the concept of total mesorectal excision ( tme ) has been the most important development in rectal cancer surgery during the last two decades . after the introduction of tme the rate of local recurrence could be dramatically reduced . even without curative approach , local recurrence was reduced to 6 - 12% and 5-year survival rate improved to 53 - 87% [ 2 - 4 ] . however , it is noteworthy , that the excellent results of a local recurrence rate of less than 5% without neoadjuvant treatment modalities as reported by heald have not been reached by the majority of rectal surgeons . quality of mesorectal excision according to m.e.r.c.u.r.y . criteria . a recent multicentre trial analysed the benefit of preoperative radiation before tme surgery . if optimal tme - quality could be achieved in a controlled scientific trial in only 50% of patients , serious concern should arise about the tme quality in the absence of pathological quality control . although most centres claim performing tme surgery , the literature evaluating tme quality is scarce . to close this gap we present our results of tme surgery after the introduction of quality controls for rectal cancer surgery at our centre in 2004 . during a period of 36 months , between january 2004 and december 2006 , 103 patients underwent surgical resection for rectal cancer at the department of surgery , st . josef hospital , ruhr- university bochum , germany . sixty percent ( 62/103 ) were male , 40% ( 41/103 ) were female . preoperative staging included complete colonoscopy or barium enema , abdominal ct scan and chest x - ray . the decision about neoadjuvant therapy was based on weekly multidisciplinary tumour board reviews . in 29% ( 30/103 ) neoadjuvant therapy was performed prior to operation , including 22% ( 23/103 ) short term radiation ( 5  5 gy ) and 7% ( 7/103 ) long term chemoradiation ( 50 gy ) . in - hospital death after anterior resection , reconstruction was achieved via stapled anastomosis ( 29 mm or 31 mm stapler ) or hand sutured coloanal anastomosis . reconstruction included the formation of a colonic pouch by performing a transverse coloplasty whenever possible . the quality of the surgical resections was first judged by macroscopic assessment of the specimens ' surface . after fixation , staining and slicing , the completeness of the mesorectum was judged by microscopic investigation . tumour type , t - stage and n - stage were documented for the purposes of the study . further recording included proximal , distal and circumferential resection margins , tumour size and histopathological grading . after anterior resection , reconstruction was achieved via stapled anastomosis ( 29 mm or 31 mm stapler ) or hand sutured coloanal anastomosis . reconstruction included the formation of a colonic pouch by performing a transverse coloplasty whenever possible . the quality of the surgical resections was first judged by macroscopic assessment of the specimens ' surface . after fixation , staining and slicing , the completeness of the mesorectum was judged by microscopic investigation . tumour type , t - stage and n - stage were documented for the purposes of the study . further recording included proximal , distal and circumferential resection margins , tumour size and histopathological grading . 8% ( 8/103 ) of patients needed urgent surgery secondary to ileus ( 3% ; 3/103 ) or perforation of rectal carcinoma ( 5% ; 5/103 ) . in 76% ( 78/103 ) an anterior resection was performed , 6% underwent ( 6/103 ) hartmann 's operation and 2% ( 2/103 ) had a colectomy . in 16% ( 17/103 ) of cases these patients either had local recurrence of rectal cancer , a tumour less than 2 cm from the anal verge , sphincter infiltration , sphincter insufficiency or malignant melanoma of the anus . major surgical complications occurred in 17% ( 18/103 ) of patients , including anastomotic leakage , wound dehiscence , intra - abdominal abscess formation , postoperative haemorrhage and failure of the rectal remnant after hartmann ' operation . major general complications occurred in 7% ( 7/103 ) including pneumonia , stroke and myocardial infarction ( table 2 ) . mortality after elective operations was 4% ( 4/95 ) , while patients undergoing urgent surgery had a mortality rate of 38% ( 3/8 ) , p = 0.026 . an evaluation of the quality of the mesorectum was possible . in 10% ( 10/103 ) 7 patients had local recurrence of rectal cancer and had already had rectal resection during prior surgery . 