title: Long-term results of rectal cancer surgery with a systematical operative approach.
abstract: BACKGROUND
  Variabilities of both oncologic and functional outcomes are major problems after rectal cancer treatment. Standardized techniques might produce more consistent surgical quality. This study reports outcomes during a 20-year period resulting from a systematically applied surgical approach.
  
  
  METHODS
  Between 1990 and 2010, 368 rectal cancer patients, treated with total mesorectal excision conducted in a standardized, stepwise approach, were prospectively entered into a database. Influence of time period, surgeon, tumor and anastomotic height, and resection type was evaluated with multivariable regression analyses adjusting for age, disease stage, diversion, and (neo)adjuvant treatment. Function outcome questionnaires were sent to 50 patients at least 5 years after surgery.
  
  
  RESULTS
  Five-year overall survival was 76.4 %. Local and distant recurrence rates were 5.2 % and 22.1 %. Anastomotic leakage occurred in 5.4 % of patients treated with low anterior resection (n = 259). Time period, surgeon, tumor and anastomotic height, diversion, and abdominoperineal resection were not independent risk factors for any of these outcome measures. Both preoperative and postoperative radiotherapy were independently associated with increased risk of metastases (P = 0.035, hazard ratio (HR) = 3.04; and P = 0.029, HR = 3.59). Function questionnaires were completed by 38 of 50 patients (76 %). One of 13 nonirradiated patients reported mild fecal incontinence compared with 20 of 25 irradiated patients reporting mostly moderate-severe incontinence (P < 0.001).
  
  
  CONCLUSIONS
  Systematically applied surgical dissection results consistently in excellent oncologic outcomes with enhanced function outcomes. The findings suggest that in the presence of highly disciplined surgery, radiotherapy might make a smaller contribution to oncologic outcome, while leading to serious adverse effects.
authors.affiliation: Department of Surgery and The Cancer Center, Beth Israel Medical Center, New York, NY, USA. mmlange@outlook.com
authors.forename: Marilyne M
authors.initials: MM
authors.lastname: Lange
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Martz
authors.forename: Beverly
authors.initials: B
authors.lastname: Ramdeen
authors.forename: Vicki
authors.initials: V
authors.lastname: Brooks
authors.forename: Kwadwo
authors.initials: K
authors.lastname: Boachie-Adjei
authors.forename: Cornelis J H
authors.initials: CJ
authors.lastname: van de Velde
authors.forename: Warren E
authors.initials: WE
authors.lastname: Enker
mesh_terms: D000368:Aged; D057868:Anastomotic Leak / Q000209:etiology; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D005242:Fecal Incontinence / Q000209:etiology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D020360:Neoadjuvant Therapy; D009362:Neoplasm Metastasis; D009364:Neoplasm Recurrence, Local / Q000601:surgery*; D016016:Proportional Hazards Models; D018714:Radiotherapy, Adjuvant / Q000009:adverse effects; D012004:Rectal Neoplasms / Q000532:radiotherapy* / Q000601:surgery*; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome