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Factors Predicting the Quality of Total Mesorectal Excision for Rectal Cancer

Leonard, Daniel MD*; Penninckx, Freddy MD, PhD; Fieuws, Steffen MSci, PhD; Jouret-Mourin, Anne MD, PhD§; Sempoux, Christine MD, PhD§; Jehaes, Constant MD; Van Eycken, Elizabeth MDon behalf of PROCARE, a multidisciplinary Belgian Project on Cancer of the Rectum

doi: 10.1097/SLA.0b013e3181efc142
Original Articles: ORIGINAL STUDY

Objective: To determine preoperative tumor-, patient-, and treatment-related factors that are independently associated with incomplete mesorectal excision.

Summary of Background Data: Incomplete total mesorectal excision (TME) for rectal cancer is associated with increased local and overall recurrences. Factors predicting incomplete mesorectal excision have scarcely been studied.

Methods: In the context of PROCARE, a Belgian multidisciplinary project on rectal cancer, the quality of 266 consecutive and anonymized TME specimens submitted by 33 candidate-TME-trainers was graded by a blinded pathology review board in a standardized manner. Uni- and multivariable analysis were performed to identify factors that can independently predict incomplete mesorectal excision.

Results: Mesorectal resection was complete in 21%, nearly complete in 47%, and incomplete in 32%. Of 57% of TME specimens the grade of resection had not been reported by the local pathologist. Incomplete TME doubled the incidence of a positive circumferential resection margin (P = 0.004). Factors found to be significantly related to incomplete TME in univariate analysis were as follows: surgeon, female gender, pathologic body mass index, low rectal cancer, negative clinical nodal status, the absence of downstaging after long-course chemoradiation, laparoscopic and converted laparoscopic resection, and abdominoperineal resection. Multivariable analysis identified pathologic body mass index (P = 0.017), the absence of downstaging after long-course chemoradiation (P = 0.0005), and laparoscopic or converted laparoscopic resection (P = 0.014) as factors that are independently associated with incomplete mesorectal excision.

Conclusion: Good TME quality cannot be guaranteed. This peer-reviewed TME assessment revealed a number of factors that are independently related to incomplete TME. Both specimen and pathology report need to be audited.

The quality of total mesorectal excision for rectal cancer has direct influence on oncological outcome. Based on the data of PROCARE, a belgian national project destined to audit and improve the quality of surgery, we analyzed potential clinical and surgical predictive factors of the qualitative outcome of surgery.

*Department of Surgery and Abdominal Transplantation, Colorectal Surgery Unit, Saint-Luc University Hospital, Brussels, Belgium;

Depart-ment of Abdominal Surgery, University Clinic Gasthuisberg, Leuven, Belgium;

Department of I-Biostat, Katholieke Universiteit Leuven and Universiteit Hasselt, Belgium;

§Department of Pathology, Saint-Luc University Hospital, Brussels, Belgium;

Department of Abdominal Surgery, Les Cliniques Saint Joseph CHC, Liege, Belgium;

Belgian Cancer Registry, Brussels, Belgium.

Supported by the Belgian Ministry of Social Affairs.

Reprints: Freddy Penninckx, MD, PhD, Department of Abdominal Surgery, University Clinic Gasthuisberg, Herestraat 49, 3000-Leuven, Belgium. E-mail: freddy.penninckx@uz.kuleuven.ac.be.

© 2010 Lippincott Williams & Wilkins, Inc.