Completion of total mesorectal excision after total neoadjuvant therapy: Analysis of volume and approach in a contemporary National Cancer Database cohort.

Abstract

Pathologic grading of the quality of total mesorectal excision specimens has become a key quality metric of rectal cancer care. While disease- and patient-specific variables influence total mesorectal excision quality, data on the impact of modifiable factors, including hospital volume and surgical approach, in the era of total neoadjuvant therapy are limited. This study aimed to investigate national rates of total mesorectal excision and associated factors in a contemporary cohort undergoing total neoadjuvant therapy for rectal adenocarcinoma. Adults with clinical stage II-III rectal adenocarcinoma diagnosed in 2022 and managed with total neoadjuvant therapy and proctectomy were identified in the National Cancer Database. Multivariable logistic regression assessed associations between patient and clinical characteristics and complete total mesorectal excision. Hospitals performing >12 proctectomies annually were considered higher volume. In a cohort of 1,077 patients (62% male, 85% white), 78% had complete, 13% near-complete, and 9% incomplete total mesorectal excision. Seventy-two percent underwent low anterior resection; the remainder underwent abdominoperineal resection. Most procedures were robotic (63%), 20% were open, and 17% laparoscopic. The majority (62%) received care at higher-volume hospitals. Surgical approach did not impact odds of complete total mesorectal excision; however, abdominoperineal resection was associated with an increased risk of incomplete total mesorectal excision (abdominoperineal resection versus low anterior resection: odds ratio, 2.99; 95% confidence interval, 1.90-4.70). Higher-volume hospitals had reduced odds of nearly complete compared with complete total mesorectal excision (odds ratio, 0.62; 95% confidence interval, 0.43-0.90). In this national cohort undergoing proctectomy following total neoadjuvant therapy, 78% rate of complete total mesorectal excision was reported. Hospital volume, but not surgical approach, impacted the odds of complete total mesorectal excision, supporting previous trials demonstrating equivalence among surgical techniques.