the concept of total mesorectal excision ( tme ) has been the most important development in rectal cancer surgery during the last two decades . after the introduction of tme the rate of local recurrence could be dramatically reduced . even without curative approach ,
local recurrence was reduced to 6 - 12% and 5-year survival rate improved to 53 - 87% [ 2 - 4 ] . however , it is noteworthy , that the excellent results of a local recurrence rate of less than 5% without neoadjuvant treatment modalities as reported by heald have not been reached by the majority of rectal surgeons .
quality of mesorectal excision according to m.e.r.c.u.r.y . criteria . a recent multicentre trial analysed the benefit of preoperative radiation before tme surgery .
if optimal tme - quality could be achieved in a controlled scientific trial in only 50% of patients , serious concern should arise about the tme quality in the absence of pathological quality control .
although most centres claim performing tme surgery , the literature evaluating tme quality is scarce . to close this gap we present our results of tme surgery after the introduction of quality controls for rectal cancer surgery at our centre in 2004 .
during a period of 36 months , between january 2004 and december 2006 , 103 patients underwent surgical resection for rectal cancer at the department of surgery , st .
josef hospital , ruhr- university bochum , germany . sixty percent ( 62/103 ) were male , 40% ( 41/103 ) were female .
preoperative staging included complete colonoscopy or barium enema , abdominal ct scan and chest x - ray .
the decision about neoadjuvant therapy was based on weekly multidisciplinary tumour board reviews . in 29% ( 30/103 )
neoadjuvant therapy was performed prior to operation , including 22% ( 23/103 ) short term radiation ( 5  5 gy ) and 7% ( 7/103 ) long term chemoradiation ( 50 gy ) . in - hospital death
after anterior resection , reconstruction was achieved via stapled anastomosis ( 29 mm or 31 mm stapler ) or hand sutured coloanal anastomosis .
reconstruction included the formation of a colonic pouch by performing a transverse coloplasty whenever possible .
the quality of the surgical resections was first judged by macroscopic assessment of the specimens ' surface .
after fixation , staining and slicing , the completeness of the mesorectum was judged by microscopic investigation .
tumour type , t - stage and n - stage were documented for the purposes of the study .
further recording included proximal , distal and circumferential resection margins , tumour size and histopathological grading .
after anterior resection , reconstruction was achieved via stapled anastomosis ( 29 mm or 31 mm stapler ) or hand sutured coloanal anastomosis .
reconstruction included the formation of a colonic pouch by performing a transverse coloplasty whenever possible .
the quality of the surgical resections was first judged by macroscopic assessment of the specimens ' surface .
after fixation , staining and slicing , the completeness of the mesorectum was judged by microscopic investigation .
tumour type , t - stage and n - stage were documented for the purposes of the study .
further recording included proximal , distal and circumferential resection margins , tumour size and histopathological grading .
8% ( 8/103 ) of patients needed urgent surgery secondary to ileus ( 3% ; 3/103 ) or perforation of rectal carcinoma ( 5% ; 5/103 ) . in 76% ( 78/103 )
an anterior resection was performed , 6% underwent ( 6/103 ) hartmann 's operation and 2% ( 2/103 ) had a colectomy . in 16% ( 17/103 ) of cases
these patients either had local recurrence of rectal cancer , a tumour less than 2 cm from the anal verge , sphincter infiltration , sphincter insufficiency or malignant melanoma of the anus .
major surgical complications occurred in 17% ( 18/103 ) of patients , including anastomotic leakage , wound dehiscence , intra - abdominal abscess formation , postoperative haemorrhage and failure of the rectal remnant after hartmann ' operation .
major general complications occurred in 7% ( 7/103 ) including pneumonia , stroke and myocardial infarction ( table 2 ) .
mortality after elective operations was 4% ( 4/95 ) , while patients undergoing urgent surgery had a mortality rate of 38% ( 3/8 ) , p = 0.026 .
an evaluation of the quality of the mesorectum was possible . in 10% ( 10/103 )
7 patients had local recurrence of rectal cancer and had already had rectal resection during prior surgery .
