Survival for rectal cancer patients and international comparisons

J. Kerr, J. Engel*, R. Eckel and D. Hölzel

Munich Cancer Registry, Ludwig-Maximillians-University, Munich, Germany

* Correspondence to: Dr J. Engel, Tumorregister München, Institut für Med. Informationsverarbeitung, Biometrie und Epidemiologie, Ludwig-Maximilians-Universität München, Marchioninistraße 15, D-81377 München, Germany. Tel: +49-89-7095-4489; Fax: +49-89-7095-4753; Email: engel{at}ibe.med.uni-muenchen.de


    Abstract
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Background: Population-based cancer registry data are important because they reflect routine care, present long-term follow-up, can show differences in treatment, outcomes and health care over time, and can be used for comparisons between regions and countries.

Patients and methods: Details of all cancer patients in the Munich region are recorded by the Munich Cancer Registry. Rectal cancer patients with an invasive primary tumor diagnosed between 1996 and 1998 were included in this analysis (n=936). Observed and relative survival are presented. Observed survival was also investigated with a Cox proportional hazards regression model.

Results: Median follow-up time of survivors was 5.7 years. Five-year relative survival for the whole sample was 62.2%. International Union Against Cancer (UICC) stage was the most important prognostic factor in the multivariate analysis. Compared with the 1992–1999 Surveillance Epidemiology and End Results (SEER) data (62.4%), relative survival for each disease stage and the whole sample were very similar. In comparison with other European registries, Munich patients had slightly higher survival rates per stage (for example, 5-year relative survival in UICC III was 58.3% in Munich, 54.6% in South East Netherlands, 33.3% in Modena and 47.4% in Cote d'Or); however, more patients in Munich were in higher disease stages with worse prognoses, indicating poorer early detection.

Conclusions: These results indicate that treatment of rectal cancer in Munich is good, but early detection could be improved. Cancer registries should publish their population-based stage data to ensure quality of care and provide regular feedback to health-care workers and decision makers. Comparisons between countries without stage data should be conducted cautiously.

Key words: cancer registry, epidemiology, rectal cancer, stage, survival


    Introduction
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Population-based cancer registry data are important because they reflect routine care, present long-term follow-up, can show differences in treatment, outcomes and health care over time, and can be used for comparisons between regions and countries. In rectal cancer, for example, few population-based epidemiological overviews are available. Rectal cancer is particularly interesting because there have been treatment changes in the last decade, some improvements in survival in the last 20 years and signs of decreased incidence [1Go–3Go].

It is particularly important to compare population outcomes of routine care with clinical trial data, which are more frequently published. Randomized control trials (RCTs) may present impressive results, but they often assess the latest treatment (perhaps not yet available to all) in exclusive patient groups in specialized settings. Furthermore, treatment guidelines are often based on such trials, but without older patients or those with comorbid conditions being included the guidelines have limited application. Cancer registries, in contrast, can show which treatments are routinely prescribed and effective in all patient groups. Furthermore, while trials tend to give the impression that we are making progress in treating patients, epidemiological data may show that this is not always the case in reality [1Go, 4Go, 5Go].

The quality of health care in different countries is also frequently debated, somewhat unscientifically, in the popular media. This can then impact on public perception and health-care policy [6Go]. League tables of cancer survival rates, however, are uninformative if stage-specific results are not considered. A high survival rate may be due to good treatment or early diagnosis or both; only additional stage data can clarify this. Without stage data it is also difficult to argue for the effectiveness of cancer screening programs and the introduction of new treatments. Although cancer registries collect population data for cancer incidence and mortality, many do not have specific disease stage information. For example, out of 40 EUROCARE registries in the 1980s, only seven had stage data in more than 75% of cases [7Go]; in another EUROCARE publication stage data from 11 registries are available [8Go].

