NORCCAG audit report 2011:mortality, survival and reconstructive

rectal surgery

David W Borowski

for the members of the Northern Region Colorectal Cancer Audit Group (NORCCAG)

Mortality & Survival1 August 2007 – 31 July 2010

Abdominal resective surgery (n=3,526)Excluding TEMS, polypectomy, stoma only

operations and per-anal excisions

Patient-related factors

9 Cancer units Individual surgeons (mortality)

> 20 CRC operations p.a.Pooled for low-volume surgeons

Mortality & SurvivalElective mortality

< 7 %

Emergency mortality< 20 %

Colorectal specialistsMDT membership (2-3 surgeons / 200,000)Caseload (>20 curative resections / year)

Mortality 169/3,526 (4.8%)Deaths % p*

Sex 0.251

Female 63 4.3

Male 106 5.1

Age <0.001

< 65 18 1.6

65-74 39 3.7

75-84 76 8.0

≥ 85 17 9.2

Unknown 19 9.5

ASA grade <0.001

I 2 0.5

II 32 2.1

III 70 7.6

IV 29 23.8

V 3 75.0

unknown 33 6.0

Deaths % p*

Tumour site 0.011

Right colon 82 6.2

Left colon 50 4.1

Rectum 37 3.8

Dukes’ stage <0.001

A 17 2.9

B 56 4.9

C 54 4.7

“D” 26 10.4

Unknown 16 4.0

Urgency <0.001

Elective / planned 96 3.4

Emergency / urgent 57 12.6

Unknown 16 7.5

Mortality 169/3,526 (4.8%)OR 95% CI p

Sex

Female 1.0

Male 1.31 0.93 – 1.84 0.124

Age

< 65 1.0

65-74 1.84 1.03 – 3.31 0.041

75-84 3.84 2.22 – 6.66 <0.001

≥ 85 3.01 1.44 – 6.28 0.003

Unknown 4.24 2.11 – 8.55 <0.001

ASA grade

I 1.0

II 2.81 0.67 – 11.83 0.159

III 7.47 1.79 – 31.1 0.006

IV 22.63 5.18 – 98.95 <0.001

V 203.18 13.0 – 3,18 <0.001

unknown 6.30 1.48 – 26.74 0.013

OR 95% CI p

Tumour site

Right colon 1.0

Left colon 0.84 0.57 – 1.24 0.384

Rectum 1.07 0.69 – 1.68 0.751

Dukes’ stage

A 1.0

B 1.28 0.71 – 2.28 0.410

C 1.26 0.70 – 2.24 0.442

“D” 2.59 1.30 – 5.16 0.007

Unknown 1.36 0.66 – 2.80 0.400

Urgency

Elective / planned 1.0

Emergency / urgent 2.45 1.65 – 3.65 <0.001

Unknown 1.90 1.05 – 3.46 0.035

Cancer unitsUnit All resections Elective Emergency

Deaths Resections % Deaths Resections % Deaths Resections %

1 8 343 2.3 6 284 2.1 1 37 2.7

2 32 554 5.8 14 451 3.1 13 63 20.6

5 25 402 6.2 9 318 2.8 15 80 18.8

7 31 550 5.6 22 473 4.7 7 60 11.7

9 16 294 5.4 9 245 3.7 6 37 16.2

10 20 451 4.4 12 339 3.5 6 56 10.7

11 9 222 4.1 6 183 3.3 3 24 12.5

12 13 289 4.5 9 241 3.7 3 44 6.8

13 15 421 3.6 9 326 2.8 3 53 5.7

All 169 3526 4.8 96 2860 3.4 57 454 12.6

Consultant teamsConsultant All resections Elective Emergency

Code Deaths Resections % Deaths Resections % Deaths Resections %

172 10 145 6.9 5 124 4.0 4 14 28.6

2359 4 73 5.5 4 66 6.1 0 3 0.0

3025 0 68 0.0 0 58 0.0 0 5 0.0

3140 5 102 4.9 3 97 3.1 1 2 50.0

5436 6 67 9.0 6 62 9.7 0 4 0.0

-//- -//- -//- -//- -//- -//- -//- -//- -//- -//-

27271 3 92 3.3 2 80 2.5 0 11 0.0

28144 2 71 2.8 2 59 3.4 0 9 0.0

Pool 65 1287 5.1 23 999 2.3 34 202 16.8