3 patients were part of another study which required immediate opening of the removed rectum for the collection of unfixed tumour biopsies from the removed tumour .
i ) in 99% ( 92/93 ) of removed tumours . in 1% ( 1/93 )
ii ) , and none ( 0/93 ) of the removed tumours had an incomplete mesorectum ( m.e.r.c.u.r.y .
macroscopic high tme quality of an unfixed rectal resection specimen showing the intact mesorectum without defects on the surface .
uicc tumour stage ; final histology ( n = 103 ) . in 98% ( 91/93 )
the circumferential resection margin was negative , showing no tumour infiltration at least 2 millimeters away from the lateral resection margin .
one patient requiring urgent surgery for perforated rectal cancer ( uicc tumour stage iiic ) had involvement of the lateral resection margin .
the other patient with lateral resection margin involvement was operated after long term chemoradiation ( uicc tumour stage iiib ) .
fifty percent ( 51/103 ) of patients were staged to have advanced rectal cancer ( > t2 or n+ ) .
of those , 61% ( 31/51 ) received neoadjuvant radiation , while 39% ( 20/51 ) underwent operation without preoperative radiation .
the reasons for primary operation without radiation in advanced stages of rectal cancer included recurrence of rectal cancer ( 7% ; 7/103 ) , suspected metastatic disease ( 9% ; 9/103 ) , urgent surgery ( 8% ; 8/103 ) , advanced age ( 2% ; 2/103 ) , severe co - morbidities ( 2% ; 2/103 ) , incompliance ( 1% ; 1/103 ) , other malignancy ( 1% ; 1/103 ) or combination of these .
the mean number of lymph nodes removed during the operation was 19 ( range 4 - 47 ) .
sixtysix percent of the removed tumours ( 68/103 ) had moderate differentiation , 17% ( 18/103 ) good differentiation and 9% ( 9/103 ) poor differentiation , while in 1% ( 1/103 ) an un differentiated tumour was found . in 7% ( 7/103 ) of cases grading was not possible .
distant metastases were pre sent in 9% ( 9/103 ) , including 6 patients with hepatic metastases , 1 patient with pulmonary and hepatic meta stases and two patients with metastases towards other organs . in 91% ( 94/103 )
patients had no distant metastases . in 2% ( 2/103 ) of the cases a macroscopic residual tumour ( r2 ) was present in the pelvis after resection .
5% ( 5/103 ) of the patients had overall r2 resection because of hepatic or pulmonary metastasis , while 2% ( 2/103 ) of the patients underwent simultaneous hepatic tumour resection resulting in r0 situation . until may 2009
this patient had palliative rectal resection for a pt3b , pn2 ( 8/22 ) , l1 , v1 , pn1 , pm1 ( hepatic and pulmonary ) , g3 , uicc - stage iv rectal cancer .
8% ( 8/103 ) of patients needed urgent surgery secondary to ileus ( 3% ; 3/103 ) or perforation of rectal carcinoma ( 5% ; 5/103 ) . in 76% ( 78/103 )
an anterior resection was performed , 6% underwent ( 6/103 ) hartmann 's operation and 2% ( 2/103 ) had a colectomy . in 16% ( 17/103 ) of cases
these patients either had local recurrence of rectal cancer , a tumour less than 2 cm from the anal verge , sphincter infiltration , sphincter insufficiency or malignant melanoma of the anus .
major surgical complications occurred in 17% ( 18/103 ) of patients , including anastomotic leakage , wound dehiscence , intra - abdominal abscess formation , postoperative haemorrhage and failure of the rectal remnant after hartmann ' operation .
major general complications occurred in 7% ( 7/103 ) including pneumonia , stroke and myocardial infarction ( table 2 ) .
mortality after elective operations was 4% ( 4/95 ) , while patients undergoing urgent surgery had a mortality rate of 38% ( 3/8 ) , p = 0.026 .
in 90% ( 93/103 ) an evaluation of the quality of the mesorectum was possible . in 10% ( 10/103 )
7 patients had local recurrence of rectal cancer and had already had rectal resection during prior surgery .
3 patients were part of another study which required immediate opening of the removed rectum for the collection of unfixed tumour biopsies from the removed tumour .
i ) in 99% ( 92/93 ) of removed tumours . in 1% ( 1/93 )
ii ) , and none ( 0/93 ) of the removed tumours had an incomplete mesorectum ( m.e.r.c.u.r.y .
macroscopic high tme quality of an unfixed rectal resection specimen showing the intact mesorectum without defects on the surface .
uicc tumour stage ; final histology ( n = 103 ) . in 98% ( 91/93 )
the circumferential resection margin was negative , showing no tumour infiltration at least 2 millimeters away from the lateral resection margin .
one patient requiring urgent surgery for perforated rectal cancer ( uicc tumour stage iiic ) had involvement of the lateral resection margin .
the other patient with lateral resection margin involvement was operated after long term chemoradiation ( uicc tumour stage iiib ) .
