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Zentralbl Chir 2007; 132(2): 85-94
DOI: 10.1055/s-2007-960623
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© Georg Thieme Verlag Stuttgart · New York

Qualitätsindikatoren bei Diagnostik und Therapie des Rektumkarzinoms

Quality Indicators for Diagnostic and Therapy of Rectal CarcinomaR. Bittner1 , J. Burghardt2 , E. Gross3 , R. T. Grundmann4 , P. Hermanek5 , C. Isbert6 , T. Junginger7 , F. Köckerling8 , S. Merkel9 , G. Möslein10 , H.-R. Raab11 , J. Roder12 , G. Ruf13 , W. Schwenk14 , J. Strassburg15 , A. Tannapfel16 , A. de Vries17 , H. Zühlke18
  • 1Arbeitsgruppe Workflow Rektumkarzinom II
    1 Klinik für Allgemein- und Viszeralchirurgie, Marienhospital, Stuttgart
  • 2Oskar-Ziethen-Krankenhaus, Berlin
  • 3I. Cirurgische Abteilung, AK Barmbeck, Hamburg
  • 4Kreiskliniken Altötting-Burghausen
  • 5Chirurgische Klinik und Poliklinik der Universität Erlangen-Nürnberg
  • 6Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Nürnberg
  • 7Klinik und Poliklinik für Allgemein- und Abdominalchirurgie, Johannes Gutenberg-Universität, Mainz
  • 8Klinik für Chirurgie, Zentrum für Minimal-Invasive Chirurgie, Klinikum Hannover-Siloah
  • 9Klinisches Krebsregister, Chirurgische Universitätsklinik, Erlangen
  • 10Abtlg. für Chirurgie, St. Josef Hospital, Bochum-Linden
  • 11Klinik für Allgemein- und Viszeralchirurgie, Klinikum Oldenburg
  • 12Abt. für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Kreisklinik Altötting
  • 13Abtlg. für Allgemein- und Viszeralchirurgie, Chirurgische Universitätsklinik, Freiburg
  • 14Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité Campus Mitte, Berlin
  • 15Chirurgische Klinik, Vivantes Klinikum im Friedrichshain, Berlin
  • 16Institut für Pathologie, Ruhr-Universität Bochum
  • 17Abtlg. für Radio-Onkologie, Landeskrankenhaus Feldkirch, Austria
  • 18Klinik für Allgemein-, Viszeral- und Gefäßchirurgie / Phlebologie, Lutherstadt Wittenberg
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Publication History

Publication Date:
03 January 2008 (online)

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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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