Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm

Summary

Background

The Stockholm I and II randomised trials demonstrated the value of preoperative radiotherapy in preventing local recurrence in rectal cancer. This study investigated the potential for further improvement by introduction of the concept of total mesorectal excision (TME) to surgeons in Stockholm, Sweden.

Methods

Workshops started in 1994 and included 11 television-based demonstrations and two histopathology sessions. The study population consisted of all patients who underwent abdominal operations for rectal cancer in Stockholm County during 1995–96 (TME project; n=447). Outcomes at 2 years were compared with those from the Stockholm I (n=790) and II (n=542) trials as historical controls.

Findings

For patients with curative abdominal resections, there were no differences between the Stockholm I (n=686), Stockholm II (n=481), and TME project (n=381) groups in 30-day mortality (30 [4%], six [1%], and 12 [3%]), anastomotic leakage (27 [10%], 18 [9%], and 23 [9%]), or all complications (204 [30%], 169 [35%], and 134 [35%]). This similarity was achieved despite a decrease in the proportion of abdominoperineal procedures from 55-60% to 27%. Local recurrence occurred in significantly fewer of the TME group than of the Stockholm I and II groups (21 [6%] vs 103 [15%] and 66 [14%], p<0·001) as did cancer-related death (35 [9%] vs 104 [15%] and 77 [16%], p>0·002).

Interpretation

A surgical teaching initiative had a major effect on cancer outcomes. The proportion of abdominoperineal procedures and the local recurrence rate decreased by more than 50% and there is already evidence of a decline in rectal-cancer mortality.

Introduction

The Stockholm Colorectal Cancer Study Group was set up in 1980 with the aim of improving outcomes in rectal cancer. During the next 10 years, the group completed two randomised trials of preoperative radiotherapy (Stockholm I and Stockholm II trials).1, 2, 3, 4 These studies, with two other Swedish trials,5, 6 provided strong evidence that short-course, high-dose, preoperative radiotherapy can reduce the risk of local recurrence after conventional surgery for rectal cancer. After reports in 1986 of local recurrence rates of below 5% with more precise surgery aimed at total mesorectal excision (TME)7, 8, the Stockholm group investigated the detail of surgical technique. A collaborative project of surgical workshops was set up in 1994 to introduce the concept of TME to surgeons in Stockholm who treat patients with colorectal cancer.

The aim of this study was to assess the effect of this collaborative surgical teaching initiative on outcome in patients with rectal cancer in the whole population of Stockholm (1·8 million inhabitants). Accurate yearly outcome data were available from the Stockholm trials; these patients were therefore chosen as historical controls.