Background
The impact of hospital volume after rectal cancer surgery is seldom investigated. This study aimed to analyse the impact of annual rectal cancer surgery cases per hospital on postoperative ...mortality and failure to rescue.
Methods
All patients diagnosed with rectal cancer and who had a rectal resection procedure code from 2012 to 2015 were identified from nationwide administrative hospital data. Hospitals were grouped into five quintiles according to caseload. The absolute number of patients, postoperative deaths and failure to rescue (defined as in‐hospital mortality after a documented postoperative complication) for severe postoperative complications were determined.
Results
Some 64 349 patients were identified. The overall in‐house mortality rate was 3·9 per cent. The crude in‐hospital mortality rate ranged from 5·3 per cent in very low‐volume hospitals to 2·6 per cent in very high‐volume centres, with a distinct trend between volume categories (P < 0·001). In multivariable logistic regression analysis using hospital volume as random effect, very high‐volume hospitals (53 interventions/year) had a risk‐adjusted odds ratio of 0·58 (95 per cent c.i. 0·47 to 0·73), compared with the baseline in‐house mortality rate in very low‐volume hospitals (6 interventions per year) (P < 0·001). The overall postoperative complication rate was comparable between different volume quintiles, but failure to rescue decreased significantly with increasing caseload (15·6 per cent after pulmonary embolism in the highest volume quintile versus 38 per cent in the lowest quintile; P = 0·010).
Conclusion
Patients who had rectal cancer surgery in high‐volume hospitals showed better outcomes and reduced failure to rescue rates for severe complications than those treated in low‐volume hospitals.
Antecedentes
El impacto del volumen hospitalario en los resultados de la cirugía del cáncer de recto ha sido poco investigado. Este estudio tuvo como objetivo analizar el impacto de los casos anuales de cirugía de cáncer de recto por hospital en la mortalidad postoperatoria (postoperative mortality, POM) y el fracaso en el rescate (failure to rescue, FtR).
Métodos
Todos los casos de pacientes hospitalizados con un diagnóstico de cáncer de recto y un código de procedimiento de resección rectal, tratados de 2012 a 2015, se identificaron a partir de datos hospitalarios administrativos a nivel nacional. Los hospitales se agruparon en cinco quintiles según el volumen de casos. Se determinó el número absoluto de pacientes, la POM y el FtR por complicaciones postoperatorias graves. El FtR se definió como la mortalidad hospitalaria después de una complicación postoperatoria documentada.
ResultadosSe identificaron 64.349 casos entre 2012 y 2015. La tasa de mortalidad hospitalaria global fue del 3,89% (n = 2.506). Las tasas brutas de mortalidad hospitalaria variaron de 5,34% (n = 687) en hospitales de muy bajo volumen a 2,63% (n = 337) en centros de muy alto volumen, con una tendencia distinta entre las categorías de centros (P < 0,001).
En el análisis de regresión logística multivariante utilizando el volumen hospitalario como efecto aleatorio, los hospitales de muy alto volumen (53 intervenciones/año) tenían una razón de oportunidades (odds ratio, OR) ajustada por riesgo de 0,58 (i.c. del 95%: 0,47‐0,73) en comparación con la tasa basal de mortalidad hospitalaria en hospitales de muy bajo volumen (6 intervenciones/año) (P < 0,001). La tasa global de complicaciones postoperatorias fue comparable entre los diferentes quintiles de volumen, pero el FtR disminuyó significativamente con el aumento del volumen de casos (15,63% FtR tras una embolia pulmonar en el quintil más alto versus 38,4% en el hospital del quintil más bajo, P = 0,01).
Conclusión
Los pacientes sometidos a cirugía de cáncer de recto en hospitales de gran volumen presentaron mejores resultados y una disminución de las tasas de fracaso en el rescate por complicaciones graves en comparación con los pacientes tratados en hospitales de bajo volumen.
In‐hospital mortality after rectal cancer surgery is strongly correlated with annual hospital caseload. This is the result of an increased failure‐to‐rescue rate in the case of postoperative complications in low‐volume hospitals rather than the result of an increased overall rate of complications.
Rectal cancer surgery and hospital volume
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
Colonic cancer is the most common cancer of the gastrointestinal tract. The aim of this study was to determine mortality rates following colonic cancer resection and the effect of hospital ...caseload on in‐hospital mortality in Germany.