This paper presents a detailed epidemiological view of rectal cancer from a population-based sample of patients diagnosed between 1996 and 1998 in Munich. This paper will also compare the Munich Cancer Registry (MCR) data with other cancer registry and trial data, where possible. This paper aims to demonstrate the importance and practical application of population-based data and the need for treatment and stage details for international comparisons.


    Methods
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Data collection
The MCR routinely records all cancer patients treated in Munich and the surrounding area. All MCR data are registered according to the official documentation guidelines for cancer registries [9Go]. At the time of this study, the population was ~2.3 million; currently it stands at 3.7 million. (The MCR collected cancer data from ~2.3 million people up to the end of 2001. The Bavarian Cancer Registration Law came into force at the beginning of 1998, which resulted in an enlargement of the catchment area to 3.7 million people in 2002.) This paper reports the results of the Munich Field Study, which monitored all rectal and breast cancer patients diagnosed between 1 April 1996 and 31 March 1998, who were resident in the Munich region. Pathology reports for solid tumors from all pathology laboratories in the Munich area were sent, on a monthly basis, to the MCR. From these reports, the total number of rectal cancer patients in the region was systematically known and the main prognostic factors, such as tumor–node–metastasis (TNM) stage, histology, tumor location and residual tumor were ascertained. In parallel, clinicians completed standardized forms concerning patients' domicile, tumor diagnosis, primary therapy, follow-up and palliative care. Doctors' letters and radiotherapy reports were also available. Life status was maintained systematically through death certificates and the inhabitants' registration office.

Data quality and register coverage
The cooperation of all pathology laboratories provides the basis for incidence. Documentation from different sources leads to a high completeness of data. In comparison with the German Saarland Cancer Registry, where for 1998 age standardized (world) incidence rates (per 100 000 population) were 18.6 (male) and 11.3 (female), the Munich rates are comparable with 16.8 (male) and 8.9 (female). Completeness concerning progression-events is different. Estimated by relative survival there is probably underdocumentation of metastases. Local recurrences, however, are almost complete following surgical removal and documentation of pathological reports. At present, follow-up, in terms of life status, is available in ~95% of the catchment area for patients registered since 1978, and for patients registered in the field study almost 99%. The Bavarian Cancer Registration Law came into force at the beginning of 1998, allowing the MCR to legally process all death certificates from the catchment area. A ‘death certificate only’ (DCO) rate, therefore, for the years 1996–1998 would not be meaningful. The proportion of microscopically verified cases of rectal cancer is over 90%.

Patient sample
Tumors found 16 cm or less from the anal margin were recorded as rectal cancer. A total of 1038 patients (living and treated in the Munich region) were diagnosed with rectal cancer between 1996 and 1998. Patients with an in situ carcinoma (n=5) or evidence of another previous or synchronous cancer (n=89; 8.6%) were excluded from this analysis. The analysis was therefore performed on the 936 patients with an invasive primary rectal cancer tumor. Survival status was assessed in June 2003, allowing at least 5 years of follow-up.

Prognostic variables
The following prognostic data were available: stage [International Union Against Cancer (UICC) and TNM], disease spread (local, regional and distant), grading, age, gender, tumor location, local recurrence, residual tumor status, adjuvant therapy and operative technique. Table 1 shows the comparison between UICC or American Joint Committee on Cancer (AJCC) stage, pT category, and the now redundant Duke's stage [10Go]. The Surveillance Epidemiology and End Results (SEER) data are divided into local, regional and distant spread, and this system is also illustrated in Table 1, in comparison with the other stage definitions. Age was divided into <65 and ≥65 years, to allow comparison with other registry data, which often use this age categorization. There were four tumor location classifications: <4 cm, 4 to <8 cm, 8 to <12 cm and >12 cm (to 16 cm). Although published studies speak of local recurrence, the definitions given indicate that, strictly speaking, they mean locoregional recurrence. For continuity, the term local recurrence will also be used throughout this paper but is defined as any recurrence of rectal cancer within the pelvis. Residual tumor (R) status was R0 (no residual tumor) compared with RX (presence of residual tumor cannot be assessed), R1(microscopic residual tumor) and R2 (macroscopic residual tumor) combined. Five adjuvant therapy possibilities were recorded: no therapy, preoperative neo-adjuvant therapy, radiation therapy only, chemotherapy only, and combined radiation and chemotherapy. Patients who received preoperative therapy were not accorded a traditional postoperative UICC or TNM stage. These patients were therefore excluded from all stage analyses. Patients with disease progression who received preoperative therapy were coded as M1 or UICC IV and included in the analyses. The operative technique, total mesorectal excision (TME), was recorded in the original operation reports and extracted from these. This may have resulted in under documentation of TME, as clinicians appear to have been reluctant to use this term, despite removing the mesorectum, because they had been performing such an operation before TME was reported.


