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Abstract

Before reading this letter, 1 we had not considered our surgery as "bad, " but rather our pathology as "excellent. " We are fortunate that our lead pathologist, Dr Mariana Berho, is internationally recognized as a leader in colorectal pathology and was the reference pathologist for the creation of the total mesorectal excision (TME) standards for the National Accreditation Program for Rectal Cancer (NAPRC). 2-5 While many, if not most, studies in the literature cite rates of complete mesorectal excision close to 100%, 6-8 our rates may be lower because of the scrutiny through which our specimens are thankfully routinely subjected.Our findings are consistent with the transanal TME study in which 100 consecutive TME specimens were assessed on a local level and then by 1 of 2 expert pathologists. 9 The 90% rate of complete or near complete TME was almost identical to that of our "bad" surgery of 87.1%. The transanal TME study found that the site pathologist agreed with the first expert reviewer in only 54% of cases, with minor disagreement in 32% of cases and major disagreement in 14% of cases.During central expert pathologist review, downgrading occurred from complete to near complete or incomplete in 13.8% of specimens originally graded by the individual site pathologists as complete. Thus, either "bad" surgery is more prevalent than previously thought or excellent pathology is less prevalent than desirable; we are not alone in our findings. [10][11][12] We are optimistic that the NAPRC will result in more pathologists being more diligent in their TME specimen reviews. Early evidence from the NAPRC indicates that outcomes are already improving.