Zusammenfassung
Diagnostik und Therapie des Rektumkarzinoms bedürfen einer laufenden Qualitätssicherung.
Für eine zusammenfassende Beurteilung wurden Qualitätsindikatoren in Form eines sog.
Indikatorprofils zusammengestellt. Dabei wurden solche Indikatoren ausgewählt, bei
denen Abweichungen vom Qualitätsziel in einem nennenswerten Anteil zu erwarten und
die vor allem für das Outcome maßgeblich sind. Für die Beurteilung der klinischen
Diagnostik wurden die Häufigkeit der Festlegung der prätherapeutischen T-, N- und
M-Kategorien und der Anteil von pT 1-Tumoren, für die pathologische Diagnostik die
Zahl histologisch untersuchter Lymphknoten und der Anteil lymphknotenpositiver Patienten
ausgewählt. Von Indikatoren der Prozessqualität der Therapie wurden aufgenommen: Anteile
von Tumorentfernung, definitiver Therapie durch lokale Tumorentfernung, neoadjuvanter
Langzeit-Radiochemotherapie, adjuvanter Therapie bei nicht neoadjuvant behandelten
Patienten, totaler / partieller Mesorektumexzision, abdominoperinealer Rektumexstirpation,
postoperativer Letalität, klinisch manifester Anastomoseninsuffizienz und neurogener
Harnblasenentleerungsstörung bei Krankenhausentlassung. Bei den Indikatoren der Ergebnisqualität
der Therapie wird zwischen sog. Surrogatindikatoren, die schon nach Durchführung der
chirurgischen Ersttherapie bestimmt werden können und zu diesem frühen Zeitpunkt starke
Hinweise auf den weiteren Krankheitsverlauf geben, und definitiven Indikatoren unterschieden.
Als Surrogatindikatoren sind von Bedeutung die Häufigkeiten von intraoperativer örtlicher
Tumorzelldissemination, R 1 / 2-Resektion und pathohistologisch CRM-positiver Tumorentfernung
sowie die Qualität der Mesorektumexzision (Anteil inkompletter Mesorektumexzisionen).
Als definitive Indikatoren werden die 5-Jahres-Lokalrezidivrate und die 5-Jahres-Gesamtüberlebensrate
empfohlen. Die entsprechenden Zielparameter für die einzelnen Indikatoren werden in
dieser Arbeit mit konkreten Zahlen hinterlegt.
Abstract
Diagnostic and treatment of rectal cancer need a continuous quality assessment. Indicators
of quality were compiled as indicator profile for a summarizing evaluation. The indicators
selected should potentially show an appreciable variation of the quality target and
in addition should be decisive for the outcome. For the evaluation of the clinical
diagnostic the frequency of the determination of the pretherapeutic T, N and M categories
and the proportion of pT 1-tumors were chosen, for the pathological diagnostic the
number of histologically examined lymph nodes and the proportion of lymphnode positive
patients. Process quality of treatment was defined by the following indicators: proportion
of tumor excision, of definite therapy by local tumor removal, of neo-adjuvant long-term
radiochemotherapy, of adjuvant treatment in patients not selected for neoadjuvant
therapy, of total / partial mesorectal excision, of abdomino-perineal resection, postoperative
mortality, frequency of clinically apparent anastomotic leakage, and of neurogenic
bladder dysfunction at hospital discharge. The indicators for the quality of the performance
of treatment were differentiated between surrogate indicators that can be determined
immediately after accomplishment of primary surgical therapy giving strong clues for
the further course of disease at an early date, and definite indicators. Important
surrogate indicators comprise the occurrence of intraoperative local tumor cell dissemination,
R 1 / 2-resection, pathohistologically CRM-positive tumor resection, and the quality
of mesorectal excision (proportion of incomplete mesorectal excision). The definite
indicators include the 5-year local recurrence rate and the 5-year overall survival
rate. The corresponding quantifying parameters for the individual indicators are specified
in this paper with precise figures.
Schlüsselwörter
Rektumkarzinom - Qualität der Behandlung - Qualitätsindikatoren - Qualitätserfassung
Key words
rectal carcinoma - quality of treatment - quality indicators - quality assessment
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Prof. Dr. Dr. h. c. P. Hermanek
Chirurgische Klinik und Poliklinik der Universität Erlangen-Nürnberg
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