Richard Bryant, Nick O Rourke ANZHPBA, Queenstown 2010

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1 Richard Bryant, Nick O Rourke ANZHPBA, Queenstown 2010

2 Purpose-built liver audit database Web-based (access from different sites) Easy data entry Easy to export data ready for analysis Good patient follow up Real-time performance analysis

Windows/Mac/Linux Access the database from any web browser

3 MySQL database PHP - programming language to dynamically produce web pages and interact with the database Runs on Windows/Mac/Linux Access the database from any web browser (computer, iphone, ipad etc.) No license fees, can be redistributed freely

4 Structured Query Language Database programming language Powerful tool for manipulating data

Patients Patient key Firstname Surname DOB 1 John Smith 1/1/1930 2 John Citizen 2/2/1950 3 Bill Smithson 1/2/1970 4 Mary Citizen 1/1/1990 SELECT Firstname, Surname, DOB, DateDiff(Now(), DOB)/365 AS

5 Patients Patient key Firstname Surname DOB 1 John Smith 1/1/ John Citizen 2/2/ Bill Smithson 1/2/ Mary Citizen 1/1/1990 SELECT Firstname, Surname, DOB, DateDiff(Now(), DOB)/365 AS Age, IIf([Age]<30,"Young",IIf([Age]<60,"Middle aged","old")) AS Agedness FROM Patients; Result set Firstname Surname DOB Age Agedness John Smith 1/1/ Old John Citizen 2/2/ Middle aged Bill Smithson 1/2/ Middle aged Mary Citizen 1/1/ Young

6 Seems a simple question In fact quite complicated

7 Granularity versus aggregation Procedure Resection Major Anatomic Purely anatomic Cyst fenestration No No No No No Right hepatectomy Yes Yes Yes Yes No Extended right hepatectomy (+4+1) Yes Yes Yes Yes Yes Left hepatectomy Yes Yes Yes Yes No Left lateral sectionectomy Yes No Yes Yes No Right hepatectomy + tumorectomy seg 3 Yes Yes Yes No No Tumorectomy 6 + tumorectomy 2 Yes No No No No Extended resection

8 Granularity versus aggregation Procedure Cyst fenestration Right hepatectomy Extended right hepatectomy (+4+1) Left hepatectomy Left lateral sectionectomy Right hepatectomy + tumorectomy seg 3 Text field Controlled user input Brisbane nomenclature Run queries on the text to group for analysis Tumorectomy 6 + tumorectomy 2

9 select procid, liverprocedure, if(liverprocedure like "%hepatectomy%" or liverprocedure like "%sectionectomy%" or liverprocedure like "%segmentectomy%" or liverprocedure like "%tumorectomy%" or liverprocedure like "%pericystectomy%", "resection", "notaresection") as isresection from tpd_liverops; select procid, liverprocedure, isresection, if(liverprocedure like "%hepatectomy%", "major", if(isresection = "resection", "minor", "notaresection")) as resectiongrade, if(liverprocedure like "%hepatectomy%" or liverprocedure like "%sectionectomy%" or liverprocedure like "%segmentectomy%", "anatomic", if(isresection = "resection", "notanatomic", "notaresection")) as isanatomic, if(liverprocedure like "%tumorectomy%", "nonanatomic", if(isresection = "resection", "notnonanatomic", "notaresection")) as isnonanatomic, if(liverprocedure like "%extended%", "extended", if(isresection = "resection", "notextended", "notaresection")) as isextended, if(liverprocedure like "%extended right hepatectomy%" or liverprocedure like "%extended left hepatectomy%", "extendedanatomic", if(isresection = "resection","notextendedanatomic", "notaresection")) as isextendedanatomic from vdm_resectionstatus;

10 Granularity versus aggregation Procedure Resection Major Anatomic Purely anatomic Cyst fenestration No No No No No Right hepatectomy Yes Yes Yes Yes No Extended right hepatectomy (+4+1) Yes Yes Yes Yes Yes Left hepatectomy Yes Yes Yes Yes No Left lateral sectionectomy Yes No Yes Yes No Right hepatectomy + tumorectomy seg 3 Yes Yes Yes No No Tumorectomy 6 + tumorectomy 2 Yes No No No No Extended resection

11 Strasberg SM. Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system. Journal of Hepato-Biliary-Pancreatic Surgery. 2005;12(5):351-5.

