AbstractsMedical & Health Science

Quality of total mesorectal excision, quality of care and prognostic factors of rectal cancer

by Daniel Leonard

Institution: Université Catholique de Louvain
Department: Institut de recherche expérimentale et clinique
Year: 2015
Keywords: Rectal cancer; Oncological outcome; Surgery; Quality indicators
Record ID: 1076038
Full text PDF: http://hdl.handle.net/2078.1/156354


The mainstay of rectal cancer treatment still relies on surgical resection, which has evolved from blunt and blind dissection to total mesorectal excision (TME) using sharp dissection under direct vision. The TME technique, popularized by Sir Heald, aims at removing the rectum and its lymphatic drainage together with the surrounding fascia recti, resulting at best in a surgical specimen with a smooth mesorectal surface. Oncological results have improved dramatically since the implementation of TME and have been shown to be influenced by the quality of TME reflected in the aspect of the specimen. In Chapter 1, based on a subgroup of 266 patients registered in the PROCARE database, we found that TME quality depends on patient, surgical and pathological factors. Univariate analyses showed that the surgeon, female gender, pathological BMI, negative clinically assessed nodal status (cN), a lower limit of the rectal cancer, cT3 to cT4 tumours not responding to neoadjuvant chemoradiation, laparoscopic resection, and APR were all significantly associated with incomplete mesorectal excision. Pathologic BMI, the absence of downstaging after long-course chemoradiation and laparoscopic resection were identified as independent prognostic factors. Even if the role of surgery remains a treatment cornerstone, modern rectal cancer management is multimodal, i.e. multidisciplinary. Consequently, in Chapter 2 the potential effect of surgical experience and volume was analysed in the broader context of hospital volume. Using a sample of 1469 patients, we investigated the impact of experience or volume of centres on the performance of every discipline involved in the management of rectal cancer as well as on the whole team's performance. Quality of care indicators and long-term oncological outcome were the end-points. The conclusions of Chapter 2 were in favour of a modest but significant effect of patient volume on surgical outcome, specifically on the rates of sphincter saving procedure and radical (R0) resections. An association was also found between hospital volume and neodjuvant treatment for cTNM stage II-III, pCRM reporting and number of lymph nodes examined in the TME specimen after CRT. Morbidity and mortality were not associated with volume. In the PROCARE database, 5-year local and overall recurrence rates were not associated with hospital volume, either before or after adjustment for patient or tumour characteristics. A sensitivity analysis performed on the population-based data set from the Belgian Cancer Registry (BCR) differed from the PROCARE results since volume was significantly associated with adjusted 30-day mortality and overall survival, but not with the sphincter preservation rate. This difference could, at least partially, be explained by the larger number of patients in the BCR and by the registration bias of PROCARE. Based on these results, we concluded that some modest volume effects existed, but that caution was warranted in their interpretation. Such findings, therefore, suggest that in the Belgian context,…