title: Evaluation of quality indicators following implementation of total mesorectal excision in primarily resected rectal cancer changed future management.
abstract: OBJECTIVE
  We evaluated the outcome of primarily resected rectal cancer patients immediately after the implementation of total meserectal excision (TME) based on potential quality indicators.
  
  
  METHODS
  Following initial teaching of two staff surgeons (PMS and AHH) by RJ Heald, 164 consecutive patients were analyzed. The following quality indicators were evaluated: (a) frequency of local recurrence, (b) number of resected lymph nodes, (c) selection of operative technique depending on tumor localization, (d) use of a protective loop ileostomy, and (e) frequency and type of adjuvant therapy.
  
  
  RESULTS
  Local recurrence rate was 8.5% after a minimum follow-up of 5 years. An increasing pT category (p < 0.02) and the presence of lymph node metastases (pN+, p < 0.05) were significantly associated with local recurrence rates. The number of resected lymph nodes was significantly associated with nodal metastases rate (p < 0.02). Patients with distal third rectal cancer underwent significantly more often an abdominoperineal amputation (p < 0.0001). Clinical course, but not the rate of anastomotic leakage (9.5%) itself was influenced by using a protective loop ileostomy. Forty-two (29.7%) patients received adjuvant therapy; however, local recurrence rate was higher in patients with adjuvant chemo-/radiotherapy (14.2% vs. 6.1%).
  
  
  CONCLUSIONS
  The local recurrence rate of 8.5% demonstrates that through consequent implementation of TME excellent onclogical results can be achieved. The number of resected lymph nodes significantly influenced the pN category. The primary construction of a protective loop ileostomy after TME became standard. Neoadjuvant chemoradiation was systematically introduced in order to improve local tumor control and prevent abdominoperineal amputations. No conclusions can be drawn concerning adjuvant therapy.
authors.affiliation: Department of General, Visceral and Tumor Surgery, University of Cologne, Cologne, Germany. paul.schneider@usz.ch
authors.forename: Paul M
authors.initials: PM
authors.lastname: Schneider
authors.forename: Daniel
authors.initials: D
authors.lastname: Vallbohmer
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Ploenes
authors.forename: Georg
authors.initials: G
authors.lastname: Lurje
authors.forename: Ralf
authors.initials: R
authors.lastname: Metzger
authors.forename: Frederike C
authors.initials: FC
authors.lastname: Ling
authors.forename: Jan
authors.initials: J
authors.lastname: Brabender
authors.forename: Uta
authors.initials: U
authors.lastname: Drebber
authors.forename: Arnulf H
authors.initials: AH
authors.lastname: Hoelscher
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057868:Anastomotic Leak; D017024:Chemotherapy, Adjuvant; D003710:Demography; D005260:Female; D006801:Humans; D007081:Ileostomy; D008198:Lymph Nodes / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000601:surgery; D019984:Quality Indicators, Health Care; D012004:Rectal Neoplasms / Q000188:drug therapy / Q000473:pathology* / Q000601:surgery*