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Table 1. Comparisons of disease staging systems for rectal cancer

 
Statistical analyses
The MCR data are managed in an Oracle database. The statistical analyses were run in SAS (version 6.1) and SPSS (version 11.5). Observed (unadjusted overall) survival was first estimated with the Kaplan–Meier method and tested with the log-rank procedure. The Kaplan–Meier curves discontinue when <10 at-risk patients remain. Relative survival was computed by the ratio of the observed survival rate to the expected survival rate [11Go]. The expected survival time of age- and gender-matched individuals was calculated from the life tables of the ‘general’ German population. Relative survival is thus used as an estimate for disease-specific survival. The 5-year relative rates for each prognostic factor were estimated. Observed survival was then investigated with a Cox proportional hazards regression model. Hazard ratios (HRs) and 95% confidence intervals (CIs) are presented. The assessed prognostic factors were entered simultaneously as independent variables in the multivariate analyses. Finally, the results were compared with available data from other cancer registries and published data.


    Results
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Patient sample
Table 2 shows the prognostic characteristics of the rectal cancer sample. One hundred and eight patients (11%) could not be given a disease stage. Of these, 72 had neo-adjuvant, preoperative therapy, meaning a traditional postoperative stage was invalid. Twelve of the total 84 neo-adjuvant patients had advanced disease (metastases) at diagnosis and were classified as UICC IV/M1. The remaining 36 patients either did not have the tumor removed or the records did not provide stage information. Five patients who were in UICC disease stage III had lymph node status data but no tumor diameter was recorded. Therefore, they could not be given a TNM classification. Grading was unavailable for 51 patients (5.4%). A total of 143 patients did not have residual tumor information (15.3%). Twenty-five patients (2.6%) did not have a tumor location. Thirty-two patients were lost to follow-up. Median follow-up time of survivors was 5.7 years.


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Table 2. Patient characteristics (n=936) and impact of prognostic factors on survival in a Cox Model (n=759)

 
Observed (overall), relative and expected survival rates for the whole sample are presented in Figure 1. This indicates that more than half of the patients survived for at least 5 years. Five-year observed survival was 52.7%; 5-year relative survival was 62.2%. To identify the influence of the main prognostic factors on observed survival, a Cox survival analysis was performed. Table 2 shows the results of this analysis, alongside the sample details for each prognostic factor. As expected, the strongest prognostic factor was UICC stage. Figure 2 shows the relative survival rates by UICC stage where the difference in survival can be seen clearly. Figure 3 indicates, however, that if UICC III patients with involved lymph nodes are divided into those with pT1-2 and pT3-4 size tumors, those with smaller tumors have higher relative survival rates. In the multivariate model (not shown), this effect was reflected in odds ratios of 2.7 and 4.9 for the two tumor sizes in this UICC stage.



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Figure 1. Expected, relative and observed survival curves.

 


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Figure 2. Relative survival curves for each International Union Against Cancer (UICC) stage.

 


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Figure 3. Relative survival curves for each tumor–node–metastasis (TNM) category.

