Skip to main content

Advertisement

SpringerLink
Log in

Evaluation of quality indicators following implementation of total mesorectal excision in primarily resected rectal cancer changed future management

  • Original Article
  • Published:
International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Background and aims

We evaluated the outcome of primarily resected rectal cancer patients immediately after the implementation of total meserectal excision (TME) based on potential quality indicators.

Patients and methods

Following initial teaching of two staff surgeons (PMS and AHH) by RJ Heald, 164 consecutive patients were analyzed. The following quality indicators were evaluated: (a) frequency of local recurrence, (b) number of resected lymph nodes, (c) selection of operative technique depending on tumor localization, (d) use of a protective loop ileostomy, and (e) frequency and type of adjuvant therapy.

Results

Local recurrence rate was 8.5% after a minimum follow-up of 5 years. An increasing pT category (p < 0.02) and the presence of lymph node metastases (pN+, p < 0.05) were significantly associated with local recurrence rates. The number of resected lymph nodes was significantly associated with nodal metastases rate (p < 0.02). Patients with distal third rectal cancer underwent significantly more often an abdominoperineal amputation (p < 0.0001). Clinical course, but not the rate of anastomotic leakage (9.5%) itself was influenced by using a protective loop ileostomy. Forty-two (29.7%) patients received adjuvant therapy; however, local recurrence rate was higher in patients with adjuvant chemo-/radiotherapy (14.2% vs. 6.1%).

Conclusions

The local recurrence rate of 8.5% demonstrates that through consequent implementation of TME excellent onclogical results can be achieved. The number of resected lymph nodes significantly influenced the pN category. The primary construction of a protective loop ileostomy after TME became standard. Neoadjuvant chemoradiation was systematically introduced in order to improve local tumor control and prevent abdominoperineal amputations. No conclusions can be drawn concerning adjuvant therapy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Kapiteijn E, van de Velde CJ (2002) Developments and quality assurance in rectal cancer surgery. Eur J Cancer 38:919–36

    Article  PubMed  CAS  Google Scholar 

  2. Peeters KC, van de Velde CJ (2005) Surgical quality assurance in rectal cancer treatment: the key to improved outcome. Eur J Surg Oncol 31:630–5

    Article  PubMed  CAS  Google Scholar 

  3. Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616

    Article  PubMed  CAS  Google Scholar 

  4. Heald RJ, Ryall RD (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet i:1479–1482

    Article  Google Scholar 

  5. MacFarlane JK, Ryall RD, Heald RJ (1993) Mesorectal excision for rectal cancer. Lancet 341:457–60

    Article  PubMed  CAS  Google Scholar 

  6. Harmon JW, Tang DG, Gordon TA, Bowman HM, Choti MA, Kaufman HS, Bender JS, Duncan MD, Magnuson TH, Lillemoe KD, Cameron JL (1999) Hospital volume can serve as a surrogate for surgeon volume for achieving excellent outcomes in colorectal resection. Ann Surg 230:404–11

    Article  PubMed  CAS  Google Scholar 

  7. Marusch F, Koch A, Schmidt U, Zippel R, Lehmann M, Czarnetzki HD, Knoop M, Geissler S, Pross M, Gastinger I, Lippert H (2001) Effect of caseload on the short-term outcome of colon surgery: results of a multicenter study. Int J Colorectal Dis 16:362–9

    Article  PubMed  CAS  Google Scholar 

  8. Mack LA, Temple WJ (2005) Education is the key to quality of surgery for rectal cancer. Eur J Surg Oncol 31:636–44

    Article  PubMed  CAS  Google Scholar 

  9. Martling A, Holm T, Rutquist L-E, Moran BJ, Heald RJ, Cedermark B (2000) Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Lancet 356:93–6

    Article  PubMed  CAS  Google Scholar 

  10. Wibe A, Carlsen E, Dahl O, Tveit KM, Weedon-Fekjaer H, Hestvik UE, Wiig JN, The Norwegian Rectal Cancer Group (2006) Nationwide quality assurance of rectal cancer treatment. Colorectal Dis 8:224–9

    Article  PubMed  CAS  Google Scholar 

  11. UICC (2002) TNM classification of malignant tumours, 6th edn. Sobin LH,Wittekind C (eds) Wiley-Liss, NewYork.

  12. Bittner R, Burghardt J, Gross E, Grundmann RT, Hermanek P, Isbert C, Junginger T, Köckeling F, Merkel S, Möslein G, Raab HR, Roder J, Ruf G, Schwenk W, Strassburg J, Tannapfel A, de Vries A, Zühlke H (2007) Quality indicators for diagnosis and therapy of rectal carcinoma. Zentralblatt Chir 132:85–94

    Article  CAS  Google Scholar 

  13. Prandi M, Lionetto R, Bini A, Francioni G, Accarpio G, Anfossi A, Ballario E, Becchi G, Bonilauri S, Carobbi A, Cavaliere P, Garcea D, Giuliani L, Morziani E, Mosca F, Mussa A, Pasqualini M, Poddie D, Tonetti F, Zardo L, Rosso R (2002) Prognostic evaluation of stage B colon cancer patients is improved by an adequate lymphadenectomy: results of a secondary analysis of a large scale adjuvant trial. Ann Surg 235:458–63

    Article  PubMed  Google Scholar 

  14. Kim J, Huynh R, Abraham I, Kim E, Kumar RR (2006) Number of lymph nodes examined and its impact on colorectal cancer staging. Am Surg 72:902–5

