Surgeons were subdivided according to the number of operations/year into high- (at least seven/year), medium- (three to six), and low- (less than three) volume surgeons.

Results

Of 1,028 patients, 800 (77.8 %) were operated by five high-volume surgeons, 193 (18.8 %) by seven medium-volume surgeons, and 35 (3.4 %) by 12 low-volume surgeons. Surgeon volume was significantly associated with postoperative mortality and the rate of positive pathological circumferential resection margin. In risk-adjusted analysis, after primary surgery, surgeon volume had a significant impact on observed overall survival and disease-free survival, but not on locoregional recurrence. After neoadjuvant radiochemotherapy, only observed overall survival was significantly influenced by surgeon volume.

Conclusions

In surgical departments with special interest in rectal carcinoma, surgeon volume has some influence on short- and long-term outcome. Irrespective of this fact, specialization, experience, individual skill, hospital organization, and regular quality assurance are essential prognostic factors ensuring good results in rectal carcinoma surgery.

Keywords

Long-term outcome Quality management Rectal carcinoma Short-term outcome Surgeon volume TME (Total mesorectal excision) surgery 

References

  1. 1.
    Meagher AP (1999) Colorectal cancer: is the surgeon a prognostic factor? A systematic review. Med J Aust 20(171):308–310Google Scholar
  2. 2.
    Iversen LH, Harling H, Laurberg S, Wille-Jørgensen P (2007) Influence of caseload and surgical speciality on outcome following surgery for colorectal cancer: a review of evidence. Part 1: short-term outcome. Colorectal Dis 9:28–37PubMedCrossRefGoogle Scholar
  3. 3.
    Iversen LH, Harling H, Laurberg S, Wille-Jørgensen P, Danish Colorectal Cancer Group (2007) Influence of caseload and surgical speciality on outcome following surgery for colorectal cancer: a review of evidence. Part 2: long-term outcome. Colorectal Dis 9:38–46PubMedCrossRefGoogle Scholar
  4. 4.
    Salz T, Sandler RS (2008) The effect of hospital and surgeon volume on outcomes for rectal cancer surgery. Clin Gastroenterol Hepatol 6:1185–1193PubMedCrossRefGoogle Scholar
  5. 5.
    Archampong D, Borowski DW, Dickinson HO (2010) Impact of surgeon volume on outcomes of rectal cancer surgery: a systematic review and meta-analysis. Surgeon 8:341–352PubMedCrossRefGoogle Scholar
  6. 6.
    Archampong D, Borowski D, Wille-Jørgensen P, Iversen LH (2012) Workload and surgeon's specialty for outcome after colorectal cancer surgery. Cochrane Database Syst Rev. 2012;3:CD005391Google Scholar
  7. 7.
    Gospodarowicz MK, Hermanek P, Henson DE (1995) (1995) Introduction. In: Hermanek P, Gospodarowicz MK, Henson DE, Hutter RVP, Sobin LH (eds) In: UICC Prognostic factors in cancer. Springer, Berlin, pp 1–11CrossRefGoogle Scholar
  8. 8.
    Gospodarowicz MK, O'Sullivan B (2001) Prognostic factors: principles and application. In: Gospodarowicz MK, Henson DE, Hutter RVP, O'Sullivan B, Sobin L, Wittekind CH (eds) UICC. Prognostic factors in Cancer. 2nd ed. Wiley, New York, pp 17–35Google Scholar
  9. 9.
    Hermanek P, Mansmann U (2001) Kriterien der Wertung von Prognosefaktoren. Chirurg 72:474–480PubMedCrossRefGoogle Scholar
  10. 10.
    Hobday TJ, Erlichman CE (2001) Colorectal cancer. In: Gospodarowicz MK, Henson DE, Hutter RVP, O'Sullivan B, Sobin L, Wittekind C (eds) UICC. Prognostic factors in Cancer. 2nd ed. Wiley, New York, pp 267–279Google Scholar