3 patients were part of another study which required immediate opening of the removed rectum for the collection of unfixed tumour biopsies from the removed tumour . i ) in 99% ( 92/93 ) of removed tumours . in 1% ( 1/93 ) ii ) , and none ( 0/93 ) of the removed tumours had an incomplete mesorectum ( m.e.r.c.u.r.y . macroscopic high tme quality of an unfixed rectal resection specimen showing the intact mesorectum without defects on the surface . uicc tumour stage ; final histology ( n = 103 ) . in 98% ( 91/93 ) the circumferential resection margin was negative , showing no tumour infiltration at least 2 millimeters away from the lateral resection margin . one patient requiring urgent surgery for perforated rectal cancer ( uicc tumour stage iiic ) had involvement of the lateral resection margin . the other patient with lateral resection margin involvement was operated after long term chemoradiation ( uicc tumour stage iiib ) . fifty percent ( 51/103 ) of patients were staged to have advanced rectal cancer ( > t2 or n+ ) . of those , 61% ( 31/51 ) received neoadjuvant radiation , while 39% ( 20/51 ) underwent operation without preoperative radiation . the reasons for primary operation without radiation in advanced stages of rectal cancer included recurrence of rectal cancer ( 7% ; 7/103 ) , suspected metastatic disease ( 9% ; 9/103 ) , urgent surgery ( 8% ; 8/103 ) , advanced age ( 2% ; 2/103 ) , severe co - morbidities ( 2% ; 2/103 ) , incompliance ( 1% ; 1/103 ) , other malignancy ( 1% ; 1/103 ) or combination of these . the mean number of lymph nodes removed during the operation was 19 ( range 4 - 47 ) . sixtysix percent of the removed tumours ( 68/103 ) had moderate differentiation , 17% ( 18/103 ) good differentiation and 9% ( 9/103 ) poor differentiation , while in 1% ( 1/103 ) an un differentiated tumour was found . in 7% ( 7/103 ) of cases grading was not possible . distant metastases were pre sent in 9% ( 9/103 ) , including 6 patients with hepatic metastases , 1 patient with pulmonary and hepatic meta stases and two patients with metastases towards other organs . in 91% ( 94/103 ) patients had no distant metastases . in 2% ( 2/103 ) of the cases a macroscopic residual tumour ( r2 ) was present in the pelvis after resection . 5% ( 5/103 ) of the patients had overall r2 resection because of hepatic or pulmonary metastasis , while 2% ( 2/103 ) of the patients underwent simultaneous hepatic tumour resection resulting in r0 situation . until may 2009 this patient had palliative rectal resection for a pt3b , pn2 ( 8/22 ) , l1 , v1 , pn1 , pm1 ( hepatic and pulmonary ) , g3 , uicc - stage iv rectal cancer . 8% ( 8/103 ) of patients needed urgent surgery secondary to ileus ( 3% ; 3/103 ) or perforation of rectal carcinoma ( 5% ; 5/103 ) . in 76% ( 78/103 ) an anterior resection was performed , 6% underwent ( 6/103 ) hartmann 's operation and 2% ( 2/103 ) had a colectomy . in 16% ( 17/103 ) of cases these patients either had local recurrence of rectal cancer , a tumour less than 2 cm from the anal verge , sphincter infiltration , sphincter insufficiency or malignant melanoma of the anus . major surgical complications occurred in 17% ( 18/103 ) of patients , including anastomotic leakage , wound dehiscence , intra - abdominal abscess formation , postoperative haemorrhage and failure of the rectal remnant after hartmann ' operation . major general complications occurred in 7% ( 7/103 ) including pneumonia , stroke and myocardial infarction ( table 2 ) . mortality after elective operations was 4% ( 4/95 ) , while patients undergoing urgent surgery had a mortality rate of 38% ( 3/8 ) , p = 0.026 . in 90% ( 93/103 ) an evaluation of the quality of the mesorectum was possible . in 10% ( 10/103 ) 7 patients had local recurrence of rectal cancer and had already had rectal resection during prior surgery . 3 patients were part of another study which required immediate opening of the removed rectum for the collection of unfixed tumour biopsies from the removed tumour . i ) in 99% ( 92/93 ) of removed tumours . in 1% ( 1/93 ) ii ) , and none ( 0/93 ) of the removed tumours had an incomplete mesorectum ( m.e.r.c.u.r.y . macroscopic high tme quality of an unfixed rectal resection specimen showing the intact mesorectum without defects on the surface . uicc tumour stage ; final histology ( n = 103 ) . in 98% ( 91/93 ) the circumferential resection margin was negative , showing no tumour infiltration at least 2 millimeters away from the lateral resection margin . one patient requiring urgent surgery for perforated rectal cancer ( uicc tumour