Low abdominoperineal excision rates are associated with high-workload surgeons and lower tumour height. Is further specialization needed?
OBJECTIVE
Wide variation, independent of disease extent and case mix, has been observed in the rate of use of abdominoperineal excision (APE) for rectal cancer. Previous analyses have, however, been confounded by failure to adjust for the location of the tumour within the rectum. This population-based study sought to examine whether variations in tumour height explained differences in APE use.


METHODS
Information was obtained on all individuals who underwent a major resection for a rectal tumour diagnosed between 1998 and 2005 across the Northern and Yorkshire regions of the UK. Median distances from the dentate line were calculated for all tumours excised by APE and compared with rates of use of APE between specialists and nonspecialist surgeons and across hospital trusts.


RESULTS
The completeness of pathological reporting of height of tumour within the rectum was variable. A low rate of APE use was associated with a lower median distance of tumours from the dentate line. Specialist colorectal cancer surgeons performed fewer APEs on patients with a tumour located lower in the rectum than nonspecialist surgeons.


CONCLUSIONS
Variations in the height of tumour did not explain the variation in APE use. Specialist high-volume surgeons undertook fewer APEs and those they performed were closer to the dentate line than low-volume nonspecialist surgeons.
Centre for Epidemiology and Biostatistics, University of Leeds, St James's Institute of Oncology, St James's Hospital, Leeds, UK. eva.morris@nycris.leedsth.nhs.uk
E J A
EJ
Morris
R
R
Birch
N P
NP
West
P J
PJ
Finan
D
D
Forman
L
L
Fairley
P
P
Quirke
D000005:Abdomen / Q000601:surgery; D003107:Colorectal Surgery / Q000706:statistics & numerical data*; D013505:Digestive System Surgical Procedures / Q000706:statistics & numerical data*; D013502:General Surgery / Q000706:statistics & numerical data*; D006801:Humans; D010502:Perineum / Q000601:surgery; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D013038:Specialization; D016526:Workload / Q000706:statistics & numerical data