title: Influence of surgery on metachronous distant metastases and survival in rectal cancer.
abstract: OBJECTIVE
  Total mesorectal excision (TME) and other technical surgical factors reduce local recurrence rate in rectal cancer. Scientific evidence of the positive effect of optimal surgery on survival is locking. Whether a reduction in the incidence of distant metastases can be achieved with optimal surgery is uncertain. We examine the effects of the quality of surgery, as reflected by local recurrence rate, on survival and the incidence of initial distant metastases.
  
  
  METHODS
  Between 1974 and 1991, 1,581 consecutive patients who underwent curative resection (RO) for rectal carcinoma were monitored for recurrence and survival. TME was introduced in 1985. No patient received adjuvant radiotherapy or chemotherapy. The median follow-up time was greater than 13 years.
  
  
  RESULTS
  The local recurrence rate decreased from 39.4% to 9.8% during the study period (P < .0001). The observed 5-year survival rate improved from 50% to 71% (P < .0001). Three hundred six patients with local recurrence had a significantly lower observed 5-year survival rate (P < .0001). A total of 1,285 patients had no local recurrence, but 275 of them developed distant metastases (International Union Against Cancer [UICC] stage I, 8%; stage II, 16%; stage III, 40%). Better-quality surgery had no effect on the incidence of initial distant metastases, which remained constant (P = .44).
  
  
  CONCLUSIONS
  Quality of surgery is an independent prognostic factor for survival in rectal cancer, but has no influence on initial occurrence of distant metastases. Local recurrence cannot be considered an outcome criterion of adjuvant treatment without consideration of the surgeon as a risk factor.
authors.affiliation: Department of Surgery, and Tumor Center, University of Erlangen, Germany. ferdinand.köckerling@chir.med.uni-erlangen.de
authors.forename: F
authors.initials: F
authors.lastname: Köckerling
authors.forename: M A
authors.initials: MA
authors.lastname: Reymond
authors.forename: A
authors.initials: A
authors.lastname: Altendorf-Hofmann
authors.forename: O
authors.initials: O
authors.lastname: Dworak
authors.forename: W
authors.initials: W
authors.lastname: Hohenberger
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D013502:General Surgery / Q000592:standards; D006801:Humans; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D009367:Neoplasm Staging; D012004:Rectal Neoplasms / Q000453:epidemiology / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D015996:Survival Rate