Improving Rectal Cancer Outcomes with the National Accreditation Program for Rectal Cancer

Abstract

Background  The treatment of rectal cancer has undergone dramatic changes over the past 50 years. It has evolved from a rather morbid disease usually requiring a permanent stoma, almost exclusively managed by surgeons, to one that involves experts across numerous disciplines to provide the best care for the patient. With significant improvements in surgical techniques, the use of chemotherapy and radiotherapy, advanced imaging, and standardization of pathological assessment, the perioperative morbidity and permanent colostomy rates have significantly decreased. We have seen improvements in the quality of the specimen and rates of recurrence as well as disease-free survival. Rectal cancer, as demonstrated in European trials, has now been recognized as a disease best managed by a multidisciplinary team.

Objective  The aim of this article is to evaluate the main body of literature leading to the advances made possible by the new American College of Surgeons Commission on Cancer National Accreditation Program for Rectal Cancer.

Results  Following the launch of the American College of Surgeons Commission on Cancer National Accreditation Program for Rectal Cancer, we expect dramatic increases in membership and accreditation, with associated improvement in center performance and, ultimately, in patient outcomes.

Limitations  The National Accreditation Program for Rectal Cancer began in 2017. To date, the only data that have been analyzed are from the preintervention phase.

Conclusions  Based on the results of studies within the United States and on the successes demonstrated in Europe, it remains our hope and expectation that the management of rectal cancer in the United States will rapidly improve.

Over the last half century, the approach to the treatment of rectal cancer has undergone a dramatic evolution. Rectal cancer treatment, in its earliest iterations, was a disease almost exclusively managed by surgeons, and today it has evolved into a disease most effectively managed by a multidisciplinary team (MDT). This approach involves a team of surgeons, pathologists, radiologists, medical oncologists, and radiation oncologists that functions best as a unified group of experts.

Initially, rectal cancer was treated with the 5-cm distal margin “rule,” ¹ which sadly led more often than in retrospect to an abdominoperineal resection. The focus on this 5-cm margin was brought into question and ultimately demonstrated to be unnecessary. The incidence of intramucosal spread of rectal cancer was found to be considerably lower than that of the colon. In 1983, at virtually the exact same time, two studies were published corroborating this finding. One by Pollett and Nicholls and the other by Williams et al. ^{2 3} These studies demonstrated that a closer distal macroscopic margin of 2 cm was, in fact, safe and did not increase local recurrence nor decrease survival. As this distal margin was safely significantly reduced, other oncological principles of the surgical approach to rectal cancer continued to be studied and evolve. In 1982, a paradigm-shifting study published by Heald et al, which placed the mesorectum in the limelight. ⁴ The mesorectum was found to be a major culprit in pelvic recurrence of rectal cancer, particularly when the radial margin of resection was involved. Heald et al applied fundamental anastomotic surgical principles to the treatment of rectal cancer, namely preserving the embryologic tissue planes of the mesorectal fascia and removing the entire mesorectal envelope en bloc. Local recurrence rates by Heald et al as well as Quirke et al ^{4 5} were demonstrated to be significantly lower when the radial margins were free of tumor. If the margin was involved, local recurrence rates were demonstrated to be in excess of 80% (vs. <5% when the margin was uninvolved). Multiple subsequent studies including one by Heald et al were able to confirm significant decreases in local recurrence as well as better functional outcomes when this now fundamental surgical approach to the mesorectal fascia was applied. ⁴ It was from these papers that the principle of total mesorectal excision (TME) was born. A subsequent study in the 1990s by Vernava et al confirmed these findings. ⁶

