This study aimed to investigate in a multicenter cohort study the radicality of colorectal cancer resections, to assess the oncosurgical quality of colorectal specimens, and to compare the performance between centers.

Objective: The decreasing proportion of physicians of Swiss origin and the increasing number of part-time jobs in operative medicine might lead to a shortage of physicians in operative disciplines in Switzerland. The objective of the present study was to analyze the current demographic situation in operative medicine in Switzerland. Methods: During the summer of 2011, a 19-item anonymous electronic questionnaire was mailed to all directors of departments in operative medicine in Switzerland. The questionnaire was designed to gather data about the characteristics of the participating departments, the demographics (including the appointment (consultant, attending or resident), the proportion of female and foreign physicians, the latter’s origin, and the number of part-time jobs with a working time between 20 and 90%), and the proportion of vacant posts. Results: Of 775 questionnaires mailed to all directors of departments in operative medicine in Switzerland, 183 (24%) were returned. Overall, 40% were female, and 42% foreign physicians. The proportion of part-time jobs amounted to 17%. Vacant posts were found in 2%. Conclusions: An expansion of study places at the medical universities and of the incentives for the incumbents in operative medicine is necessary to avert a shortage of physicians in Switzerland.

Background The sentinel lymph node (SLN) procedure has the potential to provide relevant improvement in nodal staging in colon cancer patients. However, there remains room for improvement for SLN identification and sensitivity. Therefore, the objective of the present investigation was to analyze factors influencing the success of the SLN procedure in colon cancer patients. Methods One hundred seventy-four consecutive colon cancer patients were prospectively enrolled in this multicenter study and underwent in vivo SLN procedure with isosulfan blue 1 % followed by open standard oncologic colon resection. Several patient-, tumor-, and procedure-related factors possibly influencing the SLN identification and sensitivity were analyzed. Results Sentinel lymph node identification rate and accuracy were 89.1 and 83.9 %, respectively. Successful identification of SLN was significantly associated with the intraoperative visualization of blue lymphatic vessels ( p < 0.001) and with female gender ( p = 0.024). True positive SLN results were significantly associated with higher numbers of SLN ( p = 0.026) and with pN2 stage ( p = 0.004). There was a trend toward better sensitivity in patients with lower body mass index (BMI) ( p = 0.050). Conclusions The success of the SLN procedure in colon cancer patients depends on both procedure-related factors (intraoperative visualization of blue lymphatic vessels, high number of SLN identified) and patient factors (gender, BMI). While patient factors can not be influenced, intraoperative visualization of blue lymphatics and identification of high numbers of SLN are key for a successful SLN procedure.

Solitary fibrous tumors are predominantly benign and are most commonly found in the thoracic cavity and pleura; while reports exist in the literature of malignant solitary fibrous tumors and those located in extrathoracic organs, these cases are considered extremely rare. Herein, a case is reported of a malignant solitary fibrous tumor involving the liver that was diagnosed and treated in a 62-year-old woman. The patient presented with complaints of upper abdominal pain and unintentional weight loss. Computed tomography scan of the abdomen revealed a remarkably large mass, measuring 15 cm × 10 cm × 20 cm, which appeared to be unrelated to any particular organ. The intraoperative finding of a wide communication with the left liver suggested hepatic origin, and served as an indicator for tumor resection via left hemihepatectomy. The diagnosis of solitary fibrous tumor and its malignant nature was confirmed by histological and immunohistochemical examination of the resected tissues. Hepatic solitary fibrous tumor is very rare, and surgery remains the mainstay of treatment. Due to limited reports of such tumors in the literature, little can be said about the benefit of adjuvant therapy and prognosis for the rare cases with malignant histological findings.

In 2005 the Swiss government implemented new work-hour limitations for all residency programs in Switzerland, including a 50-hour weekly limit. The reduction in the working hours of doctors in training implicate an increase in their rest time and suggest an amelioration of doctors' clinical performance and consequently in patients' outcomes and safety - which was not detectable in a preliminary study at a large referral center in Switzerland. It remains elusive why work-hour restrictions did not improve patient safety. We are well advised to thoroughly examine and eliminate the known adverse effects of reduced work-hours to improve our patients' safety.

