Meta-analysis of surgical quality-related factors associated with local recurrence rate after rectal cancer surgery

Abstract

BACKGROUND

Despite treatment advances, rectal cancer continues to pose a considerable global health burden, and local recurrence remains an important driver of long-term outcomes. Despite the evolution of surgical technique and multimodal therapy, local recurrence rates (LRRs) remain heterogeneous across institutions, thought to be related to differences in surgical quality. Local recurrence risk has been associated with several surgical quality indicators such as circumferential resection margin (CRM) involvement, total mesorectal excision (TME) quality and surgeon experience. However, the exact relative contribution of each factor is not fully defined.

AIM

To assess factors associated with a change in LRR after rectal cancer surgery and to quantify their contribution to oncological outcome by means of systematic evaluation.

METHODS

MEDLINE/PubMed, EMBASE, and the Cochrane Library were searched thoroughly through 30 November, 2025. In addition, studies correlating local recurrence with surgical quality factors (CRM status, TME quality grade, surgeon volume, hospital volume and operative time) in rectal cancer patients were included. Main outcome measures were LRR at 3 years and 5 years, and disease-free survival (DFS) and overall survival (OS). Quality assessment was done using the Newcastle-Ottawa Scale for observational studies and Cochrane Risk of Bias tool for randomized trials. Heterogeneity was assessed using I² statistic and random-effects models were used with meta-analysis for treatment comparisons.

RESULTS

Meta-analysis included 10 studies with 11525 patients. Positive CRM was the most significant predictor of local recurrence [odds ratio (OR) = 4.28, 95% confidence interval (95%CI): 3.45-5.31, P < 0.001], with a corresponding LRR at 5 years of 18.7% in positive vs 14 cases (4.2%) in CRM-negative cases. If report shows incomplete TME (mesorectal plane) yes OR = 3.16 (95%CI: 2.48-4.03, P < 0.001) compared with complete TME no compared to low-volume surgeons (< 10 cases/year), high-volume surgeons (> 20 cases/year) had lower LRR (OR = 0.58, 95%CI: 0.45-0.75, P < 0.001). The predictors of LRR included hospital volume > 50 cases/year (OR = 0.66, 95%CI: 0.51-0.86, P = 0.002). Long operative time (> 240 minutes) was associated with LRR rates (OR = 1.52, 95%CI: 1.18-1.96, P = 0.001). TME and CRM positivity were independent risk factors for worse DFS [hazard ratio (HR) = 2.84, 95%CI: 2.31-3.49 for incomplete TME and HR = 2.12, 95%CI: 1.74-2.58 for positive CRM] and OS (HR = 2.56, 95%CI: 2.08-3.15; HR = 1.89, P < 0.001).

CONCLUSION

The behaviour of LRRs after rectal cancer surgery is highly influenced by surgical quality. Modifiable factors include CRM involvement and incompleteness of TME. The results corroborate the rationale for centralization of rectal cancer surgery to high-volume centers and experienced surgeons, coupled with comprehensive quality assurance programs focused on proper TME technique and negative margins as a means to reduce LRRs and improve survival. Nonetheless, the current meta-analysis shows correlations instead of directly testing centralization policy effectiveness.

Keywords: Rectal cancer; Local recurrence; Circumferential resection margin; Total mesorectal excision; Surgical quality; Surgeon volume; Hospital volume; Meta-analysis

Core Tip: Positive circumferential resection margin identifies patients at 4.3-fold increase risk of local recurrence emergence as strongest predictor; whereas incomplete total mesorectal excision confers 3.2-fold increased risk. Recurrence rates are significantly lower at high-volume surgeons and centers. This highlights the need for surgical quality assurance programs, specialization in rectal cancer surgery and centralization of treatment to further improve oncological results. While the meta-analysis by does not explicitly test a centralization policy, its findings align with what one would expect based on the rationale for quality-based referral patterns and training initiatives.