As the surgical approach to rectal cancer was undergoing a radical change with very salutary effects, other modalities of therapy were being studied and applied. In the era leading up to TME, local recurrence was the main concern. As the local recurrence rates were dramatically improving, systemic recurrence and dissemination became the next area of focus. At that time, radiation and chemotherapy were considered adjuncts in the treatment of the disease and, in many cases, were not applied. In 1985, the Gastrointestinal Tumor Study Group conducted a large randomized controlled trial with four arms and included a total of 202 patients. The goal of the trial was to assess the effects of postoperative radiation therapy and chemotherapy on tumor recurrence and patient survival. After undergoing “curative” surgical resection for rectal adenocarcinoma, the patients were randomized and prospectively assigned to either (1) no adjuvant therapy, (2) postoperative radiotherapy with 4,000 or 4,800 rad, (3) postoperative chemotherapy (5-fluorouracil and semustine), or (4) a combination radiation therapy and chemotherapy. Patients were followed for a minimum of 5 years. After 5 years, the authors noted that the recurrence rate was highest among the control patients (55%) and lowest among patients who received a combination of adjuvant radiation and chemotherapy (33%). Time to recurrence was also significantly longer in the combination therapy group ( p  < 0.04). In their study, overall survival did not differ significantly between the treatment groups. They concluded that there was now strong supporting evidence for the use of postoperative radiation therapy in conjunction with chemotherapy in patients who underwent “curative” resection and had involvement of the perirectal fat or regional nodes. ⁷

Later studies were conducted evaluating preoperative radiotherapy, including the Swedish Rectal Cancer Trial, which was published in 1997. ⁸ This study included 1,168 patients with resectable rectal cancers between 1987 and 1990. After 5 years of follow-up, the Swedish group demonstrated that the rates of local recurrence decreased from 27% in the group of patients not receiving preoperative radiotherapy to 11% in the group of patients receiving preoperative radiotherapy ( p  < 0.001). The difference was noted across all subgroups using Dukes' stage. Overall survival was also significantly higher at 5 years in those receiving preoperative radiotherapy (58 vs. 48%; p  = 0.004). The Swedish group concluded that a short-term regimen of high-dose preoperative radiotherapy reduced rates of local recurrence and improved survival among patients with resectable rectal cancer. From this and other trials including NSABP (National Surgical Adjuvant Breast and Bowel Project) R-01 ⁹ and R-02, ¹⁰ it became clear that there was a major role for a collaborative, multimodal treatment of rectal cancer: TME, radiotherapy, and chemotherapy.

As time moved forward, rectal cancer became a much more individualized disease, and this is in large part due to advances in medical imaging. Early excitement was generated for the use of endorectal ultrasound in local staging, but subsequent papers demonstrated the vastly improved accuracy obtained with the use of high-resolution magnetic resonance imaging (MRI). ^{11 12} Recent studies by the Magnetic Resonance Imaging in Rectal Cancer European Equivalence Study (MERCURY) Study Group have also been key in proving the high degree of accuracy of high-resolution MRI. ¹³ In their study, the MERCURY group demonstrated that high-resolution MRI can accurately stage the circumferential resection margins (CRMs) to within one millimeter, suggesting that if the tumor was within 1 mm of the CRM on MRI, the margin should be considered involved and any distance beyond this was safe to assume clear. In their study, they concluded that MRI has an accuracy of 91% in predicting a clear CRM. All of these studies relied on a standard approach to the pathological assessment of the surgical specimens with subsequent retrospective imaging correlation and feedback. The significant role of the pathologist in this process is self-evident, and the importance of high-fidelity feedback to the surgeons, radiologists, and radiation oncologists became clear and the multidisciplinary approach to rectal cancer evolved.