Objective: Despite the known positive impact of surgical checklists on morbidity and mortality rates, data on the implementation of checklists in Swiss operating rooms as well as the resulting experiences are missing. The present study evaluated the general use and design of checklists in operative medicine in Switzerland, the difficulties in introduction and the subjective impact on adverse events. Methods: An anonymous national survey of directors of adult departments in operative medicine in Switzerland was conducted during spring 2011. They were identified from the database of the Swiss college of surgeons (fmCh). The survey included questions about the use, type and content of the used checklists, the prevention of mixing up patients and the awareness of wrong site surgery. Results: Overall, 237/799 (29.7%) surveys were returned. At the time of the survey, 172/233 (73.8%) departments used surgical checklists (4 missing values). The median time needed for collecting data per patient was 60 (range 10-600) seconds. In all, 46/161 (28.6%) participants reported a subjective decrease of adverse events after the introduction of a surgical checklist (11 missing values). Out of 217 respondents, 62 (28.6%) knew of one event and 87 (40.1%) of more than one event of wrong site surgery (20 missing values). Conclusions: There is still room for improvement in the use of surgical checklists, which impresses, in regard to the time needed for data collection per patient, and which is not excessively time-consuming. However, acceptance problems of the majority of respondents during the introduction phase of surgical checklists vanished over time.

BACKGROUND:The value of the sentinel lymph node (SLN) procedure in colon cancer patients remains a matter of debate. The objective of this prospective, multicenter trial was 3-fold: to determine the identification rate and accuracy of the SLN procedure in patients with resectable colon cancer; to evaluate the learning curve of the SLN procedure; and to assess the extent of upstaging due to the SLN procedure. METHODS:One hundred seventy-four consecutive colon cancer patients were enrolled onto this prospective trial. They underwent an intraoperative SLN procedure with isosulfan blue 1% injected peritumorally followed by open standard colon resection with oncologic lymphadenectomy. Three levels of each SLN were stained with hematoxylin and eosin (H&E) and immunostained with the pancytokeratin marker AE1/AE3 if H&E was negative. RESULTS:SLN identification rate and accuracy were 89.1% and 83.9%, respectively. SLN were significantly more likely to contain tumor infiltrates than non-SLN (P < 0.001). Both SLN identification rate (P = 0.021) and the sensitivity of the procedure (P = 0.043) significantly improved with experience. The use of immunohistochemistry in SLN resulted in an upstaging of 15.4% (16 of 104) stage I and II patients considered node-negative in initial H&E analysis. CONCLUSIONS:The SLN procedure for colon cancer has good identification and accuracy rates, which further improve with increasing experience. Most importantly, the SLN procedure results in upstaging of >15% of node-negative patients. The potential advantage of performing the SLN procedure appears to be particularly important in these patients because they may potentially benefit from adjuvant therapy.

PRINCIPLES:Work-hour regulations for residency programmes in Switzerland, including a 50-hour weekly limit, were set in on 1 January 2005. Patient safety was one of the major arguments for the implementation. As the effect of the restriction of residency work hours on patient care in Switzerland has not yet been evaluated on objective data, the aim of the present study was to assess its impact by comparing the patients' morbidity and mortality before (2001-2004) and after (2005-2008) the implementation.METHODS:Retrospective analysis of records of the Spitalzentrum Biel AG, a large referral center classified according to the Swiss Medical Association, collected in the database of the Association for Quality Assurance in Surgery (AQC), a prospective database of consecutive patients undergoing surgical procedures in Switzerland. A selection of 2,686 patients with common surgeries, operated on by residents, was performed.RESULTS:There were 1,259 (46.9%) patients meeting our inclusion criteria who were admitted during the period before introduction of work-hour limitation and 1,427 (53.1%) patients after introduction. The in-hospital mortality and postoperative surgical complication rate were significantly higher after the reform (p <0.05 and p <0.01, respectively). No significant differences could be found concerning the overall intraoperative (p = 0.61) and postoperative medical complication frequencies (p = 0.08).CONCLUSIONS:The work-hour limitation implemented in Switzerland was not associated with surgical patient safety measure improvement for common surgeries (i.e., morbidity and mortality rate). Further research on a nationwide basis is needed to assess the value of the higher surgical complication and mortality rate.