13 Granularity versus aggregation Procedure Resection Major Anatomic Purely anatomic Cyst fenestration No No No No No Right hepatectomy Yes Yes Yes Yes No Extended right hepatectomy (+4+1) Yes Yes Yes Yes Yes Left hepatectomy Yes Yes Yes Yes No Left lateral sectionectomy Yes No Yes Yes No Right hepatectomy + tumorectomy seg 3 Yes Yes Yes No No Tumorectomy 6 + tumorectomy 2 Yes No No No No Extended resection

14 We have a complicated question but a simple text field produces many different data points for subsequent analysis Established nomenclature Brisbane nomenclature User interface ensures the data is entered correctly Capabilities of SQL to manipulate the text data

15 Right hemihepatectomy = a fact Major resection = an interpretation of this fact Record just the facts Use the database to perform the interpretations Multiple different systems of interpretation for the one fact Interpretations are user-dependant New interpretations will appear in the future

16 Also seems a simple question Also quite complicated

17 Left hemicolectomy Hepatic metastases Left lateral sectionectomy + right portal vein ligation Primary disease-free survival Secondary disease-free survival Overall survival Right hepatectomy Tumour recurrence RFA and chemotherapy Tumour recurrence Deceased

19 Patient key Date Outcome Disease-free Diseased Deceased Operations Union query Patients Follow up

20 Date Type Findings Disease state ### Left hemicolectomy R0 Disease free ### F/U Liver mets Diseased ### LLS + R PVE 1 st stage Diseased ### F/U Still disease Diseased ### R hepatectomy 2 nd stage Disease free ### F/U Liver mets Diseased ### Chemo Liver mets Diseased ### RFA CR Disease free ### F/U Liver mets Diseased ### F/U Liver mets Diseased ### F/U Liver mets Diseased ### F/U Died Died

21 Date Type Findings Disease state ### Left hemicolectomy R0 Disease free ### F/U Liver mets Diseased ### LLS + R PVE 1 st stage Diseased ### F/U Still disease Diseased ### R hepatectomy 2 nd stage Disease free ### F/U Liver mets Diseased ### Chemo Liver mets Diseased ### RFA CR Disease free Index case = Date 1 Find the first disease free on or after index case Then find the first diseased after this = Date 2 ### F/U Liver mets Diseased ### F/U Liver mets Diseased ### F/U Liver mets Diseased ### F/U Died Died

22 Date Type Findings Disease state ### Left hemicolectomy R0 Disease free ### F/U Liver mets Diseased ### LLS + R PVE 1 st stage Diseased Index case = Date 1 ### F/U Still disease Diseased ### R hepatectomy 2 nd stage Disease free ### F/U Liver mets Diseased ### Chemo Liver mets Diseased Find the last disease free on or after index case ### RFA CR Disease free ### F/U Liver mets Diseased ### F/U Liver mets Diseased ### F/U Liver mets Diseased ### F/U Died Died Then find the first diseased after this = Date 2

23 Date Type Findings Disease state ### Left hemicolectomy R0 Disease free ### F/U Liver mets Diseased ### LLS + R PVE 1 st stage Diseased Index case = Date 1 ### F/U Still disease Diseased ### R hepatectomy 2 nd stage Disease free ### F/U Liver mets Diseased ### Chemo Liver mets Diseased ### RFA CR Disease free ### F/U Liver mets Diseased ### F/U Liver mets Diseased ### F/U Liver mets Diseased ### F/U Died Died Died = Date 2

25 Clinical risk score (CRS) Node-positive primary 1 Disease-free interval <12 months 1 Number of tumours >1 1 Preop CEA >200 1 Diameter of largest tumour >5cm 1 Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH. Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Ann. Surg. 1999;230(3):309-18; discussion

26 select tpd_liverops.procid, indication, primaryt, primaryn, primaryresectiondate, primarysynchronousliverdisease, opdate CEA, maxlesionsize, numberoflesions, if(cea > 200, 1, 0) as CEAscore, if(primaryn > 0, 1, 0) as nodescore, if(datediff(opdate, primaryresectiondate) > 365 or primarysynchronousliverdisease = 'yes', 1, 0) as delayscore, if(numberoflesions > 1, 1, 0) as numberscore, if(maxlesionsize > 50, 1, 0) as sizescore from tpd_liverops left join vdm_markercea on tpd_liverops.procid = vdm_markercea.procid left join vdm_lesionsmaxsize on tpd_liverops.procid = vdm_lesionsmaxsize.procid left join vdm_lesionsnumber on tpd_liverops.procid = vdm_lesionsnumber.procid; select procid, (CEAscore + nodescore + delayscore + numberscore + sizescore) as CRS from vdm_crsscores;

27 Rees M, Tekkis PP, Welsh FKS, O'Rourke T, John TG. Evaluation of long-term survival after hepatic resection for metastatic colorectal cancer: a multifactorial model of 929 patients. Ann Surg. 2008;247(1):