Across Europe, the use of an MDT in the treatment of rectal cancer to optimize patient outcomes has been extensively studied and proven effective. In Norway, the Norwegian Rectal Cancer Project was initiated in 1993 using a national cohort, with the goal being to improve the outcomes of patients with rectal cancer by implementing TME as the standard technique for resection. After the implementation of a training program, the proportion of patients undergoing TME increased from 78% in 1994 to 92% in 1997, whereas the local recurrence rates halved from 12% to just 6%. Four-year survival improved from 60% to 73%. They demonstrated that at a national level, refinement of surgical technique is possible and yields better results for a large number of patients. ¹⁴ In 1994, a similar TME project was undertaken in Sweden by the Stockholm Colorectal Cancer Study Group. Their study took place in Stockholm County as opposed to a nationwide project, but most surgeons in the area attended the education conference. Surgeons participated in 3 workshops, 11 video sessions, and 2 histopathology sessions. There were 447 patients in the study who underwent abdominal operations for rectal cancer during 1995 and 1996. The permanent stoma rate was reduced from more than 60% to 26.5%, 5-year local recurrence rates decreased from 22% to 19% ( p  < 0.001), and 5-year cancer-specific survival increased from 66% to 77% ( p  < 0.001). ¹⁵ In 2003, colorectal MDTs were established in all hospitals across Denmark in which rectal cancer was treated. They compared outcomes between two groups. The first was a cohort of patients in Denmark treated for rectal cancer in the 3 years leading up to MDTs, and the second was a cohort of patients in the 2 years following the establishment of an MDT. A total of 811 patients were diagnosed with rectal adenocarcinoma between 2001 and 2006 at two separate hospitals. They noted that with the implementation of an MDT, the frequency of preoperative MRIs increased in the cohort treated with an MDT and the perioperative mortality decreased. More metachronous distant metastases were found in the MDT cohort, and the overall 5-year survival increased from 37% to 51%. ¹⁶ Inspired by the Norwegian Rectal Cancer Project, a subsequent 2002 experience in Spain demonstrated that implementation of an MDT training program improves rectal cancer outcomes. The local recurrence rates in that study decreased to 4.7% and the overall survival improved to 88%. ¹⁷

Methods

This article represents a compilation of evidence (with additional supplemental data) that was used by the former Consortium for Optimizing the Surgical Treatment of Rectal Cancer (OSTRiCh) which was the task force who prompted the American College of Surgeons (ACS) Commission on Cancer (CoC) to develop and launch the National Accreditation Program for Rectal Cancer (NAPRC).

Results

Largely based on the convincing results from the previously discussed European and Scandinavian trials, the OSTRiCh group was formed in 2011 in the United States. Under the direction of the Cleveland Clinic and Cleveland Clinic Florida, OSTRiCh grew to involve 14 centers across the country and obtain a membership base in excess of 100. As Dietz noted in his 2013 publication, U.S. rectal cancer outcomes are highly variable, with the majority of rectal cancer patients being treated at low-volume hospitals. OSTRiCh's single goal was to improve the awareness of the discrepancy that exists in the various hospitals throughout the United States and document the extent of the problem. ¹⁸ OSTRiCh successfully achieved its goal and subsequently ceased to function.

Acknowledging the results of the various international studies, which proved that the creation of centers of excellence in rectal cancer surgery resulted in dramatic improvements in sphincter-sparing techniques, Ricciardi et al set out in 2007 to analyze the rates of this approach in the United States His group used data from the Nationwide Inpatient Sample, identifying patients between 1988 and 2003 who underwent sphincter-sparing surgery with reestablishment of intestinal continuity or proctectomy with colostomy. They identified a total of 41,631 patients. Of the patients, 60% underwent sphincter-sacrificing procedures. They did, however, find that the rate of sphincter-sparing procedures increased from 27% in 1988 to 48% in 2003. Logistic regression revealed that patients who were older, were male, were black, used Medicaid, or lived in lower-income zip codes were less likely to have sphincter-sparing surgery with reestablishment of intestinal continuity ( p  < 0.001). ¹⁹