Background/Aims: Temporary loop ileostomy is increasingly used in colorectal surgery but necessitates secondary closure. We evaluated postoperative complications, particularly nausea and vomiting, in patients with early, intermediate, or late elective ileostomy closure. Methods: We included all patients undergoing ileostomy closure from 2001 to 2008. Time from ileostomy construction to closure was classified as early (EC, <12 weeks), intermediate (IC, 12–18 weeks), and late (LC, >18 weeks). Using multivariable logistic regression, we compared the frequency of postoperative complications between the groups. Results: We included 134 patients (87 males; median age 71 years, range 29–91). Carcinoma of the rectum (n = 67, 50%) was the main reason for ileostomy construction. The median time to ileostomy closure was 103 days (range 8–461). Among patients with EC, IC, and LC, postoperative nausea occurred in 50.0, 73.1, and 78.6%, respectively (p = 0.006), and postoperative vomiting in 22.5, 57.7, and 59.5%, respectively (p = 0.001). Adjusting for important covariates, the odds ratio for postoperative nausea was 2.0 (95% CI 0.76–5.1) for IC and 4.1 (95% CI 1.2–14.3) for LC compared to EC (p = 0.069). For postoperative vomiting, adjusted odds ratios were 3.8 (95% CI 1.4–10.4) for IC and 4.6 (95% CI 1.4–15.5) for LC (p = 0.012). Other complications did not differ between the groups. Conclusions: These findings suggest that early ileostomy closure might reduce postoperative nausea and vomiting.

Colon cancer patients are at risk for recurrence. Recurrent disease might be curable if detected early by surveillance. However, data on the quality of surveillance are scarce. The objective of this study is to analyze the quality of surveillance after curative surgery for colon cancer among a cohort of Swiss patients.

The perioperative use of a single course adjuvant portal vein infusion chemotherapy in patients with potentially curable colorectal cancer has been shown to significantly improve overall survival but did not reduce the occurrence of liver metastases (SAKK 40/81) [Swiss Group for Clinical Cancer Research (SAKK) Lancet 345(8946):349–353, 1995]. The objective of the present prospective, three-arm randomized multicenter trial was to assess whether peripheral venous administration of adjuvant chemotherapy regimen based on 5-fluorouracil (5-FU) and mitomycin C decreases the occurrence of liver metastases as well as prolongs disease-free and overall survival.

BACKGROUND:Past studies have identified surgeon- and institution- related characteristics as prognostic factors in colorectal cancer surgery. The present work assesses the influence of the surgeon's and the hospital's caseload on long-term results of colorectal cancer surgery. METHODS:The data on 2706 patients from 2, randomized, colorectal cancer trials (Swiss Group for Clinical Cancer Research [SAKK] 40/81, SAKK 40/87) investigating adjuvant intraportal and systemic chemotherapy and 1 concurrent registration study (SAKK 40/88) were reviewed. A first analysis included 1809 eligible, nonmetastatic patients from all 3 studies. A subsequent subgroup analysis included 915 eligible patients from both randomized trials. Overall survival (OS), disease-free survival (DFS), and local recurrence (LR) were analyzed in multivariate models taking into account the possible effect of clustering. The main potential covariates were surgeon's annual caseload (>5 operations/year vs < or =5 operations/year), hospital's annual caseload (>26 operations/year vs < or =26 operations/year), tumor site, T stage, and nodal status. RESULTS:Primary analysis of all 3 studies combined found a high surgeon's caseload to be positively associated with OS (P = .025) and marginally with DFS (P = .058). Separate analysis for each trial, however, showed that a high surgeon's caseload was beneficial for outcome in both randomized trials but not in the registration study. A subgroup analysis of 915 patients with 376 rectal and 539 colonic primaries from both randomized trials, therefore, was performed. Neither age, gender, year of operation, adjuvant chemotherapy (intraportal vs systemic vs operation alone), hospital academic status (university vs non-university), training status of the surgeon (certified surgeon vs surgeon-in-training), nor inclusion in 1 of the 2 randomized trials (SAKK 40/81 vs SAKK 40/87) was a significant predictor of outcome. However, both high surgeon's and high hospital's annual caseloads were independent, beneficial prognostic factors for OS (P = .0003, P = .044) and DFS (P = .0008, P = .020), and marginally significant factors for LR (P = .057, P = .055). CONCLUSIONS:High surgeon's and hospital's annual caseloads are strong, independent prognostic factors for extending overall and disease-free survival and reducing the rate of local recurrence in 2 randomized colorectal cancer trials.

