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1 Introduction

The differences in outcome between surgeons are sometimes great and cannot only be explained by stage of disease and patients’ co-morbidity but merely of the fact that the quality in the surgical technique differs among surgeons [1].

In rectal cancer, this phenomenon has been discussed extensively. In the early 1980s, when preoperative radiotherapy was introduced to reduce the often unacceptable high local recurrence rate, some centres reported results regarding local recurrences better than standard surgery combined with radiotherapy [2–4]. All these reports pinpointed the importance of good surgical quality, and the TME technique (total mesorectal excision), i.e., dissection in the embryological plane, should be the gold standard [2]. As a consequence, several countries started training programmes, and in Scandinavia, not only the surgical technique changed but also a concentration to fewer centres has been carried out [5–7].

With a careful examination of the specimen, it is possible for the surgeon but also by the pathologists to grade the quality of surgery. If the surgeon has followed the embryological plane, which has been shown to be a barrier for local spread, no tears in the mesorectal fascia can be seen.

This chapter will describe the importance of surgical standardization and quality registration but also a structured evaluation of the specimen by the pathologists.

2 Volume

One important question has been raised in the surgical community and also among health-care providers and that is the volume for units or individual surgeons. Rectal cancer is a rather common disease with an incidence in Europe of approximately 15–20 new cases per 100,000 inhabitants. Therefore, a unit taking care of 500,000 up to 1 million inhabitants will have around 100 rectal cancers a year, which is probably a sufficient volume to require good knowledge and treatment in all level, including surgery, nursing, follow-up, etc. This is, however, not the case in the majority of countries in Europe. At several hospitals, not more than 10–20 rectal cancers are treated by more than one surgeon giving the numbers rather small. There are data from literature supporting that volume is important, but it is difficult to interpret the literature, mainly due to so many confounding factors like co-morbidity, stage of disease, social deprivation, etc. [8].

3 The Pathologist’s Evaluation of Surgical Quality

The pathologist has the ultimate position to evaluate the surgical quality. If the specimens are sent fresh to the pathology laboratory, it is possible to grade the quality of the specimen but also have photo documentation in the files. Different terminology has been proposed to classify the specimen where three groups have been proposed including a perfect specimen, rather well and a poor specimen. Professor Quirke, a pathologist from Leeds, has proposed that the three planes should be classified as follows [9]:

  1. (a)

    Mesorectal plane, indicating that the whole mesorectal fascia is intact

  2. (b)

    Intra-mesorectal plane, with minor tears in the mesorectal fascia

  3. (c)

    Muscularis propria plane, which is a specimen where lots of mesorectum is left behind and the muscle tube of the bowel can be seen macroscopically

When applying such a grading on the whole material in the MRC CR07 trial, on radiotherapy in rectal cancer, the quality of the specimen predict not only local recurrence rate but also survival [9]. For a more specific way of treating the specimen, see the chapter by Nigel Scott.

Therefore, although not yet recommended, all pathological reports should ideally have photo documentation of the specimen but also a judgement of the quality of the specimen. Based upon this grading, a constructive feedback can be given to the surgeon at the postoperative MDT conference. Moreover, by combining this grading with the preoperative MRI stage, important end point for a positive outcome, like the circumferential resection margin, can be better evaluated.

4 How to Access Quality of Surgery?

The shape and quality of the specimen is of utmost importance and can be evaluated by the pathologist as described above. However, there are several other parameters that will differ and also are indications on differences in quality. Based upon data emanated from quality assurance registries in the Scandinavian countries during the last 15 years, it is possible to evaluate the ‘overall’ outcome. Those registries are national based with participation from all hospitals. With more or less transparent reports and honest discussions among surgeons, the improvement has been dramatic in the countries involved [5–7].

Data collected in these registries are surgical procedure, level of vessel ligation, type of reconstruction and outcome in terms of complications to surgery but also cancer-related end points like local control and survival. Moreover, the diagnostic process preoperatively is registered together with the follow-up routines and the use of neo-adjuvant and/or adjuvant use of chemotherapy and radiotherapy. In some, registries also register co-morbidity and health-related parameters like smoking, BMI, etc. Also, prospective registration of the preoperative tumour stage based upon imaging as well as postoperative tumour stage based upon pathological examination exists.

The registries have annual reports with data divided upon hospitals but also showing changing’s and trends in each country. Most of the registers have been enlarged based upon the need for new items to be register and studied. Once a new parameter is involved in the registration, i.e., lymph node retrieval, the first year registration often shows unaccepted differences between units, but with transparent reports and discussions among the surgical communities in the country, the next years’ registration will often show an increase to the better, and within some years it reaches acceptable levels. Subsequently, a quality register not only guarantees good assurance that the level of care is acceptable but also acts as a vehicle for quick introduction of new treatment standards.

The experience from the Scandinavian countries has led to the same project in many European countries. In an effort to have similar programmes, ECCO has sponsored together with European Society of Surgical Oncology (ESSO) and Euro­pean Society of Coloproctology (ESCP) a collaboration with all countries with quality registration, the EURECCA project (European Registration of Cancer Care) [10]. Countries involved so far, as national registries or regional, are Belgium, Denmark, Germany, Italy, the Netherlands, Norway, Spain, Sweden and the UK.

Other important end points to be evaluated are specific complications which can be results of non-optimal surgical technique. Well-known complications or merely dysfunctions are sexual impairment, urinary dysfunctions and bowel problems [11, 12]. In all, this is a whole spectrum of quality of life. To add this in a quality registration, prospective validated questionnaires have to be used.

Regarding the sexual problems and also urinary impairments, modern more precise surgery will prevent such complications in the majority of the cases. Today, with good preoperative staging, surgeons should know if the normal plane of dissection could be followed. If that is the case, the risk of damage of the nerves should be minimal. However, if the tumour is growing outside the normal plane of dissection, the risk of nerve damage is obvious. By registering such outcome together with the knowledge of tumour stage, it is possible to increase the quality.

5 Conclusion

Quality in surgery has become an important topic in rectal cancer treatment. Lots of data support that provided surgery is done in an optimal way, one can reduce the use of radiotherapy and perhaps also reduce the use of chemotherapy. To have an immediate feedback to the surgeon whether or not the surgical procedure has been done in an optimal way, photo documentation of the specimen is essential and grading by the pathologist of the macroscopic view of the specimen is also crucial. With a quality assurance programme, the whole treatment of rectal cancer can be evaluated.