Pawel Mroczkowski

EURECCA colorectal: Multidisciplinary management: European consensus conference colon & rectum

BACKGROUND Care for patients with colon and rectal cancer has improved in the last 20years; however considerable variation still exists in cancer management and outcome between European countries. Large variation is also apparent between national guidelines and patterns of cancer care in Europe. Therefore, EURECCA, which is the acronym of European Registration of Cancer Care, is aiming at defining core treatment strategies and developing a European audit structure in order to improve the quality of care for all patients with colon and rectal cancer. In December 2012, the first multidisciplinary consensus conference about cancer of the colon and rectum was held. The expert panel consisted of representatives of European scientific organisations involved in cancer care of patients with colon and rectal cancer and representatives of national colorectal registries. METHODS The expert panel had delegates of the European Society of Surgical Oncology (ESSO), European Society for Radiotherapy & Oncology (ESTRO), European Society of Pathology (ESP), European Society for Medical Oncology (ESMO), European Society of Radiology (ESR), European Society of Coloproctology (ESCP), European CanCer Organisation (ECCO), European Oncology Nursing Society (EONS) and the European Colorectal Cancer Patient Organisation (EuropaColon), as well as delegates from national registries or audits. Consensus was achieved using the Delphi method. For the Delphi process, multidisciplinary experts were invited to comment and vote three web-based online voting rounds and to lecture on the subjects during the meeting (13th-15th December 2012). The sentences in the consensus document were available during the meeting and a televoting round during the conference by all participants was performed. This manuscript covers all sentences of the consensus document with the result of the voting. The consensus document represents sections on diagnostics, pathology, surgery, medical oncology, radiotherapy, and follow-up where applicable for treatment of colon cancer, rectal cancer and metastatic colorectal disease separately. Moreover, evidence based algorithms for diagnostics and treatment were composed which were also submitted to the Delphi process. RESULTS The total number of the voted sentences was 465. All chapters were voted on by at least 75% of the experts. Of the 465 sentences, 84% achieved large consensus, 6% achieved moderate consensus, and 7% resulted in minimum consensus. Only 3% was disagreed by more than 50% of the members. CONCLUSIONS Multidisciplinary consensus on key diagnostic and treatment issues for colon and rectal cancer management using the Delphi method was successful. This consensus document embodies the expertise of professionals from all disciplines involved in the care for patients with colon and rectal cancer. Diagnostic and treatment algorithms were developed to implement the current evidence and to define core treatment guidance for multidisciplinary team management of colon and rectal cancer throughout Europe.

EURECCA colorectal: Multidisciplinary Mission statement on better care for patients with colon and rectal cancer in Europe

BACKGROUND Care for patients with colon and rectal cancer has improved in the last twenty years however still considerable variation exists in cancer management and outcome between European countries. Therefore, EURECCA, which is the acronym of European Registration of cancer care, is aiming at defining core treatment strategies and developing a European audit structure in order to improve the quality of care for all patients with colon and rectal cancer. In December 2012 the first multidisciplinary consensus conference about colon and rectum was held looking for multidisciplinary consensus. The expert panel consisted of representatives of European scientific organisations involved in cancer care of patients with colon and rectal cancer and representatives of national colorectal registries. METHODS The expert panel had delegates of the European Society of Surgical Oncology (ESSO), European Society for Radiotherapy & Oncology (ESTRO), European Society of Pathology (ESP), European Society for Medical Oncology (ESMO), European Society of Radiology (ESR), European Society of Coloproctology (ESCP), European CanCer Organisation (ECCO), European Oncology Nursing Society (EONS) and the European Colorectal Cancer Patient Organisation (EuropaColon), as well as delegates from national registries or audits. Experts commented and voted on the two web-based online voting rounds before the meeting (between 4th and 25th October and between the 20th November and 3rd December 2012) as well as one online round after the meeting (4th-20th March 2013) and were invited to lecture on the subjects during the meeting (13th-15th December 2012). The sentences in the consensus document were available during the meeting and a televoting round during the conference by all participants was performed. All sentences that were voted on are available on the EURECCA website www.canceraudit.eu. The consensus document was divided in sections describing evidence based algorithms of diagnostics, pathology, surgery, medical oncology, radiotherapy, and follow-up where applicable for treatment of colon cancer, rectal cancer and stage IV separately. Consensus was achieved using the Delphi method. RESULTS The total number of the voted sentences was 465. All chapters were voted on by at least 75% of the experts. Of the 465 sentences, 84% achieved large consensus, 6% achieved moderate consensus, and 7% resulted in minimum consensus. Only 3% was disagreed by more than 50% of the members. CONCLUSIONS It is feasible to achieve European Consensus on key diagnostic and treatment issues using the Delphi method. This consensus embodies the expertise of professionals from all disciplines involved in the care for patients with colon and rectal cancer. Diagnostic and treatment algorithms were developed to implement the current evidence and to define core treatment guidance for multidisciplinary team management of colon and rectal cancer throughout Europe.

