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Colorectal Update Ohio Chapter- ACS Colorectal Update Ohio Chapter- ACS William C. Cirocco, MD, FACS, FASCRS FINANCIAL DISCLOSURES NONE The AMERICAN PROCTOLOGIC SOCIETY (APS) d/b/a The AMERICAN SOCIETY of COLON & RECTAL SURGEONS (ASCRS) THE AMERICAN PROCTOLOGIC SOCIETY (APS)* 1899 AMA Meeting- Columbus, OH (Joseph Mathews AMA President ’99-’00) June 6 (Tuesday) - Great Southern Hotel (High & Main Streets) June 7-8 (Wednesday/Thursday)-Hotel Chittenden & St. Anthony’s Hospital-clinicals 1949 APS 50th Meeting (Columbus, OH) May 31- June 4 Deshler-Wallick Hotel *1st APS President Joseph Mathews preferred the term “rectum and colon” instead because it clearly stated what the specialty was about (1923) American Proctologic Society (APS) ▪ Purpose - to cultivate and promote knowledge of whatever relates to disease of the colon and rectum ▪ Make care of these maladies an acceptable part of practice (previously shunned by physicians) ▪ Stop quacks and charlatans FOUNDERS OF THE APS Joseph M. Mathews, Louisville APS President (1899-00,1913-14) James P. Tuttle, New York City(Vice Pres) APS President (1900-1901) Thomas C. Martin, Cleveland- OR APS President (1901-1902) *Samuel T. Earle, Baltimore - OR APS President (1902-1903) Wm M. Beach, Pittsburgh (Sec/Treasurer)APS President (1903-1904) *J. Rawson Pennington, Chicago- OR APS President (1904-1905) Lewis A. Adler, Jr., Philadelphia APS President (1905-1906) Samuel G. Gant, Kansas City APS President (1906-1907) *A. Bennett Cooke, Nashville APS President (1907-1908) George B. Evans, Dayton APS President (1908-1909) George J. Cook, Indianapolis APS President (1910-1911) B. Merrill Ricketts, Cincinnati Leon Straus, St. Louis Others: Charles C. Allison-Omaha, Joseph B. Bacon-Chicago,Krause-Cinc * “Board of Counselors” OR- in charge of operations Programme of the 1st Meeting of Rectal Specialists at Columbus, O. June 6-9, 1899 ▪ “The importance of giving rectal diseases special study”- J Mathews, Louisville ▪ “Pruritus Ani”- James P. Tuttle, New York City ▪ “Surgical treatment of non-malignant stricture of the rectum”-J. Bacon, Chicago ▪ “A modification of Whitehead’s operation for hemorrhoids”-S. Earle Jr, Baltimore ▪ The proctoscope as a factor in Dx/Rx of simple rectal ulceration-Strauss,St. Louis ▪ “A consideration of the various forms of ulceration of the rectum”- Adler, Jr, Phila ▪ “Rectal carcinoma- excision and subsequent colotomy”- B.M. Ricketts, Cincinnati ▪ “The limitations of the Kraske operation”- Charles C. Allison, Omaha ▪ “The act of defecation”- Thomas Charles Martin, Cleveland ▪ “Constipation as considered from the standpoint of the proctologist”- A. Bennett Cooke, Nashville ▪ Paper and Exhibition of new instruments- Samuel G. Gant, Kansas City ▪ “Rectal adenomata”- William M. Beach, Pittsburgh Highlights of the APS Meeting ▪ Methods to inspect the rectum with new ‘mechanical devices’ ▪ X-ray methods to examine the intestine using Bismuth (Pennington, Chicago) ▪ Live clinic ▪ Operations (St. Anthony’s Hospital): Hemorrhoids (Sam Earle, Baltimore) Early plans of the APS ▪ Grow membership ▪ Establish a journal (Cooke 1908, Murray 1910, Terrell 1923) ▪ Promote research and education in the nation’s medical schools ▪ Provide specialty training ▪ Create an objective certification process for specialists AMERICAN BOARD of PROCTOLOGY (ABP) 1935- ABP incorporated 1937- American Board of Surgery (ABS) incorporated 1938- application to ABMS deferred to ABS 1940- approved as subsidiary board of ABS 1949- petition granted – 17th independent board of ABMS 1949 1940 Recognition 1938 by ABS as the 17th Primary/ 1937 ABP Independent 1935 ABP approved ABMS Board as ABS American application 1933 Subsidiary Board of to ABMS 1930 American deferred to Board Board of Surgery (ABS) American ABS Proctology incorporated/ Board of th (ABP) ABMS 12 Medical ACS incorporated Primary Board officially Specialties recognizes (ABMS) Proctology organized as a specialty AMERICAN BOARD of MEDICAL SPECIALTIES (ABMS)- 24 PRIMARY BOARDS 1933 Founding Members (Ophthalmology, Otolaryngology, OBGYN, Derm) 1935 Orthopedic Surg, Pediatrics, Psych & Neurology, Radiology, Urology 1936 Internal Medicine, Pathology 1937 American Board of Surgery (ABS) - #12 1940 Neurological Surgery 1941 Anesthesiology, Plastic Surgery 1947 Phys Med & Rehab 1949 American Board of Proctology (ABP)- #17, Preventive Medicine 1969 Family Medicine 1971 Allergy & Immunology, Nuclear Medicine, Thoracic Surgery 1979 Emergency Medicine 1991 Medical Genetics RECTAL CANCER National Accreditation Program for Rectal Cancer (NAPRC) 22 Local Recurrence in Rectal Cancer: 1980-2000s Colostomy Rates Year(s) n Tumor Colostomy Source Country distance Rate from anal verge Norwegian 1993- 2136 Norway <12 cm 38% Rectal Cancer 1999 Project Dutch Trial 1996- 1805 