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The Basingstoke Experience of Total Mesorectal Excision, 1978-1997

Richard J. Heald, MChir, FRCS; Brendan J. Moran, MCh, FRCS; Roger D. H. Ryall, FRCR; Rosemary Sexton, BSc; John K. MacFarlane, MD

Arch Surg. 1998;133:894-898.

Objective  To examine the role of total mesorectal excision in the management of rectal cancer.

Design  A prospective consecutive case series.

Setting  A district hospital and referral center in Basingstoke, England.

Patients  Five hundred nineteen surgical patients with adenocarcinoma of the rectum treated for cure or palliation.

Interventions  Anterior resections (n=465) with low stapled anastomoses (407 total mesorectal excisions), abdominoperineal resections (n=37), Hartmann resections (n=10), local excisions (n=4), and laparotomy only (n=3). Preoperative radiotherapy was used in 49 patients (7 with abdominoperineal resections, 38 with anterior resections, 3 with Hartmann resections, and 1 with laparotomy).

Main Outcome Measures  Local recurrence and cancer-specific survival.

Results  Cancer-specific survival of all surgically treated patients was 68% at 5 years and 66% at 10 years. The local recurrence rate was 6% (95% confidence interval, 2%-10%) at 5 years and 8% (95% confidence interval, 2%-14%) at 10 years. In 405 "curative" resections, the local recurrence rate was 3% (95% confidence interval, 0%-5%) at 5 years and 4% (95% confidence interval, 0%-8%) at 10 years. Disease-free survival in this group was 80% at 5 years and 78% at 10 years. An analysis of histopathological risk factors for recurrence indicates only the Dukes stage, extramural vascular invasion, and tumor differentiation as variables in these results.

Conclusions  Rectal cancer can be cured by surgical therapy alone in 2 of 3 patients undergoing surgical excision in all stages and in 4 of 5 patients having curative resections. In future clinical trials of adjuvant chemotherapy and radiotherapy, strategies should incorporate total mesorectal excision as the surgical procedure of choice.

From the Colorectal Research Unit, The North Hampshire Hospital, Basingstoke (Messrs Heald and Moran and Ms Sexton), and Wessex Radiotherapy Centre, Southampton (Mr Ryall), Hampshire, England, and University of British Columbia, Vancouver (Dr MacFarlane).

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