Decision-making in rectal cancer surgery: survey of North American colorectal residency programs

Although rectal cancer is common in the United States, there is significant variation in management and outcome of this disease. The aim of this study is to measure the amount of variability that exists in the way colorectal surgeons investigate and manage patients with rectal cancer.

A detailed questionnaire covering preoperative assessment, operative technique, and follow-up of primary rectal cancer was sent to all colorectal surgeons associated with colorectal residency programs throughout North America.

One hundred ten responses were obtained (response rate, 71 percent). Surgeons were in broad agreement (>75 percent agree) on the routine preoperative use of endorectal ultrasound and carcinoembryonic antigen and the postoperative use of endorectal ultrasound. There was also broad agreement about the use of adjuvant therapy and radical resection for a poorly differentiated uT2,N0 cancer, the use of total mesorectal excision for a mid rectal cancer, and for the choice of loop ileostomy if diversion is necessary. Two-thirds of the surgeons used adjuvant therapy and radical resection for a uT3,N0 cancer and preferred a follow-up schedule of three monthly visits for two years with six monthly visits for the next three years. Opinion was divided (<63 percent agreement) on the use of a preoperative liver scan, the approach to a moderately differentiated uT2,N0 cancer, the use of rectal irrigation before resection, the timing of colonoscopy in a patient with stenosing rectal cancer, and the frequency of postoperative colonoscopies.

There is considerable variation in the management of low rectal cancer advocated by colorectal surgeon educators. For each histologic and pathologic stage, opinion is divided about which operation is best. Careful outcomes analysis is required to clarify the situation.