Skip to main content
SpringerLink
Log in

Benchmarking Perioperative Outcomes of Cytoreductive Surgery for Cancer: Implications for Quality Measurement

  • Peritoneal Surface Malignancy
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Understanding variation and heterogeneity in practice patterns allows programs to develop effective strategies to improve patient outcomes. Cytoreductive surgery is a potentially highly morbid operation that could benefit from systematic assessments directed towards quality improvement. We describe the hospital-level variation and benchmarks for programs performing cytoreductive surgery.

Patients and Methods

Cytoreductive and tumor debulking operations with or without hyperthermic intraperitoneal chemotherapy performed for cancer between January 1, 2013 and June 30, 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Risk-adjusted hospital-level variation in 30-day death, serious morbidity, reoperation, readmission, and a composite of death or serious morbidity (DSM) were evaluated using hierarchical models. National Cancer Institute (NCI)-designated cancer center (NCI-CC) status was also explored.

Results

A total of 6203 operations across 589 hospitals were included, of which 56 were at NCI-CCs. Unadjusted rates of death, serious morbidity, reoperation, readmission, and DSM were 1.4%, 12.9%, 3.6%, 8.6%, and 13.4%, respectively. The coefficients of variation for hospital-level performance were 4.7%, 2.1%, 4.6%, 14.4%, and 1.0% for DSM, death, serious morbidity, unplanned reoperation, and unplanned readmissions, respectively. When compared with other hospitals, NCI-CCs had better risk-adjusted 30-day mortality (median odds ratio 0.984 versus 0.998, p < 0.001), but not for the other outcomes studied.

Conclusions

Hospital-level variation was modestly detected using the usual measures of perioperative outcomes. Given the increasing interest in cytoreductive surgery, we demonstrate a clear opportunity to not only improve the quality of our care but to also better improve the way quality is measured for these patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Glehen O, Kwiatkowski F, Sugarbaker PH, et al. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study. J Clin Oncol. 2004;22(16):3284–92. https://doi.org/10.1200/jco.2004.10.012

    Article  CAS  PubMed  Google Scholar 

  2. Yu W, Whang I, Suh I, Averbach A, Chang D, Sugarbaker PH. Prospective randomized trial of early postoperative intraperitoneal chemotherapy as an adjuvant to resectable gastric cancer. Ann Surg. 1998;228:347–54. https://doi.org/10.1097/00000658-199809000-00007

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Foster JM, Sleightholm R, Patel A, et al. Morbidity and mortality rates following cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy compared with other high-risk surgical oncology procedures. JAMA Netw Open. 2019;2(1):e186847. https://doi.org/10.1001/jamanetworkopen.2018.6847

    Article  PubMed  PubMed Central  Google Scholar 

  4. Jafari MD, Halabi WJ, Stamos MJ, et al. Surgical outcomes of hyperthermic intraperitoneal chemotherapy: analysis of the American College of Surgeons National Surgical Quality Improvement Program. JAMA Surg. 2014;149(2):170–5. https://doi.org/10.1001/jamasurg.2013.3640

    Article  PubMed  Google Scholar 

  5. Quenet F, Elias D, Roca L, et al. A UNICANCER phase III trial of hyperthermic intra-peritoneal chemotherapy (HIPEC) for colorectal peritoneal carcinomatosis (PC): PRODIGE 7. J Clin Oncol. 2018;36(18_suppl):LBA3503. https://doi.org/10.1200/jco.2018.36.18_suppl.lba3503

    Article  Google Scholar 

  6. Nathan H, Yin H, Wong SL. Postoperative complications and long-term survival after complex cancer resection. Ann Surg Oncol. 2017;24(3):638–44. https://doi.org/10.1245/s10434-016-5569-5

    Article  PubMed  Google Scholar 

  7. Aloia TA, Zimmitti G, Conrad C, Gottumukalla V, Kopetz S, Vauthey JN. Return to intended oncologic treatment (RIOT): a novel metric for evaluating the quality of oncosurgical therapy for malignancy. J Surg Oncol. 2014;110(2):107–14. https://doi.org/10.1002/jso.23626

