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Diseases of the Colon & Rectum

, Volume 45, Issue 7, pp 857–866 | Cite as

A National Strategic Change in Treatment Policy for Rectal Cancer—Implementation of Total Mesorectal Excision as Routine Treatment in Norway. A National Audit

  • Arne Wibe
  • Bjørn Møller
  • Jarle Norstein
  • Erik Carlsen
  • Johan N. Wiig
  • Richard J. Heald
  • Frøydis Langmark
  • Helge E. Myrvold
  • Odd Søreide
Original Contribution

Abstract

INTRODUCTION: Rectal cancer surgery has been characterized by a high incidence of local recurrence, an occurrence which influences survival negatively. In Norway there was a growing recognition that local recurrence rates were related to surgeon performance and that surgeons applying a standardized surgical technique in the form of total mesorectal excision could achieve better results. This contrasts with the prevailing argument voiced by many opinion leaders that local recurrence rates and possibly survival rates can only be improved by adjuvant or neoadjuvant treatment strategies. The Norwegian Rectal Cancer Project—initiated in 1993—aimed at improving the outcome of patients with rectal cancer by implementing total mesorectal excision as the standard rectal resection technique. METHODS: This observational national cohort study covers all new patients (3,319) with rectal cancer from a population of 4.5 million treated between November 1993 and August 1997. The main outcome measures were local recurrence, survival, and postoperative mortality and morbidity rates. The technique of total mesorectal excision was compared with conventional surgery. RESULTS: The proportion of patients undergoing total mesorectal excision was 78 percent in 1994, increasing to 92 percent in 1997. The observed local recurrence rate for patients undergoing a curative resection was 6 percent in the group treated by total mesorectal excision and 12 percent in the conventional surgery group. Four-year survival rate was 73 percent after total mesorectal excision and 60 percent after conventional surgery. Postoperative mortality rate was 3 percent and the anastomotic dehiscence rate was 10 percent. Radiotherapy was given to 5 percent and chemotherapy to 3 percent of the patients in the curative resection group. CONCLUSION: A refinement of the surgical resection technique for rectal cancer can be achieved on a national level, the technique of total mesorectal excision can be widely distributed, and surgery alone can give good results.

Keywords

Total mesorectal excision Rectal cancer Local recurrence Anastomotic dehiscence Survival 

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References

  1. 1.
    Hermanek, P, Wiebelt, H, Staimmer, D, Riedl, S 1995Prognostic factors of rectum carcinoma—experience from the German Multicentre Study SGCRC. German Study Group Colo-Rectal CarcinomaTumori816064Google Scholar
  2. 2.
    Holm, T, Johansson, H, Cedermark, B 1997Influence of hospital- and surgeon-related factors on outcome after treatment of rectal cancer with or without preoperative radiotherapyBr J Surg84657663Google Scholar
  3. 3.
  4. 4.
    Bjerkeset, T, Edna, TH 1996Rectal cancerEur J Surg162643648Google Scholar
  5. 5.
    O Rein, KA, Wiig, JN, Sæther, OD, Myrvold, HE 1987Local recurrence in patients with rectal cancerTidsskr Nor Laegeforen10723182320Google Scholar
  6. 6.
    Heald, RJ, Husband, EM, Ryall, RD 1982The mesorectum in rectal cancer surgery—the clue to pelvic recurrence?Br J Surg69613616Google Scholar
  7. 7.
    Heald, RJ, Ryall, RD 1986Recurrence and survival after total mesorectal excision for rectal cancerLancet114791482Google Scholar
  8. 8.
    Isbister, WH 1990Basingstoke revisitedAust N Z J Surg60243246Google Scholar
  9. 10.
    Søreide, O, Norstein, J 1997Local recurrence after operative treatment of rectal carcinomaJ Am Coll Surg1848492Google Scholar
  10. 11.
    Wiig, JN, Carlsen, E, Søreide, O 1998Mesorectal excision for rectal cancerSemin Surg Oncol157886Google Scholar
  11. 12.
    Fielding, LP, Arsenault, PA, Chapuis, PH 1991Clinicopathological staging for colorectal cancerJ Gastroenterol Hepatol6325344Google Scholar
  12. 14.
    Heald, RJ, Moran, BJ 1998Embryology and anatomy of the rectumSemin Surg Oncol156671Google Scholar
  13. 16.
    Marsh, PJ, James, RD, Schofield, PF 1995Definition of local recurrence after surgery for rectal carcinomaBr J Surg82465468Google Scholar
  14. 18.
    Dahlberg, M, Påhlman, L, Bergstrom, R, Glimelius, B 1998Improved survival in patients with rectal cancerBr J Surg85515520Google Scholar
  15. 19.
    Abulafi, AM, Williams, NS 1994Local recurrence of colorectal cancerBr J Surg81719Google Scholar
  16. 21.
    Bonfanti, G, Bozzetti, F, Doci, R 1982Results of extended surgery for cancer of the rectum and sigmoidBr J Surg69305307Google Scholar
  17. 22.
    Durdey, P, Williams, NS 1984The effect of malignant and inflammatory fixation of rectal carcinoma on prognosis after rectal excisionBr J Surg71787790Google Scholar
  18. 23.
    Hida, J, Mori, N, Kubo, R 1994Metastasis from carcinoma of the colon and rectum detected in small lymph nodes by the clearing methodJ Am Coll Surg178223228Google Scholar
  19. 24.
    Feinstein, AR, Sosis, DM, Wells, CK 1985The Will-Rogers phenomenonN Engl J Med31216041608Google Scholar
  20. 25.
    Hermanek, P 1995pTNM and residual tumour classificationWorld J Surg19184190Google Scholar

Copyright information

© The American Society of Colon and Rectal Surgeons 2002

Authors and Affiliations

  • Arne Wibe
    • 1
  • Bjørn Møller
    • 1
  • Jarle Norstein
    • 1
  • Erik Carlsen
    • 1
  • Johan N. Wiig
    • 1
  • Richard J. Heald
    • 1
  • Frøydis Langmark
    • 1
  • Helge E. Myrvold
    • 1
  • Odd Søreide
    • 1
  1. 1.University Hospital Trondheim, Trondheim, Norway, The Cancer Registry of Norway, Oslo, Norway, Ullevaal Hospital, Oslo, Norway, The Norwegian Radium Hospital, Oslo, Norway, The North Hampshire Hospital, Basingstoke, England, and The National Hospital, OsloNorway

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