stage iiic ) had involvement of the lateral resection margin . the other patient with lateral resection margin involvement was operated after long term chemoradiation ( uicc tumour stage iiib ) . fifty percent ( 51/103 ) of patients were staged to have advanced rectal cancer ( > t2 or n+ ) . of those , 61% ( 31/51 ) received neoadjuvant radiation , while 39% ( 20/51 ) underwent operation without preoperative radiation . the reasons for primary operation without radiation in advanced stages of rectal cancer included recurrence of rectal cancer ( 7% ; 7/103 ) , suspected metastatic disease ( 9% ; 9/103 ) , urgent surgery ( 8% ; 8/103 ) , advanced age ( 2% ; 2/103 ) , severe co - morbidities ( 2% ; 2/103 ) , incompliance ( 1% ; 1/103 ) , other malignancy ( 1% ; 1/103 ) or combination of these . the mean number of lymph nodes removed during the operation was 19 ( range 4 - 47 ) . sixtysix percent of the removed tumours ( 68/103 ) had moderate differentiation , 17% ( 18/103 ) good differentiation and 9% ( 9/103 ) poor differentiation , while in 1% ( 1/103 ) an un differentiated tumour was found . in 7% ( 7/103 ) of cases grading was not possible . distant metastases were pre sent in 9% ( 9/103 ) , including 6 patients with hepatic metastases , 1 patient with pulmonary and hepatic meta stases and two patients with metastases towards other organs . in 91% ( 94/103 ) patients had no distant metastases . in 2% ( 2/103 ) of the cases a macroscopic residual tumour ( r2 ) was present in the pelvis after resection . 5% ( 5/103 ) of the patients had overall r2 resection because of hepatic or pulmonary metastasis , while 2% ( 2/103 ) of the patients underwent simultaneous hepatic tumour resection resulting in r0 situation . until may 2009 this patient had palliative rectal resection for a pt3b , pn2 ( 8/22 ) , l1 , v1 , pn1 , pm1 ( hepatic and pulmonary ) , g3 , uicc - stage iv rectal cancer . the prognosis of rectal cancer depends principally on tumour stage at the time of diagnosis , while local recurrence depends rather on surgical technique . in studies on colorectal cancer , survival is most important , but trials on rectal cancer also focus on local recurrence since local control also correlates with survival . patients receiving preoperative radiotherapy before conventional resection for rectal cancer still have recurrence rates between 28% and 37% . the rate of local recurrence is directly related to the technique of rectal cancer excision , which makes surgical technique the most important factor for patients ' outcome . although tme is accepted in western countries as a standard principle of surgical treatment for rectal cancer the rate of local recurrence without radiotherapy varies between 3% and 18% . kapiteijn and his group could show that short term preoperative radiotherapy reduced the rate of local recurrence . but the fact that best results for rectal cancer surgery were reported without radiotherapy by heald who originally introduced the principle of tme makes it obvious that the surgeon plays a crucial rule for patients ' prognosis . at a mean follow up of 4,2 years after curative resection for rectal cancer heald reported a local recurrence rate of less than 3% . 1 . is the variation in local control in studies related to the surgical quality of tme ? although modern surgical treatment of colorectal cancer implies the operative principle of tme , data on tme quality of resected specimen are rare . tme quality was optimal in 47% , 40% of patients had nearly complete tme , while 13% had incomplete tme . the rate of local recurrence was 41% ( 59% overall recurrence ) , in patients with nearly complete tme the rate of local recurrence was 6% ( 17% overall recurrence ) , while in patients with optimal tme surgery the rate of local recurrence was less than 2% ( 2% overall recurrence ) . i ) , but there were 12 patients with positive resection margins , which makes local recurrence likely to occur . hermanek and heald also focused on the results of the rectal cancer study from the netherlands . they showed that not the whole series of the dutch trial did represent a standardized tme surgery since there was a high rate of incomplete mesorectal excisions for resectable rectal cancer . the variation in local control therefore seems to be an indicator for differences in surgical quality of tme . more evidence for the importance of surgical quality is the difference between multicentre trials and results from single institutions . heald 's excellent data were the result of a single