Rectal surgeons using 'wrong op'


Surgery can leave a patient needing a colostomy


Claims that many rectal cancer patients receive an "inappropriate" operation have been rejected by surgeons.
Leeds University researchers said hospital data showed the APE operation which leaves patients with a permanent colostomy was being used too often.
In the journal Gut they said introducing official targets would cut it further.
However leading colorectal surgeons said it remained the best option for many - and targets would harm care.
Every year in the UK approximately 13000 people are diagnosed with rectal cancer and 5000 die from the disease. What this does is serve notice on the profession that there has been an unacceptable level of variation in the use of this operation


Professor David Forman
Leeds University


Although radiotherapy and chemotherapy can be used to tackle it the normal approach is to try to surgically remove the tumour and then repair as far as possible the tissues of the rectum and anus.
The research compares the rates of two types of operation used in rectal cancer the abdominoperineal excision (APE) and anterior resection (AR).
The first of these involves the complete removal of the anal sphincter which means that the patient will wear a colostomy bag permanently while the second aims to keep this and hopeaaaay allow a return to normal function at some point.
The choice of operation is dictated to some degree by the size of the cancer and its position on the rectum. The lower the tumour extends the more likely it is that AR will be impossible.
Better survival
Recent evidence has suggested that the cancer is more likely to return in patients treated using APE compared with those treated using AR and guidance from the Department of Health and the National Institute for Clinical Excellence (NICE) has encouraged surgeons to consider AR in preference where possible.
The guidance suggests no more than 30% of rectal cancer operations should be APE.
The Leeds research looked at records of operations carried out in England between 1998 and 2004 and found that APE had declined from just over 30% of all operations to 23% over that period.
However there were still parts of the country where rectal cancer patients were more likely to be treated using APE with in some trusts the rate exceeding 50%.
Those living in deprived areas of the country were also more likely to receive an APE than those living in more affluent areas.
Patient choice
Professor David Forman who led the research said: "Should patients be able to look up the APE rate of their local trust before going there? I think they should.
"What this does is serve notice on the profession that there has been an unacceptable level of variation in the use of this operation and by having clear targets and guidelines and publicly available statistics and audit will help patient choice."
However the Association of Coloproctology of Great Britain and Ireland which represents colorectal surgeons said that the two procedures should not be seen as competing with each others. It said that more emphasis should be placed on the future quality of life of patients as AR operations did not always give satisfactory result and could lead to long-term incontinence and that surgeons and patients should be free to choose the right option without the pressure of official targets. A spokesman said: "Simplistic extrapolation of the conclusions described in this paper to 'clinical targets' could disadvantage some patient groups."