title: Volume and outcome in rectal cancer surgery: the importance of quality management.
abstract: OBJECTIVE
  For many years, the impact of the surgeon volume on short- and long-term outcome after rectal carcinoma surgery is controversially discussed. Literature and own department data were reviewed in order to clarify the impact of surgeon volume in the current era of total mesorectal excision surgery, multimodal therapy, quality management, and centralization of cancer care.
  
  
  METHODS
  Uni- and multivariate analysis of data from 1,028 patients with solitary rectal carcinoma, treated between 1995 and 2010 at the Department of Surgery, University Hospital, Erlangen, Germany, was performed. Surgeons were subdivided according to the number of operations/year into high- (at least seven/year), medium- (three to six), and low- (less than three) volume surgeons.
  
  
  RESULTS
  Of 1,028 patients, 800 (77.8 %) were operated by five high-volume surgeons, 193 (18.8 %) by seven medium-volume surgeons, and 35 (3.4 %) by 12 low-volume surgeons. Surgeon volume was significantly associated with postoperative mortality and the rate of positive pathological circumferential resection margin. In risk-adjusted analysis, after primary surgery, surgeon volume had a significant impact on observed overall survival and disease-free survival, but not on locoregional recurrence. After neoadjuvant radiochemotherapy, only observed overall survival was significantly influenced by surgeon volume.
  
  
  CONCLUSIONS
  In surgical departments with special interest in rectal carcinoma, surgeon volume has some influence on short- and long-term outcome. Irrespective of this fact, specialization, experience, individual skill, hospital organization, and regular quality assurance are essential prognostic factors ensuring good results in rectal carcinoma surgery.
authors.affiliation: Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstr. 12, 91054, Erlangen, Germany. werner.hohenberger@uk-erlangen.de
authors.forename: Werner
authors.initials: W
authors.lastname: Hohenberger
authors.forename: Susanne
authors.initials: S
authors.lastname: Merkel
authors.forename: Paul
authors.initials: P
authors.lastname: Hermanek
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D013505:Digestive System Surgical Procedures / Q000706:statistics & numerical data*; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D010820:Physicians / Q000706:statistics & numerical data*; D011785:Quality Assurance, Health Care; D019984:Quality Indicators, Health Care; D012004:Rectal Neoplasms / Q000188:drug therapy / Q000453:epidemiology / Q000532:radiotherapy / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult