THE SURGEON FACTOR IN RECTAL CANCER
Facing a local recurrence gives rise to an important question: Was it due to the natural course of a bad biology tumor or there was room for improvement in the technical aspects of the primary treatment, in other words, was it bad surgery?
Salvage surgery of locally recurrent rectal cancer represents a difficult clinical problem and the success rates are not very encouraging. However, approximately 30% of patients may benefit from the procedure. Recently Boyle et al. reported that 51% of patients who had a potentially curative excision of the local recurrence did not develop a second recurrence during the follow up period. Their results may be used as an indirect evidence that in approximately half of the patients local failure was related to the primary surgical treatment itself. In the other half, however, tumor biology was such an important prognostic factor that no matter how skilful the surgeon was, it was impossible to eliminate all microscopic spread and local recurrence was inevitable.
The wide range of local recurrence rates reported in the literature provides indirect evidence that surgical factors do affect outcome in rectal cancer. Surgeon variability concept in colorectal cancer was first recognized in the large bowel cancer project,  and has already been described in single-institution and multicentric studies. Different results between surgeons are inevitable, and local recurrence is considered the most representative parameter of this variability and quality of rectal surgery. In the German Study Group Colorectal Carcinoma (SGCRC) series, the multivariate analysis showed that differences in local recurrence rates from 4% to 55% among low and high-volume surgeons could be explained by differences in tumor related prognostic factor as well as by differences in surgical quality.
Incomplete dissection, local spillage of tumor cells or just bad technique may compromise the chance of local control of the tumor. Technical ability alone, however, is not the only factor in improving surgical outcome. Other factors such as knowledge, judgment, training and volume are also important. Porter et al. in a multivariate analysis of surgeon-related factors and outcome in rectal cancer, demonstrated that the risk of local recurrence is improved with colorectal surgical subspecialty training and higher volume of rectal cancer surgery performed. Non-colorectal surgeons had a higher local recurrence rate (hazard ratio 2.49, 95% CI 1.43-4.33,p<0.001) and significantly higher risk for local recurrence was demonstrated in surgeons who performed less than 21 resections (hazard ratio 1.80, 95% CI 1.36-2.40, p<0.001).  The use of preoperative external bean radiotherapy and chemoradiotherapy are proved to decrease local recurrence rates in rectal cancer. [6,7] Furthermore, new radiation techniques and chemotherapy schedules may increase the therapeutic benefit of (neo)adjuvant therapy. However, there is no consensus on timing and regimen of radiation therapy yet; it depends on surgeons’ knowledge and judgment which therapeutic strategy to use: surgery and postoperative chemoradiation, surgery alone, preoperative chemoradiation or preoperative radiaton alone.
Although surgeon-related variation in outcome in rectal cancer surgery is well established, many studies do not identify the specific technical differences which may explain the observed inter-surgeon variation. In recent years, local control has been improved by the introduction of the TME technique as first described by Heald in 1982.  Despite initial controversy TME has become the new standard of operative management for rectal cancer, replacing conventional blunt dissection technique. Whether one considers TME just a standardized name based on anatomic description rather than a new operation for rectal cancer , it definitely opened surgeons eyes regarding the importance of a careful anatomical dissection especially in cancer of mid and low rectum. One way or another is imperative that surgeons describe the technical aspects used for rectal resection, and the pathologist plays an important role in the quality control of the procedure.
Closely related to the progress of rectal surgery new anatomopathological aspects have been considered as prognostic factors as circumferential margin and integrity of the mesorectal package, highlighting the importance of the surgeon as an independent prognostic factor which determines the surgical results in rectal cancer. Inspection of the mesorectal surface gives the first indication of the quality of the resection and provides significant information about the prognosis.  In the ideal resection specimen the muscularis propria of the rectum should not be seen forming the circumferential margin, which is the second indicator of the quality of resection.  Margins smaller than 1 or 2mm from the primary tumor are considered inadequate. 
Marcos A. Bonardi, MD
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