Methods
Patients admitted with a diagnosis of colonic cancer undergoing colonic resection from 2012 to 2015 were identified from a nationwide registry using procedure codes. The outcome measure was in‐hospital mortality. Hospitals were ranked according to their caseload for colonic cancer resection, and patients were categorized into five subgroups on the basis of hospital volume.
Results
Some 129 196 colonic cancer resections were reviewed. The overall in‐house mortality rate was 5·8 per cent, ranging from 6·9 per cent (1775 of 25 657 patients) in very low‐volume hospitals to 4·8 per cent (1239 of 25 825) in very high‐volume centres (P < 0·001). In multivariable logistic regression analysis the risk‐adjusted odds ratio for in‐house mortality was 0·75 (95 per cent c.i. 0·66 to 0·84) in very high‐volume hospitals performing a mean of 85·0 interventions per year, compared with that in very low‐volume hospitals performing a mean of only 12·7 interventions annually, after adjustment for sex, age, co‐morbidity, emergency procedures, prolonged mechanical ventilation and transfusion.
Conclusion
In Germany, patients undergoing colonic cancer resections in high‐volume hospitals had with improved outcomes compared with patients treated in low‐volume hospitals.
Antecedentes
El cáncer de colon es el cáncer más frecuente del tracto digestivo. El objetivo de este estudio fue determinar las tasas de mortalidad tras resección de cáncer de colon y el efecto del volumen de casos del hospital sobre la mortalidad intrahospitalaria en Alemania.
Métodos
Los pacientes ingresados con el diagnóstico de cáncer de colon sometidos a resección colónica entre 2012 y 2015 se identificaron a partir de un registro nacional utilizando los códigos de los procedimientos. La medida de resultado fue la mortalidad intrahospitalaria. Los hospitales se clasificaron de acuerdo con su número de casos de resecciones de cáncer de colon y los pacientes fueron categorizados en 5 diferentes subgrupos en la base del volumen del hospital.
Resultados
Se revisaron 129.196 resecciones de cáncer de colon. La tasa de mortalidad fue de 5,75%, variando desde 6,92% (n = 1.775) en hospitales de bajo volumen hasta 4,80% (n = 1.239) en centros con alto volumen, con una diferencia significativa entre los escenarios de bajo y alto volumen (P < 0,001). El análisis de regresión logística multivariable puso de manifiesto que la razón de oportunidades (odds ratio, OR) ajustada al riesgo de la mortalidad intrahospitalaria fue de 0,75 (i.c. del 95% 0,66‐0,84) en hospitales con volumen muy alto que realizaban más de 85,0 intervenciones/año, en comparación con hospitales de volumen muy bajo que realizaban menos de 13 intervenciones/año, tras ajustar por sexo, edad, comorbilidad, procedimiento urgente, ventilación mecánica prolongada y transfusiones.
Conclusión
En Alemania, los pacientes sometidos a resección de cáncer de colon en hospitales de alto volumen tienen mejores resultados en comparación con los pacientes tratados en centros de bajo volumen.
In Germany, perioperative mortality for colonic cancer resection at the national level is high. Patients undergoing resection of colonic cancer in high‐volume hospitals have improved outcomes compared with those treated in low‐volume hospitals.
Mortality rate, hospital volume and CRC resections
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
Despite recent improvements in colonic cancer surgery, the rate of anastomotic leakage after right hemicolectomy is still around 6–7 per cent. This study examined whether anastomotic ...technique (handsewn or stapled) after open right hemicolectomy for right‐sided colonic cancer influences postoperative complications.
Methods
Patient data from the German Society for General and Visceral Surgery (StuDoQ) registry from 2010 to 2017 were analysed. Univariable and multivariable analyses were performed. The primary endpoint was anastomotic leakage; secondary endpoints were postoperative ileus, complications and length of postoperative hospital stay (LOS).
