Management and outcomes in digestive cancer surgery: design and initial results of a multicenter cohort study

Abstract

Background: most studies that analyze the influence of structure factors on clinical outcomes are retrospective, based on clinical-administrative databases, and mainly focusing on surgical volume.Objective: to study variations in the process and outcomes of oncologic surgery for esophagus, stomach, pancreas, liver metastases and rectum cancers in Catalonia, as well as the factors associated with these variations.Patients and method: a retrospective (2002) and prospective (2003-05) multicenter cohort study. Data forms were designed to collect patient, process, and care outcome characteristics before surgery, at hospital discharge, and at 3 and 6 months after discharge. Main outcome measures were hospital and followup mortality, complications, re-interventions, and relapse rates.Results: 49 hospitals (80%) participated in the retrospective phase, 44 of which (90%) also participated in the prospective phase: 3,038 patients (98%) were included. No differences were observed in the profile of operated patients according to hospital level of complexity, but clinical-pathological staging and other functional status variables could not be assessed because of over 20% of missing values. There was significant variability in the volume of interventions as well as in certain aspects of the healthcare process depending on type of cancer and center complexity. High rates of esophageal cancer mortality (18.2% at discharge, 27.3% at 6 months) and of complications and re-interventions for all cancers assessed, especially rectal cancer (18.4% re-interventions at 6 months), were identified.Conclusions: the study of the variability identified will require adequate risk-adjustment and should take into account different structure factors. It is necessary that information included in medical records be improved.Key words: Digestive cancer. Surgery. Medical practice variations. Structure, process, and outcomes of care. INTRODUCTIONOne of the aspects that is most debated in oncologic surgery and other fields (both surgical and medical procedures) is the relationship between the volume of patients having undergone surgery and clinical outcomes. It has been 30 years since the relationship between increased volume and improved outcomes was described (1). However, this relationship is not always observed, and the reasons why it occurs remain unknown. Several hypotheses, especially relating to surgeon-related technical factors (2-6), have been considered. However, if better outcomes are obtained in several different procedures or pathologies, healthcare organization and coordination factors should also be sought. This may be especially useful in the case of oncology, where it is necessary for professionals from different specialties to work together in tackling with diagnosis and treatment: surgery, oncology, as well as the site's central and general services.Most studies that have analyzed the influence of these physician-/center-related factors, particularly volume, on the variability of the process and outcome of cancer surgery are retrosp...

COPD is a clear risk factor for increased use of resources and adverse outcomes in patients undergoing intervention for colorectal cancer: a nationwide study in Spain

“…A previous study in our setting reported 19% prevalence of COPD in patients undergoing surgery for rectal cancer;13 however, the prevalence of COPD was lower in the aforementioned studies in more general surgical populations: 5% in Gupta et al’s cohort and 3.8% in Fields and Divino’s cohort. COPD is more common in cancer patients, in part, due to the history of smoking habit.…”

Tratamiento quirúrgico del cáncer de recto, revisión bibliográfica

“…Usando el electrocauterio o las tijeras, se rechazan estas estructuras posteriores y se deja intacto el mesorrecto. La disección anterior es tal vez una de las partes más difíciles en los hombres [32][33] . Se debe intentar incluir las dos hojas de la fascia de Denonvillier.…”

El proyecto EURECCA para el cáncer gastroesofágico

“…Se incluyeron un total de 1.121 pacientes: 233 esofagectomías y 888 gastrectomías. Al comparar estos datos con registros anteriores, se observó un drá stico descenso en el nú mero de hospitales que realizaban esta cirugía compleja, con el consiguiente incremento de las esofagectomías y gastrectomías por centro y añ o (de 3,4-7,4 y de 7,2-17, respectivamente) 6 . Se observó una disminució n de la morbilidad y la mortalidad postoperatorias, junto con un aumento de los accesos transtorá cicos y de las linfadenectomías ampliadas, así como una mayor uniformidad de los tratamientos multimodales 7,8 .…”