The individual surgeon is an independent prognostic factor for outcome in colorectal cancer surgery. The surgeon's learning curve is therefore directly related to the patient's outcome. The exact shape of the learning curve, however, is unknown. The present study reviewed supervision, training/teaching, specialization, surgeon's caseload, and hospital's caseload as the five main surgeon- and hospital-related confounding factors for outcome, and examined their influence on the learning curve as well as their interactions and prognostic significance. All five confounding factors were related to outcome. The highest degree of evidence, however, was found for training/teaching (introduction of total mesorectal excision), specialization in colorectal surgery (special interest, board-certification, specialized colorectal cancer units), and the surgeon's caseload. Five surgeon- and hospitalrelated factors directly influence the surgeon's learning curve and are therefore rightly considered predictors of outcome in colorectal cancer surgery. Improvements in supervision, training/teaching, specialization, the surgeon's caseload, and the hospital's caseload will therefore translate into enhanced patient outcome.

Deletions of chromosome band 18q21 appear with very high frequency in a variety of carcinomas, especially in colorectal cancer. Potent tumor suppressor genes located in this region encode transforming growth factor β (TGF‐β) signal transducers SMAD2 and SMAD4, and inactivation of either one leads to impaired TGF‐β‐mediated cell growth/apoptosis. Following the assignment of SMAD7 to 18q21, we first refined the SMAD7 gene position within this region by genetically mapping SMAD7 between SMAD2 and SMAD4. Further, to compare the respective frequencies of genetic alterations of these three SMAD genes in colorectal cancer, we undertook a large‐scale evaluation of the copy status of each of these genes on DNA samples from colorectal tumor biopsy material. Among a subset of 233 DNA samples for which data were available for all four genes, SMAD4, SMAD2, and the nearby gene DCC showed high deletion rates (66%, 64%, and 59%, respectively), whereas SMAD7 was deleted in only 48% of the tumors. Unexpectedly, we found some gene duplications; SMAD7 appears to be more frequently amplified (10%) than the three other genes (4–7%). Compiled data for SMAD genes in each tumor show that the most common combination (26% of all the tumors) consists of the simultaneous deletions of SMAD2 and SMAD4 associated with normal diploidy or even duplication of SMAD7. Since SMAD7 normally counteracts SMAD2 and SMAD4 in TGF‐β signaling, we hypothesize that the tumor might not benefit from simultaneous SMAD7 inactivation, thereby exerting selective pressure to retain or even to duplicate the SMAD7 gene. © 2001 Wiley‐Liss, Inc.

Untersucht wird beim colorectalen Carcinom die Wirkung einer perioperativen portalen Leberperfusion mit 5-Fluorouracil und Mitomycin C. Zur Zeit sind 409 Patienten auswertbar, 202 im Kontroll- und 207 im Behandlungsarm. Die bisherigen Resultate (März 87), bei einer Beobachtungszeit von 35 Monaten, zeigen im Behandlungsarm eine deutlich geringere Tendenz für Lebermetastasen (10,4% vs 6,3%), besonders auch in den Untergruppen (Colon 11,5% vs 6,8% und Dukes' C: 22,2% vs 6,9%). Entsprechend ist auch der Carcinom-Tod seltener (14,4% vs 12,1%; 15,8% vs 8,5% und 25,4% vs 15,5%). Die Beobachtungszeit ist für eine statistische Analyse noch zu kurz.