fifty percent ( 51/103 ) of patients were staged to have advanced rectal cancer ( > t2 or n+ ) .
of those , 61% ( 31/51 ) received neoadjuvant radiation , while 39% ( 20/51 ) underwent operation without preoperative radiation .
the reasons for primary operation without radiation in advanced stages of rectal cancer included recurrence of rectal cancer ( 7% ; 7/103 ) , suspected metastatic disease ( 9% ; 9/103 ) , urgent surgery ( 8% ; 8/103 ) , advanced age ( 2% ; 2/103 ) , severe co - morbidities ( 2% ; 2/103 ) , incompliance ( 1% ; 1/103 ) , other malignancy ( 1% ; 1/103 ) or combination of these .
the mean number of lymph nodes removed during the operation was 19 ( range 4 - 47 ) .
sixtysix percent of the removed tumours ( 68/103 ) had moderate differentiation , 17% ( 18/103 ) good differentiation and 9% ( 9/103 ) poor differentiation , while in 1% ( 1/103 ) an un differentiated tumour was found . in 7% ( 7/103 ) of cases grading was not possible .
distant metastases were pre sent in 9% ( 9/103 ) , including 6 patients with hepatic metastases , 1 patient with pulmonary and hepatic meta stases and two patients with metastases towards other organs . in 91% ( 94/103 )
patients had no distant metastases . in 2% ( 2/103 ) of the cases a macroscopic residual tumour ( r2 ) was present in the pelvis after resection .
5% ( 5/103 ) of the patients had overall r2 resection because of hepatic or pulmonary metastasis , while 2% ( 2/103 ) of the patients underwent simultaneous hepatic tumour resection resulting in r0 situation . until may 2009
this patient had palliative rectal resection for a pt3b , pn2 ( 8/22 ) , l1 , v1 , pn1 , pm1 ( hepatic and pulmonary ) , g3 , uicc - stage iv rectal cancer .
the prognosis of rectal cancer depends principally on tumour stage at the time of diagnosis , while local recurrence depends rather on surgical technique . in studies on colorectal cancer ,
survival is most important , but trials on rectal cancer also focus on local recurrence since local control also correlates with survival .
patients receiving preoperative radiotherapy before conventional resection for rectal cancer still have recurrence rates between 28% and 37% .
the rate of local recurrence is directly related to the technique of rectal cancer excision , which makes surgical technique the most important factor for patients ' outcome . although tme is accepted in western countries as a standard principle of surgical treatment for rectal cancer the rate of local recurrence without radiotherapy varies between 3% and 18% .
kapiteijn and his group could show that short term preoperative radiotherapy reduced the rate of local recurrence .
but the fact that best results for rectal cancer surgery were reported without radiotherapy by heald who originally introduced the principle of tme makes it obvious that the surgeon plays a crucial rule for patients ' prognosis . at a mean
follow up of 4,2 years after curative resection for rectal cancer heald reported a local recurrence rate of less than 3% .
1 . is the variation in local control in studies related to the surgical quality of tme ?
although modern surgical treatment of colorectal cancer implies the operative principle of tme , data on tme quality of resected specimen are rare .
tme quality was optimal in 47% , 40% of patients had nearly complete tme , while 13% had incomplete tme .
the rate of local recurrence was 41% ( 59% overall recurrence ) , in patients with nearly complete tme the rate of local recurrence was 6% ( 17% overall recurrence ) , while in patients with optimal tme surgery the rate of local recurrence was less than 2% ( 2% overall recurrence ) .
i ) , but there were 12 patients with positive resection margins , which makes local recurrence likely to occur .
hermanek and heald also focused on the results of the rectal cancer study from the netherlands .
they showed that not the whole series of the dutch trial did represent a standardized tme surgery since there was a high rate of incomplete mesorectal excisions for resectable rectal cancer .
the variation in local control therefore seems to be an indicator for differences in surgical quality of tme .
more evidence for the importance of surgical quality is the difference between multicentre trials and results from single institutions .
heald 's excellent data were the result of a single person applying a new technique .
the analysis from the netherlands might have compaired excellent surgical quality with poorer quality from different institutions .
the role of the surgeon becomes even more obvious since objective analysis of the operative quality is possible by the evaluation of the quality of tme .
therefore the documentation of tme quality by pathologists is essential to detect deficits in surgical technique .
this may lead to better tme quality and seems to be an effective tool to improve operative results . in our series
we could demonstrate that optimal tme quality can be achieved with different operative procedures in any stage of rectal carcinoma .
