Role of the surgeon as a variable in the treatment of rectal cancer

Increasingly, data are being accumulated on the influence of intersurgeon variability on outcome after curative surgical treatment of rectal carcinoma. Thus, today the individual surgeon has to be considered as an independent factor influencing locoregional recurrence, as well as survival rates. In general, higher local control and survival can be expected for specialized colorectal surgeons. There are no clear correlations between surgical volume and outcome. Interinstitutional variability in treatment results reflects intersurgeon variability, but analysis is generally more difficult because of a lack of homogeneity with respect to different confounding factors. There are several factors in surgical technique that are important for long-term outcome. Of greatest apparent importance is the adequacy of mesorectal excision (for carcinomas of the middle and lower third, total mesorectal excision; for carcinomas of the upper third, mesorectal excision down to a mesorectal plane 5 cm distal to the gross tumor margin detected by the surgeon in situ). Furthermore, intraoperative local tumor spillage (tumor perforation during mobilization, incision into the tumor), en bloc resection technique, skill, and the extent of regional lymphadenectomy may influence outcome. For quality assurance, detailed operative reports are required, as well as histopathology examinations concerning indicators of surgical oncologic quality discernable from the resection specimens. In future clinical trials of multimodal treatment of rectal cancer, quality assurance of surgery and pathology is necessary for consideration of the surgeon and surgical technique prognostic factors.