1. Exit Examinations European view M62 Coloproctolgy course, Huddersfield Lars Påhlman Dept. Surgery, Colorectal unit University Hospital, Uppsala, Sweden

2. Training in colorectal surgery Why so important  Bad results  Changes in treatment  The surgeon is important  Centralisation ?

3. Training in colorectal surgery What are the goals ?  Accreditation of surgeons  Accreditation of units  Accreditation of training program  Audit (national ?)

4. Training in colorectal surgery Which tools ?  UEMS - Section of Surgery  Division of different specialities  Coloproctology  EBSQ

5. Training in colorectal surgery European Board of Surgical Qualification = EBSQ

6. Training in colorectal surgery Division of Coloproctology  All European countries  2 members / country in the board  President + vice President  Secretary

7. Training in colorectal surgery EBSQ - Coloproctology  ~ 60 surgeons examined  From all around Europe  What is the value so far ?  Not accepted in many countries

8. Training in colorectal surgery EBSQ - Coloproctology  Yearly examinations at ESCP  Accreditation of units  ‘National’ examinations  Training program

9. Training in colorectal surgery National examinations  Lead by a national group with EBSQ - accreditation  Invited examiners from different European countries (EBSQ - accredited)

11. Training in colorectal surgery National training program The Swedish Rectal Cancer experience

12. Rectal Cancer in Sweden Bad results ? Until the end of the 80’s most centres had > 30 % local failure rate !

13. Rectal Cancer in Sweden Changes in treatment (early 80’s)  Radiotherapy !  3 major trials conducted  Centralisation ?

14. Rectal Cancer in Sweden Radiotherapy  Stockholm-Malmö trial 25 Gy preop. vs surgery alone  Uppsala trial 25 Gy preop. vs 60 Gy postop.  Swedish Rectal Cancer Trial 25 Gy preop. vs surgery alone

15. Rectal Cancer in Sweden Radiotherapy  Preop. superior to postop.  Local failure rates reduced from  30 % to 15 %  Overall survival benefit

16. Rectal Cancer in Sweden Centralisation ? In all Swedish trials 50 % of the patients were operated upon by a surgeon doing < 1 rectal cancer per year

17. Rectal Cancer in Sweden The ‘Heald’ - wave

18. Rectal Cancer in Sweden Centralisation ! (mid 90’s)  Small hospitals were closed  Workshops in TME - technique  Rectal cancer was not considered a procedure for general surgeons

19. Quality Assurance in Surgery Swedish Rectal Cancer Register Started 1995 after a long discussion regarding centralisation of rectal cancer surgery

20. Quality Assurance in Surgery Rectal Cancer ideal  End - points well defined  A common disease  Surgery an important treatment option

21. Quality Assurance in Surgery Rectal Cancer; end - points  Postop. morbidity and mortality  Sphincter preservation  Local recurrence  Survival  Quality of life

22. Quality Assurance in Surgery Rectal Cancer; how ?  Meticulous audit  Independent observer  Comparing results with others  Quality register

23. Swedish Rectal Cancer Register Organisation  Six health-care regions  Oncology centre in each region  All Department of Surgery  One responsible surgeon  Swedish cancer register

24. Swedish Rectal Cancer Register Organisation  Each region has it’s own register  Regional differences  Local research project  Same “mini - data base”

25. Swedish Rectal Cancer Register Data collection  Patients reported at discharge  Report to the cancer register by Surgeons and pathologists  The oncology centre in the region checks with the cancer register

26. Swedish Rectal Cancer Register Data base  Preop. work - out  Treatment (surgery, chemo, irradiation)  Postop. complications  Late complications  Oncological outcome

27. Swedish Rectal Cancer Register Organisation Follow - up  At minimum every year  Each time something happens  If not reported the Oncology centre sends a reminder

28. Swedish Rectal Cancer Register Data report Feed - back to surgeons  National report every year  Data divided for each region  Data for the specific surgical department

29. Swedish Rectal Cancer Register Data report 1995 - 2004   15,000 patients (  1,500 yearly)  Base - line data  Trends in treatment  5-year oncological data

30. Swedish Rectal Cancer Register Important data from 1997  Total number 1,414  48 % anterior resections  24 % abdominoperineal resections  35 % overall postop. complications  10 % re-operations within 30 days  8 % local recurrence rate  2.5 % postop. mortality

31. Survival (all patients) Relative Crude

32. Relative survival Stage I Stage II

33. Relative survival Stage III Stage IV

34. Local recurrence % (1995 - 97) All patientsR 0 surgery

35. Dutch trial - Local recurrence Patients with R 0 (n=1789) 5.8% vs 11.4% p < 0.001 TME alone RT + TME Resectable rectal cancer !

36. Quality Assurance in Surgery How to evaluate results ?  Look for changes in trends  Are guide - lines followed ?  Identify ‘bad’ units  Identify ‘bad’ doctors

37. Irrigation of the rectal stump

38. Swedish Rectal Cancer Register 5 years follow-up (1995 - 97) Local recurrence rate Irrigation Ant. Resection Hartmann Yes 96 / 1464 7 % 8 / 71 11 % No 44 / 398 11 % 11 / 115 10 % Unknown 7 / 65 11 % 1 / 17 6 % p < 0.001 n.s.

39. Dutch trial - Local recurrence rate Level from the anal verge 10.5% vs 11.9% p = 0.53 0 - 5 cm 6 - 10 cm11 - 15 cm

40. Local recurrence % (1995 - 1997) 0 - 6 cm7 - 15 cm

41. Quality Assurance in Surgery How to interfere ?  Propose training  Supervise surgery  Introduce a ‘driving - licence’ in rectal cancer surgery

45. Quality Assurance in Surgery Future  Mandatory to know the results  New generation of patients  Only the best unit will survive  Quality register the only way !

46. Rectal Cancer in Sweden A tremendous change ! From > 30 % local failure rate at the end of the 80’s in most centres to  8 % in the mid 90’s. Survival improved !

47. Rectal Cancer A tremendous change ! The same change in treatment policy has been found in Norway with similar training and audit

48. Adequate surgical resection for rectal cancer: the surgeon’s view Lars Påhlman Dept Surgery, Colorectal unit University Hospital, Uppsala, Sweden

49. It is dangerous to smoke