 
Table 3 shows 5-year relative survival rates for the main prognostic factors for each UICC stage. Doctors may use this to estimate tumor-specific survival for their own patients. For UICC I patients >65 years old, with a high tumor location, and operated by the TME technique, relative survival was higher than expected in the ‘normal’ population. Better surveillance for all illnesses due to the rectal cancer treatment and follow-up may have contributed to this result.


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Table 3. Five-year relative survival by main prognostic factors

 
Table 4 compares the Munich Field Study data with the available SEER data for 1992–1999 [12Go]. The stage distributions (based on the SEER system) and 5-year relative survival rates are fairly similar. We have divided our ‘unstaged’ data into those who received neo-adjuvant therapy (without a traditional postoperative stage) and those who had incomplete stage information, due to insufficient documentation or incomplete tumor removal. Our ‘truly’ unstaged data are comparable to the SEER data. Figure 4 pictorially presents the relative survival rates of patients in Munich with localized, regional and distant tumor stages.


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Table 4. Stage distribution and relative survival rates compared with the 1992–1999 SEER data [12Go]

 


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Figure 4. Relative survival curves for local, regional and distant disease (comparable to the Surveillance Epidemiology and End Results stage system).

 
Table 5 shows relative survival rates according to the traditional UICC staging system for the Munich population, for patients from the Eindhoven Cancer Registry in the South East Netherlands, for patients from the Modena Colorectal Cancer Registry in Italy and for patients from the Côte d'Or area in France (personal communications). Relative survival rates for each stage were generally higher in Munich. However, the number of patients with poor prognoses were greater in Munich than in Eindhoven, Modena and Côte d'Or, so that for the whole population 5-year relative survival rates were fairly similar.


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Table 5. Five-year relative survival rates by disease stage in comparison with three European registries (personal communication)

 
Table 6 compares the observed (overall) survival rates for UICC stage II and III patients, where adjuvant therapy guidelines apply, with results from the randomized trials that contributed to the establishment of the treatment guidelines [13Go]. Survival rates are similar between the population-based and trial data.


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Table 6. Five-year overall (observed) survival rates compared with data from randomized control trials [13Go]

 

    Discussion
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
This paper presents a detailed overview of rectal cancer epidemiology, showing the importance of disease stage and treatment on survival. While there have been advances in the screening and treatment of rectal cancer in the last 20 years, it is not clear whether these have been implemented and resulted in survival improvements at a population level in different countries. Differences in survival between countries are presumed to reflect differences in the quality of care. Although there are treatment and screening guidelines, these tend to vary between different countries. For example, although TME was widely adopted as the gold standard for operative treatment in the 1990s, German surgeons claim to have already been removing the mesorectum before the TME technique was reported. In The Netherlands, sigmoidoscopy screening has been well established since the 1980s. In Germany at the time of this study, only fecal occult blood testing was paid for yearly by health insurers for over 45 year olds.

Figure 5 shows a summary of rectal cancer 5-year relative survival rates from five population-based reports over the last 25 years [1Go–3Go, 7Go, 14Go]. Of the two studies that showed no significant improvement since 1990, the US study also reported no improvement in disease stage during this time, suggesting no change in screening practice [1Go]. The improvement seen in the French study was attributed to an increase in surgical and adjuvant radiotherapy treatment and an increase in the percentage of Dukes' A patients, with better prognoses [2Go]. In the south-east Netherlands, relative survival improved from 1980 to 2000, but there was no stage shift in this study since good access to sigmoidoscopy has been available in the south-east Netherlands since the early 1980s. Increased survival in this group was attributed to improved surgical treatment with the TME technique and increased use of preoperative radiotherapy [3Go]. The 62% 5-year relative survival rate in Munich from 1996 to 1998 is comparable with these international studies. This overview of the literature on long-term studies shows that there has been some improvement due to screening and treatment in rectal cancer, but variations in survival between countries exist.