missing 16 263 6.1 9 209 4.3 6 42 14.3

Total 169 3526 4.8 96 2860 3.4 57 454 12.6

Consultant information

92.599.710099.599.3

22.5

98.799.799.294.7

0%

20%

40%

60%

80%

100%

1 2 5 7 9 10 11 12 13 Total

Cancer Unit

Consultant details available Consultant details NOT available

2-year Survival 79.1%

Days survival

8007006005004003002001000

% S

urv

ival

1.0

.9

.8

.7

.6

.5

Survival

Censored

2-year Survival 79.1%

Days survival

8007006005004003002001000

% S

urv

ival

1.0

.9

.8

.7

.6

.5

.4

Dukes stage

unknown

unknown-censored

Dukes' D

Dukes' D-censored

Dukes' C

Dukes' C-censored

Dukes' B

Dukes' B-censored

Dukes' A

Dukes' A-censored

Cancer unitsUnit All resections Elective Emergency

Deaths Alive* % OS Deaths Alive* % OS Deaths Alive* % OS

1 44 99 79.5 33 75 80.4 7 10 72.5

2 86 156 80.1 49 132 85.6 23 7 52.1

5 51 112 84.6 22 102 91.3 27 8 60.7

7 93 160 77.4 71 144 79.3 18 12 62.7

9 42 60 82.5 28 46 85.0 13 5 62.3

10 87 116 72.8 48 72 78.8 16 13 59.9

11 48 57 71.9 31 42 76.2 15 2 29.9

12 35 69 83.3 20 60 88.3 13 8 61.4

13 58 105 80.4 33 67 84.7 16 5 57.4

All 544 934 79.1 335 740 83.3 148 70 57.9

* Numbers at risk remaining in the analysis at 2 years, excluding censored patients

Rectal restoration1 April 2006 – 31 July 2010

n=2,217 RC patients1,752 (79.0%) surgery

1,334 (76.1%) abdominal resections

< 30 % APER (+ Hartmanns)

Rectal surgery (n=1,752)Operation Abdominal resection Local Excision No resection Unknown

Anterior Resection 322 (24.1%)

Anterior Resection & covering stoma 490 (36.7%)

APER 342 (25.6%)

Hartmanns 100 (7.5%)

Panproctocolectomy 16 (1.2%)

Per-anal Excision / Polypectomy /

TEMS 88 (100%)

Stoma only 86 (42.3%)

Stent 28 (13.7%)

Other 64 (4.8%) 89 (43.8%)

Not given 127 (100%)

All 1,334 88 203 127

Rectal surgery (n=1,752)

76.173.765.7

86.772.7

84.483.079.574.473.2

11.613.1

16.9

8.0

8.3

9.48.58.6

14.415.0

7.21.513.4

3.517.8

3.15.41.15.69.2

0%

20%

40%

60%

80%

100%

1 2 5 7 9 10 11 12 13 Total

Cancer Unit

Abdominal resection Local excisionNo resection Operative data missing

Rectal surgery (n=1,334)

73.2 68.377.6

60.5 60.549.4

62.2 61.471.2

64.7

35.328.8

38.637.850.6

39.539.5

22.431.726.8

0%

20%

40%

60%

80%

100%

1 2 5 7 9 10 11 12 13 Total

Cancer Unit

Restorative rectal resection Permanent stoma formation

SummaryOperative mortality rates vary throughout the region between

surgeons and cancer units, but are generally within the accepted range

2-year survival rates also show variation between cancer units

Rates of rectal restoration vary greatly between cancer units, and appear to be outside the recommended minimum of 70% in some units

Inaccurrate and incomplete data collection complicates, and potentially biases, the data analysis