In 2010, Ricciardi et al published a study analyzing the variability that exists in reconstructive procedures performed in the United States following rectal cancer surgery, with a focus on geography to look for discrepancies in care. They used all-payer state hospital discharge data from 21 states from January 2002 through December 2004 to determine the rates of restorative versus nonrestorative proctectomy at the county level. The analysis included 19,912 proctectomies. Restorative techniques were used in 50.1% of patients. In approximately 26% of the counties surveyed, nonrestorative techniques (i.e., permanent colostomy) were used in more than 60% of proctectomy cases. In 54% of all counties, nonrestorative techniques were used in 41 to 60% of proctectomy cases. Only 20% of counties were characterized by rates of nonrestorative proctectomy less than 41%. They analyzed the extremal quotient, which was 16.9, and indicated significant variability between counties in colostomy formation for rectal cancer surgery. ²⁰ In a parallel study, using the same dataset, Ricciardi et al discovered on multivariate analysis that an increased presence of specialty surgeons in each county conferred a protective effect against colostomy formation following proctectomy for rectal cancer. ²¹

Ricciardi et al then delved further into the issue, publishing a study, answering the question “who performs proctectomy for rectal cancer in the United States?” This retrospective study looked at trackable state hospital discharge data from 11 states where patients underwent restorative proctectomy versus nonrestorative proctectomy (colostomy) over a 24-month study period. In 7,519 proctectomies performed by 2,588 surgeons, 38.8% of surgeons performed only nonrestorative procedures for rectal cancer. On multivariate analysis, the likelihood that a surgeon performed only nonrestorative procedures increased if that surgeon performed more integumentary procedures and decreased if the surgeon performed at least one ileoanal pouch procedure or more anorectal procedures. His group also demonstrated that patients who underwent proctectomy by the surgeons performing only nonrestorative procedures had significantly higher mortality (2.5 vs. 1.3%; p  < 0.001) and longer length of stay (11.3 vs. 9.2 days; p  < 0.001). The suggestion was made that pouch operations were surrogates for surgeons who focused their practice on colorectal disease. ²²

Another finding to this point was made by Baek et al in 2013. They analyzed 7,187 rectal cancer operations across 321 hospitals in California using the California Office of Statewide Health Planning and Development database. Hospitals were then categorized by annual volume into low (<30 cases), medium (31–60 cases), and high (>60 cases). Of the 321 hospitals, 72% were considered low volume and 8% were considered high volume. Postoperative mortality was significantly lower at high-volume centers (0.9%) versus medium- and low-volume centers (1.1 and 2.1%, respectively) ( p  < 0.001). High-volume hospitals also performed more sphincter-preserving procedures (64%) when compared with medium- and low-volume hospitals (55 and 51%, respectively) ( p  < 0.001). ²³

Most recently, Brady et al evaluated the current status of rectal cancer care in the United States. The significance of this was that these data represent the preintervention data prior to the launch of the NAPRC. They queried the National Cancer Database for nonmetastatic rectal cancer patients undergoing proctectomy. A total of 39,071 patients were identified, with a mean age of 62 years, of whom 79.8% had negative pathological margins (including proximal, distal, and circumferential) and 73% had at least 12 lymph nodes. Overall, 56% of patients in the database met all performance measures (all margins negative and at least 12 lymph nodes in the specimen). They found that patients treated at high-volume centers, defined as handling more than 30 rectal cancer cases per year, had higher odds of meeting all performance measures (odds ratio: 2.7; p  < 0.001). Six process measures were then separately evaluated. These included performance of clinical staging, obtaining pretreatment carcinoembryonic antigen (CEA) level, treatment starting within 60 days of diagnosis, tumor regression grading performed when applicable (clinical stage II and III receiving neoadjuvant therapy), assessment of CRM, and assessment of proximal and distal margins. In four of the six process measures, the rate of completion was >85%, noting that the pretreatment CEA level was the most commonly omitted variable. Achievement of all process measures occurred in <44% of the 39,071 patients. Clearly, these results verify that at a national level, significant opportunities exist to improve the care of rectal cancer patients. ²⁴ The ACS CoC NAPRC Standards are included in Table 1 . ²⁵

Table 1. Updated October 2017 Version of the CoC NAPRC Standards.