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Figure 5. Five-year relative survival rates (%) in population studies from 1975 to 2000 [1Go–3Go, 7Go, 14Go].

 
In a EUROCARE II publication, 5-year relative survival rates in Europe for rectal cancer between 1985 and 1989 were 42%, compared with 60% in the USA [15Go]. This difference was partly attributed to differences in stage distributions: 19% M1 patients in the USA and up to 29% in Finland. Other analyses have also found that differences in survival between different countries narrow when corrections for disease stage are made.

To conduct an up to date comparison, we have collected data from US and European registries with stage data during a similar time period to the Munich study. Compared with the south-east Netherlands, Modena and Côte d'Or, 5-year relative survival rates were slightly higher in Munich for each disease stage. However, 52% of Munich patients were in UICC stage III or IV. This indicates that treatment in Munich is good but, in comparison with other regions in Europe, our rectal cancer early detection rates are poor. Differences in treatment between The Netherlands and Germany may explain the difference in relative survival rates. For example, adjuvant chemotherapy is not recommended in The Netherlands [3Go]. In Germany, combined chemo- and radiotherapy is recommended in UICC II and III patients, and in this study this treatment provided a significant survival benefit for some patients. Another difference is that the Netherlands study indicated greater use of preoperative radiotherapy (30% versus 9%) [3Go]. Preoperative radiotherapy was recommended in this region of The Netherlands; it was not strongly recommended in Munich at this time. The greatest differences in 5-year relative survival, however, were in UICC I and II patients (8%), where adjuvant therapy is not used as much. The difference in stage distribution is likely to be due to better access to screening in south-east Netherlands [3Go]. Age differences may also play a role. Patients from The Netherlands had different 5-year relative survival rates depending on age: <60 years, 69%; 60–74 years, 63%; and 75 + years, 49% [3Go]. For the same age groups our 5-year relative survival rates were 64%, 63% and 63%. Moreover, only 25% of Munich patients were in the oldest age group compared with 36% in Eindhoven.

Our relative survival rates were more similar to the US registries in the SEER report across all stages [12Go]. It is not known whether patients undergoing neo-adjuvant therapy were included in the SEER data. If so, this may have inflated the SEER results. In Munich there were 8% fewer patients with regional spread, but 4% more M1 patients. The decrease in the number of SEER patients with distant spread (19% in 1989 [15Go] to 15% in 1999 [12Go]) would indicate improved early detection in the USA. Indeed, 48.4% (male) and 42.5% (female) of over 65 years olds had a blood test within the last year or colorectal endoscopy within the last 5 years [16Go]. One registry, in California, not included in the 1975–2000 SEER report, however, had lower incidence of UICC III tumors than Munich [17Go]. The 2-year unadjusted observed survival rates for a comparable sample in Munich were, however, higher than those reported in California. Since the 1989 comparison between Europe and the USA [15Go], when European relative survival rates were almost 20% lower, relative survival rates have not improved significantly in the USA [1Go]. In contrast, nowadays, the relative survival rates in Munich (62.2) and The Netherlands (61) [3Go] are comparable with the USA (62.4) [12Go]. Although there was less room for improvement in America, the European nations should be pleased to be making progress and ‘catching up’, so to speak.

Our analysis, as expected, showed that UICC stage was the strongest prognostic factor, even when controlling for age, operation method and treatment modalities. This indicates that more early detection of rectal cancer could improve survival rates. Fecal occult blood testing and sigmoidoscopy, for example, have been shown to reduce colorectal cancer mortality and most importantly incidence [1Go, 16Go, 18Go]. Currently in Germany, fecal occult blood testing is paid for yearly by health insurers for over 50 year olds and colonoscopy is recommended at 55 and 65 years. No program exists, however, to ensure that the population is systematically offered these tests or invited to attend screening. There is a vast literature that indicates which groups should be targeted and how attendance can be improved. If screening is to increase, however, diagnostic facilities and funding are required [18Go].