Netherlands/Sweden <15 cm 32% 1999 MRC CRO-7 1998- 1350 UK/Canada/NZ/SAF <15 cm 35% 2005 German Trial 1994- 799 Germany <16 cm 25% 2002 Trans-Tasman 2001- 323 Australia/New <12 cm 33% 2006 Zealand AHRQ and 2002- 19,912 USA rectum 50% OSHPD (CA) 2004 Variability in the Outcomes of Rectal Cancer in the USA ▪ What operation is being done? ▪ Where? ▪ Who ? ▪ Is treatment evidence-based? ▪ Outcomes? WHAT? University of Minnesota Study 2007 ▪ NATIONWIDE INPATIENT SAMPLE ▪ 20% stratified random sample of U.S. inpatients ▪ 1988-2003 41,631 pts radical proctectomy 16,510 (40%) 25,121 (60%) sphincter-sparing colostomy ▪ Increase in sphincter-preservation rate from 27% in 1988 to 48% in 2003 ▪ Rate flat after 1999 ▪ Elderly, black, men, Medicaid, low-income zip code: predicted colostomy ▪ “most radical resections for rectal cancer in U.S. hospitals result in a colostomy” Dis Colon Rectum 2007; 50:1119-1127 WHERE? How Experienced (in rectal cancer) is the Typical U.S. Hospital? Answer: ▪ NOT VERY! hospitals CoC ▪ 70% of hospitals treat < 20 patients/year Percentage of Percentage (n=1327) ▪ Only 30% of hospitals are “high volume” by common definition (>20 patients/year) ▪ Only 6% of hospitals treat > 50 patients/year 29 Are U.S. Rectal Cancer Patients Being Shifted to High Volume Centers? Answer: rectal patientsrectal ▪ No CoC ▪ More than half of patients treated in hospitals that treat (n=21,393) Percentage of Percentage <30 cases/year ▪ Only 25% of patients treated in the highest volume centers 30 Only 30% patients 72% of hospitals treated in “high” “low” volume volume hospitals Hospital Volume Outcome Low Medium High p value Yearly case volume (avg) 1-5 6-10 11-24 Number of hospitals 232 65 24 Number of patients 2364 2686 2137 Mortality (%) 2.1 1.1 0.9 <0.001 Complications (%) 22 24 20 0.709 Sphincter preservation (%) 51 55 64 <0.001 Length of stay (mean # days) 9.7 9.2 8.8 <0.001 CALIFORNIA Office of Statewide Health Planning and Development database (2000-2005) Mortality, colostomy rate, and LOS higher in low volume hospitals WHO? ▪ 11 states’ hospital discharge data 2003-2004* ▪ >7500 proctectomies by 2600 surgeons ▪ 40% of surgeons performed ONLY non-restorative procedures (APR) ! ▪ higher mortality rates (2x) and longer LOS (2 days) ▪ “Restorative” (LAR) surgeons were specialized by virtue of more pelvic pouch and anorectal operations * Dis Colon Rectum 2011; 54:1210-5 ▪ Hospital discharge data from 21 states with county-level place of residence information (2002-04) ▪ 20,000 proctectomies ▪ 50% of cases non-restorative (APR) ▪ 26% counties > 60% APR rate ▪ Only 20% of counties with colostomy rate <40% Agency for Healthcare Research and Quality Office of Statewide Health Planning and Development Calif. Dis Colon Rectum 2010; 53:874-880 ▪ Tumor characteristics from SEER, ▪ “High Stoma Counties”(26% of screening rates from Medicare, all counties >60% APR rate) hospital characteristics from AHA, and surgeon specialty from ASCRS and SSO rosters ▪ Defined as >60% permanent colostomy (APR) rate (mean 71%) ▪ Less likely to have MRI or PET scanner “data support concept that surgeon ▪ Less likely to be teaching specialization and familiarity with hospital rectal cancer treatment are important ▪ Significantly fewer specialty determinants of rectal cancer care” surgeons Dis Colon Rectum 2011; 54:207-13 What are the Oncologic Outcomes of Rectal Cancer Treatment in the U.S.? ▪ Local recurrence rates ▪ Disease-free survival Circumferential Resection Margin (CRM) ▪ Closest measured distance from outermost edge of tumor or involved lymph node to the mesorectal fascia (<1 mm = “involved”)* ▪ Powerful prognostic factor for local and distant recurrence and survival** ▪ Convenient and immediate quality measure for surgical technique and pre-treatment decision-making process J Clin Oncol 2008;26:303-312 * College of American Pathologists 2011 **Nagtegaal and Quirke. J Clin Oncol 2008;26:303-312 National Cancer Data Base (NCDB): +CRM data ▪ NCDB 2010-2011 ▪ Clinical stage I-III ▪ N=16,619 patients ▪ 17% with + CRM ▪ Variation by clinical stage and operation type ▪ No variation by facility type, volume, or NCRT Rickles, et al. Annals of Surgery Establish CRM Tumor spread at CRM Satellite tumor deposits < 1mm of CRM = Positive CRM Nagtegaal. J Clin Oncol 2005 Grading of the Specimen after TME Mesorectal plane (a): The rectum is dissected from the pelvis en bloc with the mesorectum and the totality of its lymph nodes- resulting in a complete bulky mesorectum with only minor irregularities. Intramesorectal plane (b): The mesorectum is disrupted during the dissection and irregularities can be seen on its surface without exposure of the muscularis propria. Muscularis propria plane (c):The muscularis propria is exposed, and the circumferential margin of resection
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