Chapter 1: Program Management  Standard 1.1: Commission on Cancer Accreditation  The facility must be accredited by the Commission on Cancer (CoC) before earning accreditation by the National Accreditation Program for Rectal Cancer (NAPRC)  Standard 1.2: Rectal Cancer Multidisciplinary Care  The rectal cancer program must have a defined Rectal Cancer Multidisciplinary Team with a minimum of one appointed physician member from each of the following specialties: surgery, pathology, radiology, medical oncology, and radiation oncology  Standard 1.3: Rectal Cancer Multidisciplinary Team Attendance  Each required Rectal Cancer Multidisciplinary Team member or the member's designated alternate attends at least 50 percent of the Rectal Cancer Multidisciplinary Team meetings held each calendar year.  Standard 1.4: Rectal Cancer Multidisciplinary Team Meetings  Each calendar year, the Rectal Cancer Multidisciplinary Team meets at least twice each month. At least one RC-MDT member from each of the required specialties must be in attendance at each RC-MDT meeting.  Standard 1.5: Rectal Cancer Program Director  Each calendar year, the facility appoints a Rectal Cancer Program Director who chairs the Rectal Cancer Multidisciplinary Team (RC-MDT). The RCP Director is the liaison between the RC-MDT and its facility's Commission on Cancer committee. The RCP Director is responsible for evaluating, interpreting, and reporting the RCP's performance through internal audits and National Cancer Database (NCDB) data. The RCP Director reports the analysis of NCDB data to the RC-MDT at least four times each calendar year.  Standard 1.6: Rectal Cancer Program Coordinator  A Rectal Cancer Program Coordinator is appointed each calendar year to coordinate activities of the Rectal Cancer Multidisciplinary Team. Policies and procedures are in place to define patient coordination activity, including, but not limited to: communication between departments within the facility, referring physicians, and patients; coordinating patient appointments; and oversight of data collection.  *Standard 1.7: Rectal Cancer Program Education  All surgeon, pathologist, and radiologist physician members of the Rectal Cancer Multidisciplinary Team complete the NAPRC-endorsed education module related to their respective specialties. Chapter 2: Clinical Services  Standard 2.1: Review of Diagnostic Pathology  Each calendar year, all rectal cancer patients who are diagnosed elsewhere who have received no previous treatment have biopsy pathology slides and/ or reports reviewed by an appropriate, appointed member of the Rectal Cancer Multidisciplinary Team (RC-MDT). All patients diagnosed elsewhere who received previous treatment elsewhere must have documentation of a rectal cancer diagnosis in the patient's medical record before initiation of treatment at the accredited Rectal Cancer Program (RCP). Ninety-five percent of previously undiagnosed, previously untreated rectal cancer patients receive confirmation of diagnosis by biopsy before treatment at the accredited Rectal Cancer Program.  Standard 2.2: Staging before Definitive Treatment  Ninety-five percent of all previously untreated rectal cancer patients are staged (systemic and local tumor) before definitive treatment. Systemic staging is completed by Computerized Tomographic (CT) or Positron Emission Tomographic-Computed Tomographic (PET/CT) scanning of the chest, abdomen, and pelvis. Local tumor staging is completed by rectal cancer protocol Magnetic Resonance Imaging (MRI) of the pelvis.  Standard 2.3: Standardized Staging Reporting for Magnetic Resonance Imaging Results  Each calendar year, 90 percent of pretreatment MRI exams for previously untreated rectal cancer patients are read by a radiologist who is an appointed member of the Rectal Cancer Multidisciplinary Team. Staging results for 95 percent of previously untreated rectal cancer patients who complete MRI exams are recorded in a standardized report containing the minimum required elements.  Standard 2.4: Carcinoembryonic Antigen Level  For 75 percent of previously untreated rectal cancer patients, a carcinoembryonic antigen (CEA) level is obtained before definitive treatment and the pretreatment CEA level is recorded in the patient's medical record.  