Rectal cancer: from outcomes of care to process of care.

This paper represents a current opinion on the impact surgeons may have on the variability of the quality of care of rectal cancer surgery. No systematic review of the evidence available in the literature is provided. The objective is to present a concise insight on selected outcomes of care studies, to review the limitations of such studies and to discuss the value of process of care studies. Outcomes of care studies measure what happens to patients, and process of care studies measure what is done to patients. Three variables are reviewed: training, volume and individual skill. It is concluded that the quality of the selected outcomes of care studies is not sufficient to draw definitive conclusions on whether surgeons are a variable. Further efforts should prompt process of care studies on rectal cancer surgery. This implies that outcomes should be measured, processes of care modified and outcomes measured again. This cycle should be continuously repeated in order to achieve the best quality of care

Circumferential resection margin involvement after laparoscopic abdominoperineal excision for rectal cancer.

AIM: This study aimed to evaluate circumferential resection margin (CRM) involvement in patients with rectal adenocarcinoma after laparoscopic abdominoperineal excision (APR). METHOD:   Prospectively collected data were analyzed on consecutive patients who underwent laparoscopic APR for histologically proven rectal cancer following neoadjuvant chemotherapy, from 1998 to 2006. Patients with no sphincter involvement were not included and underwent intersphincteric resection with coloanal anastomosis. CRM involvement was defined as ≤ 2 mm using a standardized pathology protocol. Data were presented as mean ± SD or as median (range). RESULTS: Seventy-four patients (60 ± 14 years of age; body mass index = 29.7 ± 7.9 kg/m(2) ) underwent laparoscopic APR. The distance of the tumour from the anal verge was 3.1 ± 0.93 cm. All patients had sphincter involvement. The operative time was 180 ± 73 min, and estimated blood loss was 269 ± 149 ml. There were no conversions and no postoperative mortality. The adverse event rate was 11%. There were two reoperations and three readmissions. Seventy-one patients had a T3 tumour and three patients had a T4 tumour. The median tumour size was 3.1 (range, 0-10) × 3 (range, 0-8.5) × 2 (range, 0-3.6) cm, and 26 (range, 3-41) lymph nodes were harvested. The median CRM was 7 (range, 1-11) mm. This was localized at the waist of the specimen in 12 (16.2%) of patients. Adjuvant therapy was given to 92% and 97% of patients with an involved and an uninvolved CRM, respectively. At 50 ± 27 months of follow up of 73 patients, 12 had CRM involvement and had a significantly decreased cancer-specific survival (log rank test, P = 0.002). CONCLUSION: Laparoscopic APR resulted in CRM involvement in 16.2% of patients with rectal cancer

Laparoscopic Intracorporeal Ileocolic Resection for Crohn\u27s Disease: Is It Safe?

PURPOSE: The aim of this study was to assess the impact of laparoscopic ileocolic resection with intracorporeal vascular division and anastomosis on the outcome of patients with terminal ileal Crohn\u27s disease. METHODS: Prospective data on patients undergoing laparoscopic ileocolic resection for Crohn\u27s disease confined to terminal ileum and cecum with or without fistulas were reviewed. Exclusion criteria were frozen abdomen, recurrent Crohn\u27s disease following resection, and perforated Crohn\u27s disease. Laparoscopic ileocolic resection involved a lateral-to-medial approach encompassing ten sequential steps. Values were medians (range). RESULTS: From January 1992 to June 2006, 80 laparoscopic ileocolic resections were attempted with a 1.2 percent conversion rate. Sixty-two women and 18 men, age 40 (19-55) years, had a body mass index of 26 (18-37) and an American Society of Anesthesiologists\u27 score of 1 (1-3), and 23.7 percent had previously undergone abdominal surgery. Operating time was 155 (130-210) minutes. Estimated blood loss was 250 (50-600) ml. Length of the skin incision at the specimen extraction site was 35 (30-44) mm. The complication/reoperation rate was 7.5 percent. The readmission rate was 3.7 percent. Except for smoking (P \u3c 0.005), there were no significant differences between patients with and those without complications. The recurrence rate was 30 percent (24 of 80). The median time to recurrence was 64 months. CONCLUSION: Laparoscopic ileocolic resection with intracorporeal vascular division and anastomosis resulted in a favorable outcome in selected patients with refractory terminal ileal Crohn\u27s disease

How accurate are published recurrence rates after rectal prolapse surgery? A meta-analysis of individual patient data.

