The delivery of surgery has never been more focussed on quality. Patients deserve consistent standards regardless of where they live or are treated. The pursuit of excellence requires the definition of standards and the search is on to find what parameters best guarantee equal patient outcome and care. In a recent paper in Gut, the careful work by Morris et al highlights how wide variation in outcome can occur and shows the importance of population-based audit to monitor trends.1 Certainly, while sphincter preservation is often considered a patient priority Morris et al illustrate that operative choice can profoundly affect quality of care and therefore careful monitoring can indicate room for improvement. A separate area of controversy is the role of lymph node evaluation as a marker of quality assurance. Undoubtedly lymph node evaluation is important but opinions differ as to the exact role that lymph nodes play in rectal cancer management.

Total mesenteric excision: a new paradigm

In the early 1980s local recurrence of rectal cancer was 20–40%.2 In an attempt to address this issue a more radical local excision was trialled to assess whether careful removal of the whole of the mesorectum would cause a beneficial effect. This work, performed at Basingstoke and now known as total mesorectal excision, revolutionised rectal cancer, reducing local recurrence to 5–10%.3 It was postulated at that time that radical local excision resulted in eradication of disease prior to systemic spread, therefore …