Introduction: The certification of oncological units as colorectal cancer centers (CrCCs) has been proposed to standardize oncological treatment and improve the outcomes for patients with colorectal cancer (CRC). The proportion of patients with CRC in Germany that are treated by a certified center is around 53%. Lately, the effect of certification on the treatment outcomes has been critically discussed. Aim: Our aim was to investigate the treatment outcomes in patients with rectal carcinoma at certified CrCCs, in German hospitals of different medical care levels. Methods: We performed a retrospective analysis of a prospective, multicentric database (AN Institute) of adult patients who underwent surgery for rectal carcinoma between 2002 and 2016. We included 563 patients from 13 hospitals of different medical care levels (basic, priority, and maximal care) over periods of 5 years before and after certification. Results: The certified CrCCs showed a significant increase in the use of laparoscopic approach for rectal cancer surgery (5% vs. 55%,p< 0.001). However, we observed a significantly prolonged mean duration of surgery in certified CrCCs (161 Min. vs. 192 Min.,p< 0.001). The overall morbidity did not improve (32% vs. 38%,p= 0.174), but the appearance of postoperative stool fistulas decreased significantly in certified CrCCs (2% vs. 0%,p= 0.036). Concerning the overall in-hospital mortality, we registered a positive trend in certified centers during the five-year period after the certification (5% vs. 3%,p= 0.190). The length of preoperative hospitalization (preop. LOS) was shortened significantly (4.71 vs. 4.13 days,p< 0.001), while the overall length of in-hospital stays was also shorter in certified CrCCs (20.32 vs. 19.54 days,p= 0.065). We registered a clear advantage in detailed, high-quality histopathological examinations regarding the N, L, V, and M.E.R.C.U.R.Y. statuses. In the performed subgroup analysis, a significantly longer overall survival after certification was registered for maximal medical care units (p= 0.029) and in patients with UICC stage IV disease (p= 0.041). In patients with UICC stage III disease, we registered a slightly non-significant improvement in the disease-free survival (UICC III:p= 0.050). Conclusions: The results of the present study indicate an improvement in terms of the treatment quality and outcomes in certified CrCCs, which is enforced by certification-specific aspects such as a more differentiated surgical approach, a lower rate of certain postoperative complications, and a multidisciplinary approach. Further prospective clinical trials are necessary to investigate the influence of certification in the treatment of CRC patients.
引言：为规范肿瘤治疗并改善结直肠癌患者的预后，将肿瘤科室认证为结直肠癌中心的做法已被提出。在德国，约有53%的结直肠癌患者在认证中心接受治疗。近期，认证对治疗结果的影响引发了广泛讨论。目的：本研究旨在探讨德国不同医疗层级医院中，经认证的结直肠癌中心对直肠癌患者的治疗效果。方法：我们对前瞻性多中心数据库（AN研究所）进行了回顾性分析，该数据库收录了2002年至2016年间接受直肠癌手术的成年患者。我们纳入了来自13家不同医疗层级医院（基础医疗、重点医疗和顶级医疗）的563例患者，覆盖认证前后各5年的数据。结果：认证结直肠癌中心在直肠癌手术中腹腔镜使用率显著提高（5% vs. 55%，p<0.001），但平均手术时间显著延长（161分钟 vs. 192分钟，p<0.001）。总体并发症发生率未见改善（32% vs. 38%，p=0.174），但术后粪瘘发生率在认证中心显著降低（2% vs. 0%，p=0.036）。在院内总死亡率方面，认证中心在认证后五年期间呈现积极趋势（5% vs. 3%，p=0.190）。术前住院时间显著缩短（4.71天 vs. 4.13天，p<0.001），总住院时间在认证中心也呈缩短趋势（20.32天 vs. 19.54天，p=0.065）。在N、L、V及M.E.R.C.U.R.Y.状态的精细化组织病理学检查方面，认证中心展现出明显优势。亚组分析显示，顶级医疗单位的患者总生存期在认证后显著延长（p=0.029），UICC IV期患者的总生存期亦显著改善（p=0.041）。UICC III期患者的无病生存期略有改善但未达统计学显著性（p=0.050）。结论：本研究结果表明，认证结直肠癌中心在治疗质量和预后方面有所改善，这得益于认证相关的特定优势，如更精细化的手术方式、特定术后并发症发生率降低以及多学科协作模式。未来仍需开展前瞻性临床试验以进一步验证认证对结直肠癌患者治疗的影响。
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