Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
Dig Dis. 2012;30 Suppl 2:126-31. doi: 10.1159/000342041. Epub 2012 Nov 23.
Colorectal cancer is the cancer with the second highest cancer incidence in Europe. Roughly, 1 out of 3 patients with a colorectal malignancy has a rectal carcinoma. Surgery is the cornerstone in the curative treatment of rectal cancer. In the 1980s with conventional surgery, the 5-year local recurrence rate was over 20% and the 5-year overall survival rate around 50%. In the Swedish Rectal Cancer trial, in which 1,168 patients were included, preoperative radiotherapy in addition to conventional surgery resulted in a reduction of more than 50% in the 5-year local recurrence rate in comparison to conventional surgery alone (11 vs. 27%; p < 0.001). In addition, the 5-year overall survival rate improved from 48 to 58% if patients were treated with preoperative radiotherapy in addition to conventional surgery (p = 0.004). With total mesorectal excision (TME), by which the rectum with its mesorectum and visceral fascia are dissected sharply and under direct vision, local recurrence rates dropped and overall survival improved. In the Dutch TME trial, 5 × 5 Gy preoperative radiotherapy in combination with TME surgery was compared to TME surgery alone (1,861 patients). In this trial, the 5-year local recurrence rate for patients treated with TME surgery alone was similar to patients treated in the Swedish Rectal Cancer trial with blunt dissection in combination with preoperative 5 × 5 Gy radiotherapy (11%). If preoperative radiotherapy was added to TME surgery, the 5-year local recurrence rate was reduced to 5.6%. The overall survival rate at 5 years was 64% for both patients treated with TME surgery alone and patients treated with preoperative radiotherapy followed by TME surgery, compared to 48% for patients treated with blunt dissection alone in the previously mentioned Swedish trial. TME surgery is now considered the standard surgical procedure for rectal cancer. However, even if TME surgery is performed, surgical quality varies. First, these results indicate that improvements in the surgical procedure itself can result in major progress regarding long-term oncological outcome, such as decreased local recurrence rates and improved overall survival. Second, it illustrates that variation in surgical quality could lead to large differences in outcome. Recently, it was shown that surgical variation is not only important for patients with rectal cancer, but also plays an important role for the outcome of patients with colon cancer.
结直肠癌是欧洲发病率第二高的癌症。大约每 3 名结直肠恶性肿瘤患者中就有 1 名患有直肠癌。手术是直肠癌治愈治疗的基石。在 20 世纪 80 年代，采用传统手术，5 年局部复发率超过 20%，5 年总生存率约为 50%。在瑞典直肠癌试验中，纳入了 1168 名患者，术前放疗加常规手术与单纯常规手术相比，5 年局部复发率降低了 50%以上（11%比 27%；p<0.001）。此外，如果患者接受术前放疗加常规手术治疗，5 年总生存率从 48%提高到 58%（p=0.004）。通过全直肠系膜切除术（TME），直肠及其直肠系膜和内脏筋膜被锐性解剖并在直视下进行，局部复发率下降，总生存率提高。在荷兰 TME 试验中，5×5 Gy 术前放疗联合 TME 手术与单纯 TME 手术进行比较（1861 例患者）。在这项试验中，单独接受 TME 手术治疗的患者 5 年局部复发率与在瑞典直肠癌试验中接受钝性分离联合术前 5×5 Gy 放疗的患者相似（11%）。如果在 TME 手术中加入术前放疗，5 年局部复发率降低至 5.6%。单独接受 TME 手术治疗的患者和接受术前放疗后接受 TME 手术治疗的患者的 5 年总生存率均为 64%，而在前面提到的瑞典试验中，仅接受钝性分离的患者为 48%。TME 手术现在被认为是直肠癌的标准手术程序。然而，即使进行了 TME 手术，手术质量也存在差异。首先，这些结果表明，手术过程的改进可以在长期肿瘤学结果方面取得重大进展，例如降低局部复发率和提高总体生存率。其次，它表明手术质量的差异可能导致结果的巨大差异。最近的研究表明，手术的差异不仅对直肠癌患者很重要，而且对结肠癌患者的预后也很重要。