In the Munich population, operative technique and adjuvant therapy treatment were also significant predictors of survival. Such details are often not available in population-based studies. The 5-year relative survival for patients in the Munich population treated with TME (76.2%) was comparable with the survival rate (80%) achieved by Heald himself, the founder of TME [19Go]. The 5-year relative survival benefits of combined therapy were also comparable with a national US sample [20Go] and the Munich data for 5-year observed survival compared well with data from RCTs investigating adjuvant therapy treatment [13Go]. The recurrence rates in these trials were high, however, indicating that good surgical control may also have contributed to the high survival rates in Munich. Nonetheless, this would suggest that when treatments are implemented outside of trials they achieve similar survival benefits. For improvements in survival to be seen, however, more patients would have to receive the recommended therapy. In this sample only one-third of patients received the recommended combined adjuvant therapy and less than one-quarter of surgeons reported using the TME technique.

While it is useful for doctors to know how they are performing in comparison with other countries and hospitals, it is equally important for cancer patients to know their prognosis. With improved treatment and earlier diagnosis, survival rates in some cancers are now relatively high. Some stages have relative survival rates comparable with expected survival rates in the ‘normal’ population, for example. For rectal cancer patients in UICC stage I, 97% were likely to live for >5 years after their diagnosis. Patients should hear this good news when applicable, especially since cancer is still considered a death sentence. Furthermore, to enable informed treatment decisions, patients must also be aware of their survival chances with different therapy alternatives. Patients should at least be informed and given the opportunity to discuss treatment options, even if ultimately they prefer the physician to choose or make a recommendation. In response to this trend, many useful decision-making models and tools have been developed to help the doctor and patient [21Go]. Although these tools may be valuable, without accurate population-based survival data to compare in the models, their use is limited. Population data, provided by cancer registries, is therefore extremely important for both doctors and patients.

In conclusion, we can say that in comparison with Europe, the survival rates in Munich were high but the early detection rates poor. In comparison with RCTs, our treatment effects were good, but the application of recommended treatment in the population could be improved. To help to improve routine care, the MCR must provide regular feedback to doctors on their performance, for example through the Internet. Of greatest importance, however, is the implementation of a systematic colorectal cancer screening program, drawing on the vast literature investigating how to increase screening acceptance and uptake. In addition, doctors can ease the burden and fear of cancer by giving patients detailed information about their chances of survival. Finally, this paper has shown that it is unwise to compare data across countries without stage data: the media and politicians should take note. Even with stage data, comparisons are difficult because of population variations, and different analysis and treatment strategies. Despite limitations of some missing data for prognostic factors and of missing covariates for some process quality indicators, e.g. for exact adjuvant treatment, it is useful to communicate distributions of prognostic factors and survival, thus describing whether results of innovative clinical trials have transferred to population level care [22Go].