Primary appendiceal carcinoma – Epidemiology, surgery and survival: Results of a German multi-center study

BACKGROUND While carcinoma of the colon is a common malignancy, primary carcinoma of the appendix is rare. Many retrospective reviews outlined experience from different centers on appendiceal neoplasms. However, the study population is often small because it is so rare. The aim of this study was to analyze the type of surgery and survival of patients with appendiceal malignancies using data from a German multi-center observational study (31 341 patients). METHODS During a five-year period, 196 consecutive patients with malignant appendiceal tumors were distributed into four groups: appendiceal carcinoids, adenocarcinoma, mucinous adenocarcinoma and adenosquamous carcinoma. The following parameters were analyzed: demographics, clinical presentation, comorbidities, type and appropriateness of surgery, final pathology and survival. RESULTS Adenocarcinoma had the highest incidence (50.5%). The most common presentation was that of acute appendicitis. Mean age at presentation was youngest for carcinoid tumors. Carcinoid tumors had lowest tumor size and localized disease was present in 72.9%. Metastatic spread at presentation was highest for adenosquamous and mucinous adenocarcinoma and each had a distinct pattern. Right hemicolectomy was performed in 71.4%, limited resection in 11.7%. Overall 5-year survival was 83.1% for carcinoid vs. 49.2% for non-carcinoid tumors. Histological subtype and tumor stage significantly affected survival. CONCLUSIONS Long-term outcome of carcinoid tumors is superior to non-carcinoid neoplasms. Among all appendiceal neoplasms, adenosquamous carcinoma is the rarest histological subtype which is most commonly associated with advanced tumor stage and worst prognosis. Appropriate oncologic resection is being performed in a significant percentage of cases in Germany. However, the high rate of right hemicolectomy in patients with small carcinoid tumors needs to be critically discussed.

Experts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: Science, opinions and experiences from the experts of surgery

The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process. Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer. Surgery is the cornerstone of curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?

Consensus statementExperts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: Science, opinions and experiences from the experts of surgery

The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process. Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer. Surgery is the cornerstone of curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?

Surgical practices for malignant left colonic obstruction in Germany

AIM Data from the multicentric observation study Kolon/Rektum-Karzinome (Primärtumor) (primary colorectal carcinoma) are adduced to assess the status of surgical treatment of this condition in Germany and to compare different operative approaches in the emergency treatment of obstructive left-sided colon cancer, especially diversion (Hartmanns procedure) and primary anastomosis. PATIENTS AND METHODS Out of 15,911 patients with cancer of the left colon, recorded between 01.01.2000 and 31.12.2004, a total of 743 patients underwent emergency surgery for an obstructive tumour, performed as a radical resection. These patients were compared in respect of their risk profile and postoperative result. RESULTS In 57.9% (n=430) a one-stage operation (Group I), in 11.7% (n=87) a primary anastomosis with protective stoma (Group II), and in 30.4% (n=226), Hartmanns procedure (Group III) was performed. In Group III more patients were male, overweight and multimorbid, and more had advanced-stage tumours. The morbidity and hospital mortality (overall hospital mortality, 7.7%; n=57) did not differ significantly between the groups. The insertion of a protective stoma did not affect the rate of anastomotic insufficiency (Group I, 7%; Group II, 8.0%). CONCLUSIONS Primary anastomosis for emergency left colon carcinoma obstruction should only be regarded as indicated in cases where the risk profile is favourable. Our results suggest that in advanced obstruction and in high-risk cases Hartmanns procedure should be used. A protective stoma did not appear to confer any advantage.

Quality assessment of colorectal cancer care: an international online model

Aim  We present an alternative approach to quality assessment in colorectal cancer, enabling a direct comparison of improvement at the level of the care provider.

Risk factors, short and long term outcome of anastomotic leaks in rectal cancer

Background An anastomotic leak (AL) after colorectal surgery is one major reason for postoperative morbidity and mortality. There is growing evidence that AL affects short and long term outcome. This prospective German multicentre study aims to identify risk factors for AL and quantify effects on short and long term course after rectal cancer surgery. Methods From 1 January 2000 to 31 December 2010 381 hospitals attributed patients to the prospective multicentre study Quality Assurance in Colorectal Cancer managed by the Otto-von-Guericke-University Magdeburg (Germany). Included were 17 867 patients with histopathologically confirmed rectal carcinoma and primary anastomosis. Risk factor analysis included 13 items of demographic patient data, surgical course, hospital volume und tumour stage. Results In 2 134 (11.9%) patients an AL was diagnosed. Overall hospital mortality was 2.1% (with AL 7.5%, without AL 1.4%; p < 0.0001). In multivariate analysis male gender, ASA-classification ≥III, smoking history, alcohol history, intraoperative blood transfusion, no protective ileostomy, UICC-stage and height of tumour were independent risk factors. Overall survival (OS) was significantly shorter for patients with AL (UICC I-III; UICC I, II or III - each p < 0.0001). Disease free survival (DFS) was significantly shorter for patients with AL in UICC I-III; UICC II or UICC III (each p < 0.001). Rate of local relapse was not significantly affected by occurrence of AL. Conclusion In this study patients with AL had a significantly worse OS. This was mainly due to an increased in hospital mortality. DFS was also negatively affected by AL whereas local relapse was not. This emphasizes the importance of successful treatment of AL related problems during the initial hospital stay.

Low‐volume centre vs high‐volume: the role of a quality assurance programme in colon cancer surgery

Aim  The study aimed to determine whether hospitals within a quality assurance programme have outcomes of colon cancer surgery related to volume.

Laparoscopy in the surgical treatment of rectal cancer in Germany 2000–2009

Aim  The goal of this registry study was to compare open surgery with planned laparoscopy and then with laparoscopic to open conversion for rectal cancer surgery.