although we had a relatively high rate of abdominoperineal resections this did not increase the rate of incomplete tme .
other institutions showed that optimal tme quality can be achieved by individual training after instruction by tme trained surgeons . all operations except for urgent surgery
were supervised by surgeons being experienced in tme surgery for several years . during the whole study operations were performed by 7 different surgeons from our institution .
the introduction of tme surgery can be associated initially with higher rates of anastomotic leakage , but several studies showed that these findings would improve during the routine application of tme surgery [ 21 - 23 ] . during the time of our study there were 4 of 78 cases with a clinical apparent anastomotic leakage .
an explanation for the high rate of hartmann 's stump leakage is that these were all urgent operations for perforated rectal cancer in patients requiring high dose catecholamines imparing wound healing .
two patients died secondary to generalised peritonitis after hartmann 's operation , the other patient died due to excessive liver metastases after urgent colectomy . in our series
the mean number of removed lymph nodes was 19 ( range 4 - 47 ) .
patients with less than 12 lymph nodes removed during the operation either had a local recurrence of rectal cancer or had undergone neoadjuvant radiation .
apart from tme quality another marker for mastery in rectal cancer surgery is the achievement of negative resection margins .
a distance of more than 1 mm from the tumour to the border of resection is considered to be a negative margin , although a recent analysis reported a distance of 2 mm to be the limit
. there may be further discussion about the exact distance for negative resections margins , but the optimal technique to obtain free resection margins is total mesorectal excision since it has been shown that tme achieves a negative resection margin in up to 96% of resected specimen .
they analysed the importance of tme to obtain free circumferential resection margins showing that in patients with positive crm the rate of incomplete tme was 44% while in patients with negative crm the rate of incomplete tme was only 11% .
furthermore lateral margin involvement was more likely to occur in advanced tumour stages than in tumours with positive lymph nodes .
in uicc stage iii with positive crm secondary to incomplete mesorectal excision there were significantly more patients with lateral margin involvement , by the primary tumour than by positive lymph nodes .
compared to the results from the literature ranging between 18% and 28% of resection margin involvement our findings reflect another effect of optimal tme surgery . taken both together , the accuracy of mesorectal excision and the analysis of circumferential resection margins are effective in predicting patients ' prognosis .
negative resection margins unfortunately do not only depend on surgical technique but on tumour size and tumour stage at the time of operation .
although radiotherapy has been shown to improve outcome for patients with resectable rectal cancer , subgroup analysis from the dutch trial showed that there is no benefit for patients with uicc tumour stage i or iv in the upper part of the rectum .
therefore it is important to improve selection criteria for the application of preoperative radiotherapy to protect patients from the side effects of radiation without benefit . in our analysis
we could show that optimal tme quality is feasible in all stages of rectal cancer .
high quality tme surgery can be performed with a rate of morbidity and mortality comparable to the results from the literature . with adequate surgical expertise high quality tme surgery
future studies should evaluate outcome and local recurrence in accordance to the degree of tme quality .
 backgroundthe concept of total mesorectal excision has revolutionised rectal cancer surgery . 
 tme reduces the rate of local recurrence and tumour associated mortality . however , in clinical trials only 50% of the removed rectal tumours have an optimal tme quality . 
 patients : during a period of 36 months we performed 103 rectal resections . 
 the majority of patients ( 76% ; 78/103 ) received an anterior resection . 
 the remaining patients underwent either abdominoperineal resection ( 16% ; 17/103 ) , hartmann 's procedure ( 6% ; 6/103 ) or colectomy ( 2% ; 2/103).resultsin 90% ( 93/103 ) tme quality control could be performed . 
 99% ( 92/93 ) of resected tumours had optimal tme quality . in 1% ( 1/93 ) 
 the mesorectum was nearly complete . 
 none of the removed tumours had an incomplete mesorectum . in 98% ( 91/93 ) the circumferential resection margin was negative . 
 major surgical complications occurred in 17% ( 18/103 ) . 
 5% ( 4/78 ) of patients with anterior resection had anastomotic leakage . 
 17% ( 17/103 ) developed wound infections . 
 mortality after elective surgery was 4% ( 4/95).conclusionoptimal tme quality results can be achieved in all stages of rectal cancer with a rate of morbidity and mortality comparable to the results from the literature . 
 future studies should evaluate outcome and local recurrence in accordance to the degree of tme quality . 
Background
Patients and methods
TME surgery
TME quality
Results
Operative results
Histopathological results
Discussion
Conclusion