    Acknowledgements
 
We appreciate the cooperation of Lonneke van de Poll and Jan Willem Coebergh from Eindhoven Cancer Registry, Piero Benatti from Modena Colorectal Cancer Registry, and Stephanie Norman and Jean Faivre from the Côte d'Or Cancer Registry, and thank them for providing us with stage survival comparisons. We would also like to thank the MCR staff for their cooperation and the reliable infrastructure. Such a work-intensive observational study is impossible without dedicated staff. The Munich Field Study is funded by the Federal Ministry of Health. The Munich Field Study is integrated in the MCR, which is part of the Munich Comprehensive Cancer Center, an institution of the Ludwig-Maximilians-Universität und der Technischen Universität. Additionally, funding is given by the Deutsche Krebshilfe, and the Bavarian Ministry of Health. Additionally, we thank all the following hospitals and departments that participated in the documentation of the medical data: Klinikum rechts der Isar der TU, Chirurgische Klinik und Poliklinik (Professor Siewert, PD Dr Nekarda, Dr Vogelsang, Dr Snopkowski); Klinikum der Ludwig Maximilians Universität–Großhadern, Chirurgische Klinik und Poliklinik (Professor Jauch, Professor Schildberg (em.), PD Dr Heiss, Dr Lau-Werner, PD Dr Müller, Dr Hornung); Klinikum der Ludwig Maximilians Universität–Innenstadt, Chirurgische Klinik und Poliklinik (Professor Mutschler, Professor Siebeck, Dr Schorr); Städt. Krankenhaus München-Neuperlach, 1. Chirurgische Abteilung (Professor Günther, Dr Staimmer, Dr Bergmann, Dr Holzfurtner, Dr Langer); Städt. Krankenhaus München-Schwabing, Visz. Chirurgische Abteilung (Professor Waldner, Dr Göring); Städt. Krankenhaus München-Harlaching, Chirurgische Abteilung (Professor Horn, Dr Kluge); Städt. Krankenhaus München-Bogenhausen, Abteilung für Allgemein- und Unfallchirurgie (Professor Heitland, Dr Wilhelm); Kreisklinik Fürstenfeldbruck, Chirurgische Abteilung (Dr Knapp, Dr Kauffmann, Dr Gyßling); Rotkreuzkrankenhaus, Chirurgische Abteilung (Professor Schoenberg, Dr Paskuda, Dr Fuchs); Krankenhaus des Dritten Ordens, Abteilung Allgemein- und Gefäßchirurgie, Schilddrüsenchirurgie (Dr Pütterich, Dr Löppert); Krankenhaus der Barmherzigen Brüder, Chirurgische Abteilung (Professor Reuter, Dr Papadakis); Maria-Theresia-Klinik, Chirurgische Abteilung (Dr Hoffmann, Dr Zimmermann, Dr Grunow, Dr Konietzny); Privatklinik Dr Rinecker, Chirurgie (Dr Rinecker, Dr Göring); Kreiskrankenhaus München-Pasing, Kreiskrankenhaus München-Pasing (Dr Laqua, Dr Kießling); Kreiskrankenhaus Landshut-Achdorf, Chirurgische Abteilung (Professor Raab); Klinikum Landshut, Chirurgische Abteilung (Dr Filler); Privatklinik Bogenhausen, Chirurgie (Dr Huber, Dr Osterholzer, Dr Schmick); Kreiskrankenhaus Starnberg, Chirurgische Abteilung (Professor Stahlknecht, Dr Schmitz); Chirurgische Klinik Seefeld (Dr Hermes, Dr Hofinger); Kreisklinik Dachau, Abteilung für Allgemeinchirurgie (Dr Birkhofer, Dr Hildebrand); Kreiskrankenhaus Ebersberg, Chirurgische Abteilung (Professor Dostal, Dr Molitor, Dr Sobez); Krankenhaus der Missionsbenediktinerinnen Tutzing, Chirurgische Abteilung (Dr Wiesmeier, Dr Dietl); Kreiskrankenhaus Erding, Abteilung für Viszeral- und Thoraxchirurgie (Dr Boedecker, Dr Nagel, Dr Maier); Privatklinik Josephinum, Chirurgische Abteilung (Dr Holzmann, Dr Grube, Dr Sassen); Kreiskrankenhaus Freising, Chirurgische Abteilung (Dr Zeller, Dr Hirster); Klinik Dr Wolfart, Chirurgische Abteilung (Dr Hungbauer, Dr Czerny); Klinik Dr Schreiber, Chirurgische Abteilung (Dr Schreiber); Krankenhaus Martha Maria, Chirurgie (Dr Fürst, Professor Spelsberg); Kreiskrankenhaus München-Perlach, Chirurgische Abteilung (Dr Burghart, Dr Scharff); Klinik Olympiapark, Chirurgie (Dr Buess).

Received for publication July 26, 2004. Revision received November 19, 2004. Accepted for publication November 23, 2004.


    References
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
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