Standard 2.5: Rectal Cancer Multidisciplinary Team Treatment Planning Discussion  Before the initiation of definitive treatment, all rectal cancer patients must have an individualized treatment planning discussion conducted at a Rectal Cancer Multidisciplinary Team meeting.  Standard 2.6: Treatment Evaluation and Recommendation Summary  Before the initiation of definitive treatment, a standardized treatment evaluation and recommendation summary is completed and provided to the primary care and/or referring physician for at least 50 percent of rectal cancer patients.  Standard 2.7: Definitive Treatment Timing  Eighty percent of all previously untreated rectal cancer patients begin definitive treatment within 60 days of initial clinical evaluation at the accredited Rectal Cancer Program.  *Standard 2.8: Surgical Resection and Standardized Operative Reporting  Each calendar year, 80 percent of surgical resections for rectal cancer patients are performed by a surgeon who is an appointed member of the Rectal Cancer Multidisciplinary Team. Operative reports for 95 percent of all rectal cancer patients who undergo surgical resection for rectal cancer are recorded in a standardized synoptic report format containing the minimum required elements.  Standard 2.9: Pathology Reports after Surgical Resection  Each calendar year, 90 percent of definitive rectal cancer surgical resection specimens of the primary tumor performed at the accredited rectal cancer program are read and the pathology report completed by an appointed Rectal Cancer Multidisciplinary Team pathologist. Pathology reports for 95 percent of rectal cancer patients undergoing a definitive surgical resection of the primary tumor at the accredited rectal cancer program are completed within two weeks of the definitive surgical resection, contain all required College of American Pathologists (CAP) data elements, and use a standardized synoptic format.  Standard 2.10: Photographs of Surgical Specimens  Each calendar year, a minimum of 65 percent of all eligible surgical specimens are photographed to include anterior, posterior, and lateral views. Photographs of the fresh or formalin fixed ex-vivo specimen may be obtained using any standard digital camera in either the operating room or in the pathology laboratory. These images are subsequently presented to and discussed by the Rectal Cancer Multidisciplinary Team and are electronically stored with patient identifier.  Standard 2.11: Multidisciplinary Team Treatment Outcome Discussion  Within four weeks of definitive surgical treatment completion, an individualized treatment outcome discussion occurs for all rectal cancer patients at a Rectal Cancer Multidisciplinary Team meeting.  Standard 2.12: Treatment Outcome Discussion Summary  Each calendar year, a standardized treatment summary is provided to at least 50 percent of all rectal cancer patients within four weeks of the Multidisciplinary Team Treatment Outcome Discussion. A copy is provided to the primary care and/or referring physician.  Standard 2.13: Adjuvant Therapy after Surgical Resection  Each calendar year, 50 percent of all eligible rectal cancer patients who elect to initiate recommended adjuvant treatment regimen begin within eight weeks of definitive surgical resection of the primary tumor. Referrals for adjuvant treatment are evaluated and monitored by the Rectal Cancer Program Coordinator and reported to the Rectal Cancer Multidisciplinary Team. Chapter 3: Quality Improvement  *Standard 3.1: Rapid Quality Reporting System  The Rectal Cancer Program actively participates in the Rapid Quality Reporting System (RQRS), submits all eligible rectal cancer cases for all valid performance measures, and adheres to the RQRS terms and conditions.  *Standard 3.2: Accountability and Quality Improvement Measures Each calendar year, the expected Estimated Performance Rate (EPR) is met for each accountability and quality improvement measure as defined by the National Accreditation Program for Rectal Cancer (NAPRC).