BACKGROUND: The literature shows wide variations of recurrence rates (RRs) after abdominal surgery for rectal prolapse. The aim of this meta-analysis was to evaluate the accuracy of published RRs. METHODS: An electronic search was performed with no restrictions. Inclusion criterion was abdominal surgery in at least 10 adults with follow-up evaluation of any length of time. Two reviewers screened 1669 references. A total of 190 investigators were asked to provide individual patient data that should be the same used at the time their reports were written. The RR was estimated by actuarial analysis. Investigators were asked for comments on results. RESULTS: Individual patient data from 6 reports published with 273 patients (186 women, 87 men) with a median age of 54 years (range, 18-88 y) were available. Abdominal surgery included mobilization with pexy (88%), with additional resection (7%), or mobilization only (5%). There were 16 recurrences at a median follow-up period of 3.94 years (range, .05-15.11 y). The effect of age (hazard ratio [HR], 2.010; P = .3443), sex (HR, 2.070; P = .4260), surgical technique (HR, .743; P = .7669), and publication (HR, 1.014; P = .8747) on RR was not significant. Two publications reported a RR of 0. In another report, the published and estimated RRs of 15% did not differ. Published RRs differed from estimated RRs in 3 reports (2.5% vs 4%; 7% vs 54%; and 9.6% vs 36%). The pooled odds ratios of 6 reports revealed a borderline significant difference between the published and estimated RRs (P = .066). CONCLUSIONS: Published RRs differed by as much as 47% from the RRs estimated by actuarial analysis depending on event definition and how the data were censored

Recurrence rates after abdominal surgery for complete rectal prolapse: a multicenter pooled analysis of 643 individual patient data.

PURPOSE: This study was designed to determine what impact surgical technique, means of access, and method of rectopexy have on recurrence rates following abdominal surgery for full-thickness rectal prolapse. METHODS: Consecutive individual patient data on age, gender, surgical technique (mobilization-only, mobilization-resection-pexy, or mobilization-pexy), means of access (open or laparoscopic), rectopexy method (suture or mesh), follow-up length, and recurrences were collected from 15 centers performing abdominal surgery for full-thickness rectal prolapse between 1979 and 2001. Recurrence was defined as the presence of full-thickness rectal prolapse after abdominal surgery. Chi-squared test and Cox proportional hazards regression analysis were used to assess statistical heterogeneity. Recurrence-free curves were generated and compared using the Kaplan-Meier method and log-rank test, respectively. RESULTS: Abdominal surgery consisted of mobilization-only (n = 46), mobilization-resection-pexy (n = 130), or mobilization-pexy (n = 467). There were 643 patients. After excluding center 8, there was homogeneity on recurrence rates among the centers with recurrences (n = 8) for age (hazards ratio, 0.6; 95 percent confidence interval, 0.2-1.7; P = 0.405), gender (hazards ratio, 0.6; 95 percent confidence interval, 0.1-2.3; P = 0.519), and center (hazards ratio, 0.3; 95 percent confidence interval, 0.1-1.5; P = 0.142). However, there was heterogeneity between centers with (n = 8) and without recurrences (n = 6) for gender (P = 0.0003), surgical technique (P \u3c 0.0001), means of access (P = 0.01), and rectopexy method (P \u3c 0.0001). The median length of follow-up of individual centers varied from 4 to 127 months (P \u3c 0.0001). There were 38 recurrences at a median follow-up of 43 (range, 1-235) months. The pooled one-, five-, and ten-year recurrence rates were 1.06, 6.61, and 28.9 percent, respectively. Age, gender, surgical technique, means of access, and rectopexy method had no impact on recurrence rates. CONCLUSIONS: Although this study is likely underpowered, the impact of mobilization-only on recurrence rates was similar to that of other surgical techniques

Clinical evaluation of a new ultrasonic Doppler instrument (SonoDoppler) for the detection of blood flow during laparoscopic procedures.

Complications may be avoided by exactly clarifying the structures in the operative field during laparoscopic surgery. We aimed to study the efficiency of a new ultrasonic Doppler device, SonoDoppler, which offers an easy and efficient way of mapping the anatomy. The design of the study was prospective, open observational and carried out on a sample of 51 patients who were operated on in four hospitals. The surgeons were asked to identify a common hepatic artery, cystic artery and portal vein during a laparoscopic cholecystectomy, and corresponding structures during other laparoscopic procedures using the SonoDoppler, instrument. Total operation time (skin-to-skin) and duration of the SonoDoppler, use were measured. The main outcome measures were gain of additional safety and clinical value. A number of evaluations concerning the ergonomics, functionality and interactions with other instruments were also carried out. The SonoDoppler, instrument has the potential to help to assess and clarify the anatomy during laparoscopic procedures. Its use can be advocated not only for inexperienced surgeons, to help them map the vessels during surgery, but also for experienced surgeons during complicated cases and advanced procedures