    PubMed  Google Scholar 

  15. Tsai HL, Lu CY, Hsieh JS, Wu DC, Jan CM, Chai CY, Chu KS, Chan HM, Wang JY (2007) The prognostic significance of total lymph node harvest in patients with T2-4N0M0 colorectal cancer. J Gastrointest Surg 11:660–5

    Article  PubMed  Google Scholar 

  16. Schiessel R, Novi G, Holzer B, Rosen HR, Renner K, Hölbling N, Feil W, Urban M (2005) Technique and long-term results of intersphincteric resection for low rectal cancer. Dis Colon Rectum 48:1858–65

    Article  PubMed  Google Scholar 

  17. Wallace MH, Glynne-Jones R (2007) Saving the sphincter in rectal cancer: are we prepared to change practice? Colorectal Dis 9:302–8

    Article  PubMed  CAS  Google Scholar 

  18. Zolciak A, Bujko K, Kepka L, Oledzki J, Rutkowski A, Nowacki MP (2006) Abdominoperineal resection or anterior resection for rectal cancer: patient preferences before and after treatment. Colorectal Dis 8:575–80

    Article  PubMed  CAS  Google Scholar 

  19. Bossema E, Stiggelbout A, Baas-Thijssen M, van de Velde C, Marijnen C (2008) Patients’ preferences for low rectal cancer surgery. Eur J Surg Oncol 34(1):42–48

    PubMed  CAS  Google Scholar 

  20. Gastinger I, Marusch F, Steinert R, Wolff S, Koeckerling F, Lippert H (2005) Working Group ‘Colon/Rectum Carcinoma’. Protective defunctioning stoma in low anterior resection for rectal carcinoma. Br J Surg 92:1137–42

    Article  PubMed  CAS  Google Scholar 

  21. Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R (2007) Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 246:207–14

    Article  PubMed  Google Scholar 

  22. Arenas RB, Fichera A, Mhoon D et al (1998) Total mesenteric excision in the surgical treatment of rectal cancer: a prospective study. Arch Surg 133:608–611

    Article  PubMed  CAS  Google Scholar 

  23. Tocchi A, Mazzoni G, Lepre L et al (2001) Total mesorectal excision and low rectal anastomosis for the treatment of rectal cancer and prevention of pelvic recurrences. Arch Surg 136:216–220

    Article  PubMed  CAS  Google Scholar 

  24. Law WL, Chu KW (2004) Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients. Ann Surg 240:260–8

    Article  PubMed  Google Scholar 

  25. Bernardshaw SV, Øvrebø K, Eide GE, Skarstein A, Røkke O (2006) Treatment of rectal cancer: reduction of local recurrence after the introduction of TME—experience from one University Hospital. Dig Surg 23:51–9

    Article  PubMed  Google Scholar 

  26. Nagtegaal ID, van de Velde, Marijnen CA (2005) Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol 23:9257–64

    Article  PubMed  Google Scholar 

  27. Merkel S, Mannsmann U, Hohenberger W, Hermanek P (2009) Time to locoregional recurrence after curative resection of rectal carcinoma is prolonged after neoadjuvant treatment. A systematic review and meta-analysis. Colorectal Disease 13(2):123–131

    Article  Google Scholar 

  28. Quirke P, Morris E (2007) Reporting colorectal cancer. Histopathology 50:103–112

    Article  PubMed  CAS  Google Scholar 

  29. Engel J, Kerr J, Eckel R, Günther B, Heiss M, Heitland W, Jauch KW, Siewert JR, Hölzel D (2005) Quality of treatment in routine care in a population sample of rectal cancer patients. Acta Oncol 44:65–74

    Article  PubMed  Google Scholar 

  30. Douglass HO Jr, Moertel CG, Mayer RJ et al (1986) Survival after postoperative combination treatment of rectal cancer. N Engl J Med 315:1294–1295

    Article  PubMed  Google Scholar 

  31. Krook JE, Moertel CG, Gunderson LL et al (1991) Effective surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med 324:709–715

    Article  PubMed  CAS  Google Scholar 

  32. Gastrointestinal Tumor Study Group (1985) Prolongation of the disease-free interval in surgically treated rectal carcinoma. N Engl J Med 312:1465–1472

    Article  Google Scholar 

  33. O’Connell MJ, Martenson JA, Wieand HS et al (1994) Improving adjuvant therapy for rectal cancer by combining protracted-infusion fluorouracil with radiation therapy after curative surgery. N Engl J Med 331:502–507

    Article  PubMed  Google Scholar 

  34. Sauer R, Becker H, Hohenberger W et al (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of General, Visceral and Tumor Surgery, University of Cologne, Cologne, Germany

    Paul M. Schneider, Daniel Vallbohmer, Yvonne Ploenes, Georg Lurje, Ralf Metzger, Frederike C. Ling, Jan Brabender & Arnulf H. Hoelscher

  2. Department of Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland

    Paul M. Schneider & Georg Lurje

  3. Institute of Pathology, University of Cologne, Cologne, Germany

    Uta Drebber

Authors
  1. Paul M. Schneider
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daniel Vallbohmer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yvonne Ploenes
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Georg Lurje
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ralf Metzger
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Frederike C. Ling
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jan Brabender
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Uta Drebber
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Arnulf H. Hoelscher
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Paul M. Schneider.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Schneider, P.M., Vallbohmer, D., Ploenes, Y. et al. Evaluation of quality indicators following implementation of total mesorectal excision in primarily resected rectal cancer changed future management. Int J Colorectal Dis 26, 903–909 (2011). https://doi.org/10.1007/s00384-011-1155-2

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-011-1155-2

Keywords

Search

Navigation