  11. 11.
    Compton CC (2006) Colorectal cancer. In: Gospodarowicz MK, O’Sullivan B, Sobin LH (eds) UICC. Prognostic factors in cancer, 3rd ed. Wiley, New York, pp 133–137Google Scholar
  12. 12.
    Archampong D, Borowski DW (2012) Impact of hospital volume on outcomes of rectal cancer surgery: a systematic review and meta-analysis. Int J Colorectal Dis in pressGoogle Scholar
  13. 13.
    Heald RJ, Husband EM, Ryall RDH (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616PubMedCrossRefGoogle Scholar
  14. 14.
    Quirke P, Morris E (2007) Reporting colorectal cancer. Histopathology 50:103–112PubMedCrossRefGoogle Scholar
  15. 15.
    Hohenberger W, Merkel S, Matzel K, Bittorf B, Papadopoulos T, Goehl J (2006) The influence of abdomino-peranal (intersphincteric) resection of lower third rectal carcinoma on the rates of sphincter preservation and locoregional recurrence. Colorectal Dis 8:23–33PubMedCrossRefGoogle Scholar
  16. 16.
    Sauer R, Becker H, Hohenberger W et al (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740PubMedCrossRefGoogle Scholar
  17. 17.
    Rödel C, Liersch T, Becker H et al (2012) Preoperative chemoradiotherapy and postoperative chemotherapy with fluorouracil and oxaliplatin versus fluorouracil alone in locally advanced rectal cancer: initial results of the German CAO/ARO/AIO-04 randomised phase 3 trial. Lancet Oncol 13:679–687PubMedCrossRefGoogle Scholar
  18. 18.
    Schmiegel W, Reinacher-Schick A, Arnold D et al (2008) S3-Leitlinie Kolorektales Karzinom – Aktualisierung 2008. Ergebnis einer evidenzbasierten Konsensuskonferenz (8.–9. Juni 2007). Z Gastroenterol 46:799–840PubMedCrossRefGoogle Scholar
  19. 19.
    UICC (2009) TNM classification of malignant tumors. 7th ed. (Sobin LH, Gospodarowicz MK, Wittekind Ch, eds) Wiley, Oxford, UKGoogle Scholar
  20. 20.
    Fielding LP, Stewart-Brown S, Dudley HA (1978) Surgeon-related variables and the clinical trial. Lancet 2(8093):778–779PubMedCrossRefGoogle Scholar
  21. 21.
    Phillips RKS, Hittinger R, Blesovsky L, Fry JS, Fielding LP (1984) Local recurrence following 'curative' surgery for large bowel cancer: I. The overall picture. Br J Surg 71:12–16PubMedCrossRefGoogle Scholar
  22. 22.
    McArdle CS, Hole D (1991) Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival. BMJ 302:1501–1505PubMedCrossRefGoogle Scholar
  23. 23.
    Hermanek P, Wiebelt H, Staimmer D, Riedl S (1995) Prognostic factors of rectum carcinoma—experience of the German Multicentre Study SGCRC. German Study Group Colo-Rectal Carcinoma. Tumori 81(3 Suppl):60–64PubMedGoogle Scholar
  24. 24.
    Hermanek P, Hohenberger W (1996) The importance of volume in colorectal cancer surgery. Eur J Surg Oncol 22:213–215PubMedCrossRefGoogle Scholar
  25. 25.
    Hohenberger W (1997) The effect of specialization or organization of rectal cancer surgery. In: Soreide O, Norstein J (eds) Rectal cancer surgery—optimization, standardization, documentation. Springer, Berlin, pp 353–363CrossRefGoogle Scholar
  26. 26.
    Hermanek P (1999) Impact of surgeon's technique on outcome after treatment of rectal carcinoma. Dis Colon Rectum 42:559–562PubMedCrossRefGoogle Scholar
  27. 27.
    Hermanek P, Sobin LH (1995) Colorectal carcinoma. In: Hermanek P, Gospodarowicz MK, Henson DE, Hutter RVP, Sobin L (eds) UICC. Prognostic factors in cancer. 1st ed. Springer, Berlin, pp 64–79CrossRefGoogle Scholar
