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

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 11 (n=542) trials as historical controls. Findings For patients with curative abdominal resections, there were no differences between the Stockholm 1 (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.