title: Impact of surgeon organization and specialization in rectal cancer outcome.
abstract: OBJECTIVE
  The present study was designed to assess the differences in the outcome of patients with rectal cancer treated by a group of surgeons before and after being organized as a Coloproctology Unit at the same University Department of Surgery.
  
  
  METHODS
  Comparison of two periods of rectal cancer surgery: I (1986-91) and II (1992-95). Period I: 94 patients were operated on by 14 general surgeons. Period II: 108 patients were operated on by only 4 surgeons of the same group organized as a Colorectal Surgery Unit after visiting referral centres abroad, adopting techniques such as total mesorectal excision (TME) for middle and low rectal cancer and washout of rectal stump. Mean follow-up during periods I and II was 69.1 and 42.0 months, respectively. A prospective data base analysis was used. Survival and local recurrence rates were calculated by the actuarial method. For comparison between groups the log rank method was used.
  
  
  RESULTS
  The two groups were comparable with respect to mean age, gender, TNM and rectal tumour location. A significant increase in radical resectability and a decrease of the Abdominoperineal resection (APR)/Low anterior resection (LAR) ratio were observed in the second period. The overall pelvic recurrence rate was 25% in the first period and 11 in the second (P < 0.01). Significant differences were also found when the patients with LAR were compared between both periods, 30% vs 9% (P < 0.01) and specially when the 10 cm anal verge distance was considered to divide the LAR groups. No differences were found regarding the APR procedures in both periods. There was improved cancer-specific survival for the LAR group in the second period (P=0.03).
  
  
  CONCLUSIONS
  Specialization and centralization influence the quality of rectal cancer surgery, mainly local recurrence rates and survival after low anterior resection.
authors.affiliation: Coloproctology Unit, Hospital Clínico Universitario, University of Valencia, Valencia, Spain. eggranero@airtel.net
authors.forename: E
authors.initials: E
authors.lastname: García-Granero
authors.forename: R
authors.initials: R
authors.lastname: Martí-Obiol
authors.forename: J
authors.initials: J
authors.lastname: Gómez-Barbadillo
authors.forename: J
authors.initials: J
authors.lastname: García-Armengol
authors.forename: P
authors.initials: P
authors.lastname: Esclapez
authors.forename: A
authors.initials: A
authors.lastname: Espí
authors.forename: E
authors.initials: E
authors.lastname: Jiménez
authors.forename: M
authors.initials: M
authors.lastname: Millán
authors.forename: S
authors.initials: S
authors.lastname: Lledó