Quality control in surgery of locally advanced rectal cancer

BACKGROUND: The role of surgery in the therapeutic balance of locally advanced rectal neoplasms needs to be redefined in the light of recent reports on the efficacy of radio- and chemotherapy in neoadjuvant treatment. METHODS: For this purpose, the authors analysed the results of 104 locally advanced rectal neoplasms during the decade 1987-1996 all of whom had undergone priority surgery (100% operability) using a decidedly radical approach. Of this continuous series, 70 were T4 M0 (Group A) and 34 T4 M1 (Group B). Resectability in Group A was 97.1% (87% R0 excisions) with sphincteric recovery in 72.8%. Resectability was 73.5% in Group B (20% R0 excisions) with sphincteric recovery in 60%. RESULTS: Total operative mortality was 4.7% (2.9% for R0 operations, 10.2% for R2), morbidity was 24%. No survivor died during the follow-up: there were 6 local recidivations for 68 R0 operations (8.8%), half of which were only local. The mean survival for the entire series was 34 months: 4-5 months for R0 operations; for R1-R2 operations: 18 months for M0, 8 months for M1. None of the patients with local residual disease undergoing postoperative radiochemotherapy were recovered during surgery. CONCLUSIONS: A comparative evaluation of the results obtained with those reported in the literature involving single or multicentre series pretreated with radio- or chemotherapy is relatively difficult and non-indicative owing to the numerous disparate aspects that have been the subject of debate and comment, ranging from the definition of locally advanced rectal cancer to the grounds for selecting patients and the comparative groups treated with out-of-date surgical standards.