person applying a new technique . the analysis from the netherlands might have compaired excellent surgical quality with poorer quality from different institutions . the role of the surgeon becomes even more obvious since objective analysis of the operative quality is possible by the evaluation of the quality of tme . therefore the documentation of tme quality by pathologists is essential to detect deficits in surgical technique . this may lead to better tme quality and seems to be an effective tool to improve operative results . in our series we could demonstrate that optimal tme quality can be achieved with different operative procedures in any stage of rectal carcinoma . although we had a relatively high rate of abdominoperineal resections this did not increase the rate of incomplete tme . other institutions showed that optimal tme quality can be achieved by individual training after instruction by tme trained surgeons . all operations except for urgent surgery were supervised by surgeons being experienced in tme surgery for several years . during the whole study operations were performed by 7 different surgeons from our institution . the introduction of tme surgery can be associated initially with higher rates of anastomotic leakage , but several studies showed that these findings would improve during the routine application of tme surgery [ 21 - 23 ] . during the time of our study there were 4 of 78 cases with a clinical apparent anastomotic leakage . an explanation for the high rate of hartmann 's stump leakage is that these were all urgent operations for perforated rectal cancer in patients requiring high dose catecholamines imparing wound healing . two patients died secondary to generalised peritonitis after hartmann 's operation , the other patient died due to excessive liver metastases after urgent colectomy . in our series the mean number of removed lymph nodes was 19 ( range 4 - 47 ) . patients with less than 12 lymph nodes removed during the operation either had a local recurrence of rectal cancer or had undergone neoadjuvant radiation . apart from tme quality another marker for mastery in rectal cancer surgery is the achievement of negative resection margins . a distance of more than 1 mm from the tumour to the border of resection is considered to be a negative margin , although a recent analysis reported a distance of 2 mm to be the limit . there may be further discussion about the exact distance for negative resections margins , but the optimal technique to obtain free resection margins is total mesorectal excision since it has been shown that tme achieves a negative resection margin in up to 96% of resected specimen . they analysed the importance of tme to obtain free circumferential resection margins showing that in patients with positive crm the rate of incomplete tme was 44% while in patients with negative crm the rate of incomplete tme was only 11% . furthermore lateral margin involvement was more likely to occur in advanced tumour stages than in tumours with positive lymph nodes . in uicc stage iii with positive crm secondary to incomplete mesorectal excision there were significantly more patients with lateral margin involvement , by the primary tumour than by positive lymph nodes . compared to the results from the literature ranging between 18% and 28% of resection margin involvement our findings reflect another effect of optimal tme surgery . taken both together , the accuracy of mesorectal excision and the analysis of circumferential resection margins are effective in predicting patients ' prognosis . negative resection margins unfortunately do not only depend on surgical technique but on tumour size and tumour stage at the time of operation . although radiotherapy has been shown to improve outcome for patients with resectable rectal cancer , subgroup analysis from the dutch trial showed that there is no benefit for patients with uicc tumour stage i or iv in the upper part of the rectum . therefore it is important to improve selection criteria for the application of preoperative radiotherapy to protect patients from the side effects of radiation without benefit . in our analysis we could show that optimal tme quality is feasible in all stages of rectal cancer . high quality tme surgery can be performed with a rate of morbidity and mortality comparable to the results from the literature . with adequate surgical expertise high quality tme surgery future studies should evaluate outcome and local recurrence in accordance to the degree of tme quality .