Results of extrafascial excision and conventional surgery for rectal cancer at Auckland Hospital

Background: Recent studies have suggested that local recurrence rates following rectal cancer surgery are reduced if the mesorectum is removed intact within its fascia propria. The present study aims to compare the outcomes of conventional surgery for rectal cancer and surgery in which the rectum and mesorectum are removed by the technique of extrafascial excision (EFE). Methods: All patients undergoing surgery for rectal cancer at Auckland Hospital from 1980 to 1996 were identified. Demographic, tumour, operation, outcome, survival and follow-up data were obtained from patient charts, New Zealand (NZ) Death Registry, death-certificates and the NZ Electoral Roll. Complication rates, recurrence rates, overall and cancer-free survival and treatment costs were calculated for each group. Results: A total of 262 patients had curative surgery (138 had conventional surgery, 124 had EFE). The groups were similar with respect to age, sex, operation performed and Dukes' stage. There was no difference in complication rates between the groups. Mean follow-up was 7 years in survivors. Twenty-nine conventional-surgery (21%) and eight EFE (6%) patients developed local pelvic recurrence. The 5-year actuarial local recurrence rates were 30% and 10%, respectively (P = 0.0006). The 5-year overall survival was 54% for conventional surgery and 60% for EFE (P = 0.23). The 5-year cancer-free survival was 63% for conventional surgery and 74% for EFE (P = 0.02). Average initial costs were NZ$15 717 and NZ$15 158 for conventional surgery and EFE, respectively. The average cost of local recurrence was an additional NZ$10 471. Conclusions: The present study adds further support to the growing evidence that excision of the mesorectum within an intact fascial envelope reduces local recurrence rates after surgery for rectal cancer. There appears to be an associated improvement in cancer-free survival. Complication rates and cost were not increased in the patients having EFE.