Results
A total of 4062 patients who had undergone open right hemicolectomy for colonic cancer were analysed. All patients had an ileocolic anastomosis, 2742 handsewn and 1320 stapled. Baseline characteristics were similar. No significant differences were identified in anastomotic leakage, postoperative ileus, reoperation rate, surgical‐site infection, LOS or death. The stapled group had a significantly shorter duration of surgery and fewer Clavien–Dindo grade I–II complications. In multivariable logistic regression analysis, ASA grade and BMI were found to be significantly associated with postoperative complications such as anastomotic leakage, postoperative ileus and reoperation rate.
Conclusion
Handsewn and stapled ileocolic anastomoses for open right‐sided colonic cancer resections are equally safe. Stapler use was associated with reduced duration of surgery and significantly fewer minor complications.
Hand‐sewn anastomosis and stapled ileo‐colostomy for right hemicolectomy for right‐sided colon cancer are equally safe in terms of postoperative complications. Use of any stapler, however, is associated with reduced operation time and significantly fewer minor (Clavien–Dindo grade I and II) complications.
Fewer minor complications with staplers
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Tumors of the appendix are not a uniform group but differ significantly in terms of their origin/histology and metastatic behavior. Furthermore, tumors of the appendix are often diagnosed as ...incidental findings after appendectomy for acute appendicitis. A subgroup of these neoplasms are low-grade appendiceal mucinous neoplasms (LAMN). These are mucus-forming tumors of the appendiceal lumen, which can lead to rupture of the appendix and seeding into the abdominal cavity. Therefore LAMN are considered precursors of pseudomyxoma peritonei (PMP). It is essential to clearly differentiate the subgroups of LAMN as well as the resection status. According to this it is determined whether (radical) appendectomy is a sufficient therapy or further treatment, such as ileocecal resection with hyperthermic intraperitoneal chemotherapy (HIPEC) or cytoreductive surgery (CRS) is necessary. There is no standardized concept regarding the follow-up after resection of LAMN. Generally, it is recommended to perform a computed tomography (CT) scan of the abdomen and determination of tumor markers 6 months postoperatively and then once a year. A recommendation regarding the duration of follow-up is difficult as there are case reports in which PMP has occurred more than 15 years after removal of LAMN.
Since the introduction of competition in the telecommunications sector, private firms have been facing new possible choices concerning their telecommunications systems. To evaluate these ...possibilities the traditional microeconomic production theory proves to be helpful. Cost minimal solutions to practical problems of a new entrant in the telecommunication market, the technology of which is modelled as a production function, are presented.PUBLICATION ABSTRACT
Transforming growth factor β (TGF‐β) as well as tumor necrosis factor α (TNF‐α) gene expression are up‐regulated in chronically inflamed liver. These cytokines were investigated for their influence ...on apoptosis and proliferation of activated hepatic stellate cells (HSCs). Spontaneous apoptosis in activated HSC was significantly down‐regulated by 53% ± 8% (P < .01) under the influence of TGF‐β and by 28% ± 2% (P < .05) under the influence of TNF‐α. TGF‐β and TNF‐α significantly reduced expression of CD95L in activated HSCs, whereas CD95 expression remained unchanged. Furthermore, HSC apoptosis induced by CD95‐agonistic antibodies was reduced from 96% ± 2% to 51 ± 7% (P < .01) by TGF‐β, and from 96% ± 2% to 58 ± 2% (P < .01) by TNF‐α, suggesting that intracellular antiapoptotic mechanisms may also be activated by both cytokines. During activation, HSC cultures showed a reduced portion of cells in the G0/G1phase and a strong increment of G2‐phase cells. This increment was significantly inhibited (G1 arrest) by administration of TGF‐β and/or TNF‐α to activated cells. In liver sections of chronically damaged rat liver (CCl4 model), using desmin and CD95L as markers for activated HSC, most of these cells did not show apoptotic signs (TUNEL‐negative). Taken together, these findings indicate that TGF‐β and/or TNF‐α both inhibit proliferation and also apoptosis in activated HSC in vitro. Both processes seem to be linked to each other, and their inhibition could represent the mechanism responsible for prolonged survival of activated HSC in chronic liver damage in vivo.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
A growing number of patients in Germany receive a long-term prophylactic anticoagulation with phenprocoumone or one of the novel direct oral anticoagulants (NOAC), such as dabigatran, rivaroxaban or ...apixaban. The most common indication for an oral anticoagulant therapy is atrial fibrillation (approximately 75%) where the anticoagulant therapy can reduce the risk for an embolic event, particularly stroke by 60%. Operations carried out during such a therapy can result in major bleeding complications. On the other hand, suspending anticoagulant therapy can lead to an increased risk of thromboembolisms. Thus, the preoperative assessment should address the bleeding risk of the planned operation, the individual risk of thromboembolism, as well as other factors, such as patient age and renal function. If the individual assessment shows a substantial risk of perioperative bleeding when anticoagulant treatment is continued and a substantial risk of thromboembolism if the treatment is suspended, then a perioperative bridging, for example with low molecular weight heparin, is necessary. Perioperative bridging also leads to an increased risk of perioperative bleeding. Thus, undifferentiated bridging for all patients with atrial fibrillation with anticoagulant treatment is not recommended. Instead, the indications for a perioperative bridging should be decided according to individual risk profiles.