    Article  PubMed  PubMed Central  Google Scholar 

  8. Kim BJ, Caudle AS, Gottumukkala V, Aloia TA. The impact of postoperative complications on a timely Return to Intended Oncologic Therapy (RIOT): the role of enhanced recovery in the cancer journey. Int Anesthesiol Clin. 2016;54(4):e33–46. https://doi.org/10.1097/aia.0000000000000113

    Article  PubMed  Google Scholar 

  9. Liu JB, Berian JR, Liu Y, Ko CY, Weber SM. Trends in perioperative outcomes of hospitals performing major cancer surgery. J Surg Oncol. 2018;118(4):694–703. https://doi.org/10.1002/jso.25171

    Article  CAS  PubMed  Google Scholar 

  10. Liu JB, Berian JR, Liu Y, Cohen ME, Ko CY, Hall BL. Procedure-specific trends in surgical outcomes. J Am Coll Surg. 2018;226(1):30–36.e4. https://doi.org/10.1016/j.jamcollsurg.2017.09.019

    Article  PubMed  Google Scholar 

  11. Konstantinidis IT, Chouliaras K, Levine EA, Lee B, Votanopoulos KI. Frailty correlates with postoperative mortality and major morbidity after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2017;24(13):3825–30. https://doi.org/10.1245/s10434-017-6111-0

    Article  PubMed  Google Scholar 

  12. Cohen ME, Ko CY, Bilimoria KY, et al. Optimizing ACS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and surgical focus. J Am Coll Surg. 2013;217(2):336–46.e1. https://doi.org/10.1016/j.jamcollsurg.2013.02.027

    Article  PubMed  Google Scholar 

  13. Ko CY, Hall BL, Hart AJ, Cohen ME, Hoyt DB. The American College of Surgeons National Surgical Quality Improvement Program: achieving better and safer surgery. Jt Comm J Qual Patient Saf. 2015;41(5):199–204. https://doi.org/10.1016/s1553-7250(15)41026-8

    Article  PubMed  Google Scholar 

  14. NCI-Designated Cancer Centers - National Cancer Institute. https://www.cancer.gov/research/nci-role/cancer-centers. Accessed 23 Feb 2020

  15. Benchimol EI, Smeeth L, Guttmann A, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement. PLOS Med. 2015;12(10):e1001885. https://doi.org/10.1371/journal.pmed.1001885

    Article  PubMed  PubMed Central  Google Scholar 

  16. Cohen ME, Liu Y, Liu JB, Ko CY, Hall BL. Use of a single CPT code for risk adjustment in American College of Surgeons NSQIP Database: is there potential bias with practice-pattern differences in multiple procedures under the same anesthetic? J Am Coll Surg. 2018;226(3):309–16. https://doi.org/10.1016/j.jamcollsurg.2017.12.020

    Article  PubMed  Google Scholar 

  17. Chua TC, Yan TD, Saxena A, Morris DL. Should the treatment of peritoneal carcinomatosis by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy still be regarded as a highly morbid procedure?: A systematic review of morbidity and mortality. Ann Surg. 2009;249(6):900–7. https://doi.org/10.1097/sla.0b013e3181a45d86

    Article  PubMed  Google Scholar 

  18. Liu JB, Huffman KM, Palis BE, et al. Reliability of the American College of Surgeons Commission on Cancer’s quality of care measures for hospital and surgeon profiling. J Am Coll Surg. 2017;224(2):180–190.e8. https://doi.org/10.1016/j.jamcollsurg.2016.10.053

    Article  PubMed  Google Scholar 

  19. Maciver AH, Al-Sukhni E, Esquivel J, Skitzki JJ, Kane JM, Francescutti VA. Current delivery of hyperthermic intraperitoneal chemotherapy with cytoreductive surgery (CS/HIPEC) and perioperative practices: an international survey of high-volume surgeons. Ann Surg Oncol. 2017;24(4):923–30. https://doi.org/10.1245/s10434-016-5692-3