Abbreviations: CoC, Commission on Cancer; NAPRC, National Accreditation Program for Rectal Cancer.

Source: reproduced with permission of the American College of Surgeons National Accreditation Program for Rectal Cancer ( https://www.facs.org/~/media/files/quality%20programs/cancer/naprc/naprc%20standards%20manual.ashx , page 4).

Note: As of October 2017, standards and information denoted with an asterisk have components that are still in development by the NAPRC or its partners. Programs will not be held to all compliance requirements for these standards until an official announcement is made by the NAPRC. Further details, clarifications, and updates regarding these standards and NAPRC policies are provided on the NAPRC web page.

Discussion

A call to action was issued by an alarming report from the U.S.-based Institute of Medicine in 2013. The report issued by Levit et al described a call to action in the United States, referring to the current model of cancer care as being “in crisis.” They detailed our current system as one that lacks communication and coordination of care as well as patient-centered outcomes, and has large discrepancies between what surgeons perceive as quality and the actual clinical results that occur. They emphasized the importance of outcomes reporting and tracking at the national level, with the already evident improvements in care that these programs offer to patients. ²⁶

In sectors outside colorectal surgery within the United States, implementation of large-scale quality improvement programs has shown significant success. These types of programs have existed for many years for trauma centers through the ACS Committee on Trauma (COT) and have been cited as a major factor in the pursuit of standardization of high-quality care for the injured patient. As Maggio et al detailed in 2009, commitment to COT verification has shown improvement in patient outcomes and financial performance. After implementing the standards required by the ACS COT, their group noted an increase in admissions of 30%, representing a 7.6% annual increase due to increase in interfacility transfers, and increase in severe trauma patients with an associated decrease in mortality rate of 47% for this group, a rate at almost half the national average. They also noted a 78% increase in revenue and a sustained increase in hospital profitability. ²⁷ Clearly, participating in this program confers benefits to both the patient and the facility delivering care.

Success has also been noted at hospitals participating in the ACS National Surgical Quality Improvement Program (NSQIP). In a 2016 study by Cohen et al, ACS NSQIP data were used to create prediction models for various NSQIP participating facilities. They used these models to analyze mortality, morbidity, and surgical site infections (SSIs). For each model, each hospital, and year of first participation (hospital cohort), hierarchical model observed/expected (O/E) ratios were computed. Hospital-averaged log O/E ratio slopes were generally negative, indicating improving performance over time. For all hospitals, 62, 70, and 65% of hospitals had negative slopes for mortality, morbidity, and any SSI, respectively. They noted significant annual reductions in these hospitals' rates of mortality, morbidity, and SSI (with respect to the prior year's rates). ²⁸

Similar to the NAPRC, bariatric surgery has recently implemented the Metabolic and Bariatric Surgery Accreditation and Quality Program (MBSAQIP). In 2012, the ACS and the American Society for Metabolic and Bariatric Surgery merged their respective bariatric surgery accreditation programs into the MBSAQIP to achieve one national accreditation standard for bariatric surgery centers. ²⁹ This program serves multiple purposes, all centered on improving patient care. Technical aspects of the operations performed, and patient variables and outcomes can all be examined on a large (or small) scale, allowing for substantial improvement in each of the collected variables. In 2016, Berger et al published the first report from the MBSAQIP, examining the impact of different surgical techniques on outcomes for patients undergoing laparoscopic sleeve gastrectomy. From this dataset, they were able to evaluate a substantial number of sleeve gastrectomy procedures (189,477), and with this amount of data, study power was no longer an issue. They were able to answer the long-debated question of staple line reinforcement in sleeve gastrectomy, showing that although 80% of surgeons used reinforcement techniques, there was a significantly higher association with leak but lower staple line bleed rates. ³⁰ The value these accreditation programs add to patient care and the specialty is clear and certainly the way of the future.

Conclusion

Based on the convincing, reproducible results of the European trials in colorectal surgery and additionally in other specialties within the United States, it is our expectation that similar results will soon be achieved in the United States. It is our hope that more than 300 hospitals within the United States will seek accreditation by the NAPRC.