Diabetes mellitus is the most frequent metabolic disorder in the western world with a prevalence of 3% in adults under 65 years of age and 14.3% in adults over 65 years of age. Due to the increasing ...age of our population, the number of patients taking oral antidiabetic drugs has increased. Thus, operating physicians must make a risk-adapted decision whether the medication can be continued perioperatively or if certain drugs must be paused, and if so, with what risks. Operative interventions can lead to a number of metabolic shifts, which change the normal glucose metabolism. Hyperglycemia in the perioperative period is a risk factor for postoperative sepsis, dysfunction of the endothelium, cerebral ischemia and poor wound healing. Due to perioperative fasting oral antidiabetic medication can lead to severe hypoglycemia if taken during this period. This leads to an increased morbidity and mortality in the perioperative period and extends the duration of stay in the intensive care unit (ICU) as well as the overall hospital stay. Oral antidiabetic medication should be paused on the day of the operation and restarted in line with the gradual postoperative return to solid food. Especially metformin, the most commonly used medication in the treatment of type 2 diabetes, should be paused perioperatively due to the severe side effect of lactate acidosis.
In 2010 Germany had 447,300 new cases of cancer. From 2000 to 2010 the incidence of cancer increased by 21% in men and by 14% in women. The change in the age structure with an aging population is the ...crucial influencing factor. Various cancer types can now be treated by oral antitumor agents used as a chronic medication. Physicians must decide whether the oral antitumor agents can be continued perioperatively or if certain drugs must be paused and if so, with what risks. Oral antitumor agents are a very heterogeneous group of medication. The use of oral antitumor agents during the perioperative period has not been thoroughly examined, but most often a perioperative interruption is recommended. In general, poor wound healing is a frequent complication of this group of medication. The handling of oral antitumor agents in the perioperative period should be based on an individual decision with consideration of the desired therapy goal as well as the individual prognosis. In general, all oral antitumor agents are chronic medication and are continued until a loss of efficacy or intolerable side effects occur. A potentially curative therapy should be paused for the shortest possible time in order not to jeopardize the remission already achieved. Furthermore, generally accepted recommendations concerning the interval between chemotherapy and a planned operation have not yet been established. A rough rule of thumb could be to plan the operation after the regeneration of the blood count or at the same point in time of the next planned chemotherapy.
Every year 16 million operations are performed in Germany. Many patients have an autoimmune disorder, for example rheumatoid arthritis, psoriasis or chronic inflammatory bowel disease, which requires ...treatment. Immunosuppressants are widely applied. Physicians must make a risk-adapted decision whether the immunosuppressant medication can be continued perioperatively or if certain drugs must be paused and if so, with what risks. The handling of immunosuppressants during the perioperative period is very relevant as many patients, for example with rheumatoid arthritis are in need of a hip or knee replacement or patients with inflammatory bowel disease need an operation due to the chronic illness. The interruption of an immunosuppressant therapy should be discussed in an interdisciplinary board according to the underlying disease, because the continuation of immunosuppressants perioperatively can lead to an increased rate of complications, especially wound healing disorders. If a patient is on a glucocorticoid therapy the following must be considered: during the perioperative period the body has an increased demand for glucocorticoids due to the stress reaction. If glucocorticoids are administered in a dosage of more than 7.5 mg/day equivalent of prednisolone this stress reaction is inhibited. Thus, in these cases a perioperative substitution with hydrocortisone is recommended.
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