    Article  PubMed  Google Scholar 

  20. Turaga K, Levine E, Barone R, et al. Consensus guidelines from The American Society of Peritoneal Surface Malignancies on standardizing the delivery of hyperthermic intraperitoneal chemotherapy (HIPEC) in colorectal cancer patients in the United States. Ann Surg Oncol. 2014;21(5):1501–5. https://doi.org/10.1245/s10434-013-3061-z

    Article  CAS  PubMed  Google Scholar 

  21. Raspé C, Flöther L, Schneider R, Bucher M, Piso P. Best practice for perioperative management of patients with cytoreductive surgery and HIPEC. Eur J Surg Oncol. 2017;43(6):1013–27. https://doi.org/10.1016/j.ejso.2016.09.008

    Article  PubMed  Google Scholar 

  22. Operative Standards for Cancer Surgery. https://shop.lww.com/Operative-Standards-for-Cancer-Surgery/p/9781451194753. Accessed 23 Feb 2020

  23. Izquierdo F, Sherman SK, Schuitevoerder D, Turaga KK. Modern surgical techniques in cytoreductive surgery. J Gastrointest Surg. 2019;24(2):454–9. https://doi.org/10.1007/s11605-019-04243-8

    Article  PubMed  Google Scholar 

  24. Merkow RP, Chung JW, Paruch JL, Bentrem DJ, Bilimoria KY. Relationship between cancer center accreditation and performance on publicly reported quality measures. Ann Surg. 2014;259(6):1091–7. https://doi.org/10.1097/sla.0000000000000542

    Article  PubMed  Google Scholar 

  25. Valle M, Federici O, Carboni F, et al. Postoperative infections after cytoreductive surgery and HIPEC for peritoneal carcinomatosis: proposal and results from a prospective protocol study of prevention, surveillance and treatment. Eur J Surg Oncol. 2014;40(8):950–6. https://doi.org/10.1016/j.ejso.2013.10.015

    Article  CAS  PubMed  Google Scholar 

  26. Tun S, Eng OS, Malec M. Health-related quality of life after cytoreductive surgery/HIPEC for mucinous appendiceal cancer: results of a multicenter randomized trial comparing oxaliplatin and mitomycin. Ann Surg Oncol. 2019;27(3):630–1. https://doi.org/10.1245/s10434-019-08106-z

    Article  PubMed  Google Scholar 

  27. Tan JW-S, Tan GHC, Ng WY, et al. High-grade complication is associated with poor overall survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Int J Clin Oncol. 2020. https://doi.org/10.1007/s10147-019-01609-5

    Article  PubMed  Google Scholar 

Download references

Funding

There was no specific funding attributable to this work.

Author information

Authors and Affiliations

  1. Department of Surgery, University of Chicago Medicine, Chicago, IL, USA

    Jason B. Liu MD, MS, Darryl Schuitevoerder MD, Charles C. Vining MD, Yaniv Berger MD, Kiran K. Turaga MD, MPH & Oliver S. Eng MD

Authors
  1. Jason B. Liu MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Darryl Schuitevoerder MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Charles C. Vining MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yaniv Berger MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kiran K. Turaga MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Oliver S. Eng MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jason B. Liu MD, MS.

Ethics declarations

Disclosures

The authors have no conflicts of interest, financial or otherwise, to report.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 15 kb)

Supplementary material 2 (DOCX 12 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Liu, J.B., Schuitevoerder, D., Vining, C.C. et al. Benchmarking Perioperative Outcomes of Cytoreductive Surgery for Cancer: Implications for Quality Measurement. Ann Surg Oncol 27, 5039–5046 (2020). https://doi.org/10.1245/s10434-020-08815-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-020-08815-w

Search

Navigation