28 select tpd_liverops.procid, primaryn, primarygrade, extrahepaticdisease, margin, numberoflesions, maxlesionsize, CEA, if(primaryn > 0, 2, 0) as bpinodescorepre, if(primaryn > 0, 2, 0) as bpinodescorepost, if(primarygrade = 'well differentiated', 0, if(primarygrade = 'moderately differentiated', 3, if(primarygrade = 'poorly differentiated', 5, 0))) as bpigradescorepre, if(primarygrade = 'well differentiated', 0, if(primarygrade = 'moderately differentiated', 2, if(primarygrade = 'poorly differentiated', 4, 0))) as bpigradescorepost, if(coalesce(cea, 0) < 6, 0, if(cea > 60, 3, 2)) as bpiceascorepre, if(coalesce(cea, 0) <6, 0, if(cea > 60, 3, 1)) as bpiceascorepost, if(numberoflesions >3, 4, 0) as bpinumberscorepre, if(coalesce(maxlesionsize, 0) < 50, 0, if(maxlesionsize > 100, 8, 2)) as bpisizescorepre, if(coalesce(maxlesionsize, 0) <50, 0, if(maxlesionsize > 100, 7, 2)) as bpisizescorepost, if(isnull(margin), 0, if(margin < 1, 11, 0)) as bpimarginscorepost, if(extrahepaticdisease = 'yes', 7, 0) as bpiextrahepaticscorepre, if(extrahepaticdisease = 'yes', 4, 0) as bpiextrahepaticscorepost from tpd_liverops left join vdm_lesionsnumber on tpd_liverops.procid = vdm_lesionsnumber.procid left join vdm_lesionsmaxsize on tpd_liverops.procid = vdm_lesionsmaxsize.procid left join vdm_markercea on tpd_liverops.procid = vdm_markercea.procid; select procid, bpinodescorepre, bpigradescorepre, bpisizescorepre, bpinumberscorepre, bpiextrahepaticscorepre, bpiceascorepre, bpinodescorepost, bpigradescorepost, bpisizescorepost, bpiceascorepost, bpiextrahepaticscorepost, bpimarginscorepost, (bpinodescorepre + bpigradescorepre + bpisizescorepre + bpinumberscorepre + bpiextrahepaticscorepre + bpiceascorepre) as bpipre, (bpinodescorepost + bpigradescorepost + bpisizescorepost + bpiceascorepost + bpiextrahepaticscorepost + bpimarginscorepost) as bpipost from vdm_bpiscores;

29 How well are we doing Continuous assessment Account for patient risk factors Important outcomes Mortality Bleeding Margins

30 Variable life-adjusted display Running total of cummulative actual versus expected mortality Risk for each procedure is identified Survival score goes up by the risk of death Death score goes down by the risk of survival

31 10% expected mortality Series1

32 10% expected mortality Mortality doubles to 20% Series1

34 Calculate the risk R for an adverse outcome VLAD score if no adverse outcome = +R VLAD score if adverse outcome = -(1-R) Adverse outcomes Mortality Bleeding Positive margins

35 Belghiti J, Hiramatsu K, Benoist S, et al. Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection. J. Am. Coll. Surg. 2000;191(1):38-46.

36 Emergency resection 25% Bilirubin >50 20% Cirrhosis 9% Liver resection with added procedure for malignancy 6% ASA >1 3% Major resection for malignancy 2% Others 0.1% Belghiti J, Hiramatsu K, Benoist S, et al. Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection. J. Am. Coll. Surg. 2000;191(1):38-46.

37 select tpd_liverops.procid, if(tpd_liverops.acuity = "emergency", 0.25, if(tpd_liverops.preopbili >50, 0.2, if(tpd_liverops.underlyingliver like "%cirrhosis%", 0.09, if((coalesce(tpd_liverops.otherprocedure, "") <> "" and tui_indications.ismalignant = "yes"), 0.06, if(tpd_liverops.asa > 1, 0.03,if(vdm_resectiongrades.resectiongrade = "major" and tui_indications.ismalignant = "yes", 0.02, 0.001)))))) as deathvladrisk, tpd_liverops.acuity, tpd_liverops.preopbili, tpd_liverops.underlyingliver, tpd_liverops.otherprocedure, tpd_liverops.asa, tpd_liverops.liverprocedure, tui_indications.ismalignant, vdm_resectiongrades.resectiongrade from tpd_liverops left join tui_indications on tpd_liverops.indication = tui_indications.indication left join vdm_resectiongrades on tpd_liverops.procid = vdm_resectiongrades.procid;

38 Welsh FKS, Tekkis PP, O'Rourke T, John TG, Rees M. Quantification of risk of a positive (R1) resection margin following hepatic resection for metastatic colorectal cancer: an aid to clinical decision-making. Surg Oncol. 2008;17(1):3-13.

39 Welsh FKS, Tekkis PP, O'Rourke T, John TG, Rees M. Quantification of risk of a positive (R1) resection margin following hepatic resection for metastatic colorectal cancer: an aid to clinical decision-making. Surg Oncol. 2008;17(1):3-13.

