Rates of Circumferential Resection Margin Involvement Vary Between Surgeons and Predict Outcomes in Rectal Cancer Surgery

Recent studies have revealed continuing high rates of local recurrence after surgery for rectal cancer. 1,2 If local recurrence develops, the prognosis is poor, with a 90% chance of subsequent death from the disease. It has become apparent in recent years that not only do the pathologic characteristics of rectal cancer influence the long-term outcome in terms of local recurrence and survival, but also that the surgeon is an important variable. This point has been highlighted by the work of Heald et al, 3 McArdle and Hole, 4 Enker et al, 5 the German Study Group for Colorectal Carcinoma, 6 and others. 7,8 Arbman et al 9 have shown that adopting the technique of total mesorectal excision (TME) can result in a 20% improvement in the 4-year survival rate, and the Norwegian Rectal Cancer Group 2 showed a greater than 20% reduction in local recurrence after the introduction of TME in a study involving more than 3,000 patients, although marked variations between different surgical units still existed at the end of the study. Recently the Stockholm group 10 have reported equivalent data, with a further study highlighting the importance of assessing the circumferential resection margin (CRM) before surgery. 11 Such variations in surgery clearly show the need to define a parameter that may be used as an immediate indicator of quality of surgery, and to assess the benefit of intervention using videos, tuition, or other methods. This assumes even greater importance if we consider that many surgeons performing rectal cancer surgery, particularly those carrying out only a few operations per year, do not have the time or resources to audit their local recurrence and survival figures. Many of those who do use different denominators in the expression of their results (e.g., curative cases, R0 resections, cancer-specific survival, overall survival), some of which are open to criticism because of their subjective nature. Involvement of the CRM by tumor has been shown to be closely related to local recurrence and survival rates 12–15 and is the indicator for postoperative chemoradiotherapy in the current international MRC CR07 trial. The aim of this study was to examine whether, in an era of changing surgical practice, CRM involvement is a useful clinical governance tool as an immediate indicator of changing quality of surgery, ultimately leading to improved survival rates.