  28. 28.
    Bilimoria KY, Phillips JD, Rock CE, Hayman A, Prystowsky JB, Bentrem DJ (2009) Effect of surgeon training, specialization, and experience on outcomes for cancer surgery: a systematic review of the literature. Ann Surg Oncol 16:1799–1808PubMedCrossRefGoogle Scholar
  29. 29.
    Möhner M, Slisów W (1990) Effect of regional centralized treatment on chances of survival in rectal cancer in East Germany. Zentralbl Chir 115:801–812PubMedGoogle Scholar
  30. 30.
    Påhlman L, Bohe M, Cedermark B et al (2007) The Swedish rectal cancer registry. Br J Surg 94:1285–1292PubMedCrossRefGoogle Scholar
  31. 31.
    Larson DW, Marcello PW, Larach SW et al (2008) Surgeon volume does not predict outcomes in the setting of technical credentialing: results from a randomized trial in colon cancer. Ann Surg 248:746–750PubMedCrossRefGoogle Scholar
  32. 32.
    Kapiteijn E, Putter H, van de Velde CJ, Cooperative investigators of the Dutch ColoRectal Cancer Group (2002) Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg 89:1142–1149PubMedCrossRefGoogle Scholar
  33. 33.
    Martling A, Cedermark B, Johansson H, Rutqvist LE, Holm T (2002) The surgeon as a prognostic factor after the introduction of total mesorectal excision in the treatment of rectal cancer. Br J Surg 89:1008–1013PubMedCrossRefGoogle Scholar
  34. 34.
    Hermanek P, Mansmann U, Staimmer DS, Riedl S, Hermanek P (2000) The German experience: the surgeon as a prognostic factor in colon and rectal cancer surgery. Surg Oncol Clin N Am 9:33–49PubMedGoogle Scholar
  35. 35.
    Hogan AM, Kennelly R, Winter DC (2009) Volume-outcome analysis in rectal cancer: a plea for enquiry, evidence and evolution. Eur J Surg Oncol 35:111–112PubMedCrossRefGoogle Scholar
  36. 36.
    German Cancer Society [Deutsche Krebsgesellschaft] (2012) Erhebungsbogen für Darmkrebszentren der Deutschen Krebsgesellschaft. http://www.onkozert.de/downloads/eb_darm-C1(03.12.2010).doc. Accessed 28 August 2012
  37. 37.
    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 236:583–592PubMedCrossRefGoogle Scholar
  38. 38.
    Borowski DW, Bradburn DM, Mills SJ, Bharathan B, Wilson RG, Ratcliffe AA, Kelly SB, Northern Region Colorectal Cancer Audit Group (NORCCAG) (2010) Volume-outcome analysis of colorectal cancer-related outcomes. Br J Surg 97:1416–1430PubMedCrossRefGoogle Scholar
  39. 39.
    Rogers SO Jr, Ayanian JZ, Ko CY, Kahn KL, Zaslavsky AM, Sandler RS, Keating NL (2009) Surgeons' volume of colorectal cancer procedures and collaborative decision-making about adjuvant therapies. Ann Surg 250:895–900PubMedCrossRefGoogle Scholar
  40. 40.
    Compton CC, Fielding LP, Burgart LJ et al (2000) Prognostic factors in colorectal cancer. College of American Pathologists Consensus Statement 1999. Arch Pathol Lab Med 124:979–994PubMedGoogle Scholar
  41. 41.
    Merkel S, Mansmann U, Hohenberger W, Hermanek P (2011) Time to locoregional recurrence after curative resection of rectal carcinoma is prolonged after neoadjuvant treatment: a systematic review and meta-analysis. Colorectal Dis 13:123–131PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Werner Hohenberger
    • 1
  • Susanne Merkel
    • 1
  • Paul Hermanek
    • 1
  1. 1.Department of SurgeryFriedrich-Alexander-Universität Erlangen-NürnbergErlangenGermany

Personalised recommendations