The references included in this review were identified from the author's personal knowledge of the field, reference lists from relevant previously published works, and abstracts and personal communications from relevant meetings. A detailed search of PubMed using the terms “total mesorectal excision”, “quality of surgery”, and “circumferential margin” was also done. Prominent researchers known to be active in the field were searched for by name and their latest papers were included.
ReviewTraining and quality assurance for rectal cancer: 20 years of data is enough
Section snippets
Surgery for rectal cancer
Local recurrence rates for rectal cancer vary from around 6% to 50%, 14, 15, 16, 17, 18 and outcomes differ widely between 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and between surgeons.19, 20 As a result, 5–year survival can vary from 30% to 68%.3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 However, variations in surgical performance can also have profound effects on quality of life and cause syndromes including permanent stoma formation, incontinence of faeces and urine,
Standard surgery versus mesorectal excision
Standard surgical technique describes the removal of the rectum by blunt digital dissection. This procedure was reported as recently as 200222—a United States surgical textbook describes the “sucking noise” made by removal of the rectum via blunt digital dissection. Such traumatic surgery not only leads to a failure to remove the mesorectum intact but also frequently disrupts important pelvic nerves. The alternative approach, mesorectal excision, 3 involves removal of the mesorectum by sharp
Pathological evidence for variation in the quality of surgery
Two pathological assessments seem to be important in judging the standard of surgery: CRM involvement and the gross appearance of the surgically resected specimen. The frequency of abdominoperineal excision also seems to be an indicator of the technical expertise of the surgeon with abdominoperineal excision rates falling with surgical tuition for mesorectal excision.12, 34, 35
The circumferential margin is an extensive surgically created plane of dissection produced during the removal of the
The effect of adoption of mesorectal excision
Heald has been training surgeons for 20 years, leading to a number of single-surgeon or centre series10, 46, 47, 48 where use of mesorectal excision had an immediate effect on local recurrence and rates of permanent stoma formation. Since 1994, Heald has been invited to undertake TME surgical training programmes in Norway11 and Stockholm, 12 and to train surgeons in the Dutch study comparing TME with TME plus short-course Swedish-style radiotherapy.13 “British-style” pathology training was also
The role of the oncologist
The value of short-course radiotherapy for all patients undergoing resection for rectal cancer is still controversial.13, 52, 53 It is clear that risk of local recurrence can be reduced, 13, 52 but in the presence of excellent surgery its effect on long-term survival is still unproven. The ongoing MRC CR07 trial will add further evidence to this debate, particuarly about the value of short-course radiotherapy with respect to the completeness and quality of surgery.
For advanced rectal cancer,
Radiology
Application of newer MRI techniques has had a substantial effect on selection of patients with rectal cancer for individualised therapy.56, 57, 58, 59, 60, 61 For the first time, the surgical planes of resection can be clearly seen and sites where tumour or deposits reside can be visualised. This technology can also help assess the ease of the operation and how likely it is that the tumour can be successfully cleared. Multidisciplinary teams are now able to debate and plan appropriate therapy.
Pathology
The pathologist is also an important member of the team. In addition to assessing the completeness of excision and auditing the quality of surgery, they have several crucial roles. They must interact closely with the radiologist to ensure quality control for MRI diagnoses. Comparison of scans and macroscopic photographs of resected tissue samples at multidisciplinary team meetings is also essential. It is important to establish the number of tumour-positive lymph nodes63, 64, 65 with as high a
North America
Despite the efforts of Enker, 8, 9 recognition of the importance of improving quality of surgery and pathology has been slow to develop in the USA and Canada. Pockets of interest exist, and undoubtedly there are good TME surgeons, 68, 69 but it is only recently that official surgical and pathology guidelines have included reporting the CRM.70, 71, 72 Remarkably, there are no published papers on the frequency of CRM involvement and its association with survival in North America, and the
Where do we go now?
We now have excellent evidence that rectal cancer requires a multi-disciplinary approach with a focus on achievement of clear circumferential mesorectal and levator surgical margins. Use of MRI to predict potentially involved margins preoperatively enables treatment teams to shrink or destroy the tumour with neoadjuvant therapy before an attempt at curative surgery is made. Optimum surgical technique will enable clearance of CRM, and good histopathology will confirm complete removal and provide
Financial benefits
Assuming a programme cost of £6 million and a 3–year period when 30 000 patients will present with rectal cancer in England, the individual cost per patient would be less than £200. If there is a 20% reduction in cancer deaths then each will have been bought at a cost of £1000. Given that the team skills are likely to improve with time, and not deteriorate, over 10 years the figures change to less than £60 per patient and below £300 for each life saved. Such value for money does not include the
Search strategy and selection criteria
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(2002)