40 Welsh FKS, Tekkis PP, O'Rourke T, John TG, Rees M. Quantification of risk of a positive (R1) resection margin following hepatic resection for metastatic colorectal cancer: an aid to clinical decision-making. Surg Oncol. 2008;17(1):3-13.

41 select tpd_liverops.procid, tpd_liverops.structuresinvolved, tpd_liverops.previousresection, vdm_lesionsnumber.numberoflesions, vdm_weights.vautheyweight, vdm_lesionstotalvolume.totallesionvolume, vdm_childscoretotals.childscore, vdm_lesionslaterality.bilateral, vdm_lesionslaterality.caudate, vdm_lesionstotalvolume.totallesionvolume/(vdm_weights.vautheyweight + vdm_lesionstotalvolume.totallesionvolume) as volumeratio, vdm_resectiongrades.isanatomic, vdm_resectiongrades.isnonanatomic, vdm_resectiongrades.isextended, if(vdm_lesionsnumber.numberoflesions > 3 and (vdm_lesionstotalvolume.totallesionvolume/(vdm_weights.vautheyweight + vdm_lesionstotalvolume.totallesionvolume)) > 0.5, 14, if(vdm_lesionsnumber.numberoflesions > 3 and (vdm_lesionstotalvolume.totallesionvolume/(vdm_weights.vautheyweight + vdm_lesionstotalvolume.totallesionvolume)) < 0.5, 3, 0)) as lesionscore, if(vdm_lesionslaterality.bilateral = "yes", 11, if(vdm_lesionslaterality.caudate = "yes", 9, 0)) as distributionscore, if(vdm_childscoretotals.childscore > 5, 5, 0) as lftscore, if(vdm_resectiongrades.isnonanatomic = "nonanatomic" and vdm_resectiongrades.isanatomic = "notanatomic", 15, if(vdm_resectiongrades.isanatomic = "anatomic" and vdm_resectiongrades.isextended = "extended" and vdm_resectiongrades.isnonanatomic = "nonanatomic", 11, if(vdm_resectiongrades.isextended = "extended" and vdm_resectiongrades.isanatomic = "anatomic", 9, if(vdm_resectiongrades.isanatomic = "anatomic" and vdm_resectiongrades.isnonanatomic = "nonanatomic", 5, 0)))) as resectionscore, if(tpd_liverops.previousresection = "yes", 11, 0) as repeatscore from tpd_liverops left join vdm_lesionsnumber on tpd_liverops.procid = vdm_lesionsnumber.procid left join vdm_weights on tpd_liverops.procid = vdm_weights.procid left join vdm_lesionstotalvolume on tpd_liverops.procid = vdm_lesionstotalvolume.procid left join vdm_childscoretotals on tpd_liverops.procid = vdm_childscoretotals.childscore left join vdm_lesionslaterality on tpd_liverops.procid = vdm_lesionslaterality.procid left join vdm_resectiongrades on tpd_liverops.procid = vdm_resectiongrades.procid;

42 select vdm_crcmarginvladsubscores.procid, vdm_crcmarginvladsubscores.lesionscore + vdm_crcmarginvladsubscores.distributionscore + vdm_crcmarginvladsubscores.lftscore + vdm_crcmarginvladsubscores.resectionscore + vdm_crcmarginvladsubscores.repeatscore as crcmarginvladtotalscore from vdm_crcmarginvladsubscores; select vdm_crcmarginvladtotalscore.procid, vdm_crcmarginvladtotalscore.crcmarginvladtotalscore, tui_crcmarginvladrisktable.risk from vdm_crcmarginvladtotalscore left join tui_crcmarginvladrisktable on vdm_crcmarginvladtotalscore.crcmarginvladtotalscore = tui_crcmarginvladrisktable.totalscore; select tpd_liverops.procid, vdm_crcmarginvladrisk.risk, vdm_maxcompgrade.maxcompgrade, if(vdm_maxcompgrade.maxcompgrade = 5, (risk/100) -1, (risk/100)) as crcmarginvladscore from tpd_liverops left join vdm_crcmarginvladrisk on tpd_liverops.procid = vdm_crcmarginvladrisk.procid left join vdm_maxcompgrade on tpd_liverops.procid = vdm_maxcompgrade.procid;

43 No good data model Bleeding is associated with poorer outcomes Set our own acceptable parameters depending on the type of surgery Develop a statistical model

44 Open-source web-based database Easy input, easy output, let the database do the hard work in between Record only the facts, let the database do the interpretations Nomenclature is power Real time analysis and audit

Surgical Management of Advanced Stage Colon Cancer. Nathan Huber, MD 6/11/14

Surgical Management of Advanced Stage Colon Cancer Nathan Huber, MD 6/11/14 Colon Cancer Overview Approximately 50,000 attributable deaths per year Colorectal cancer is the 3 rd most common cause of cancer-related