Defining key interventions for rectal cancer surgery: a literature review and expert panel consensus.

Introduction
Despite minimally invasive surgery (MIS) and Enhanced Recovery Programs (ERP), rectal cancer surgery continues to carry a substantial risk of postoperative morbidity and mortality [1–4]. In addition to patient-related factors, organizational and process elements—such as high surgeon and hospital volumes and consistent use of a multidisciplinary team (MDT)—are associated with improved oncological and functional outcomes [5, 6]. However, translating evidence-based recommendations into routine, reproducible practice remains challenging.
Care pathways are an established method to embed complex perioperative interventions and to reduce unwarranted variation. Multiple studies have shown that well-designed pathways improve surgical outcomes and resource utilization [7–10]. For example, Howell et al. demonstrated that pathway-driven interventions can reduce adverse events in surgery by standardizing critical perioperative steps [9], and Seys et al. highlighted their value for reliable implementation across institutions [11].
Several international frameworks now define contemporary standards for high-quality rectal cancer care. These include the National Accreditation Program for Rectal Cancer (NAPRC) of the American College of Surgeons (ACS) and the Optimizing the Surgical Treatment of Rectal Cancer (OSTRiCh) consortium, the Enhanced Recovery After Surgery (ERAS®) Society’s guidelines, and the American Society of Colon and Rectal Surgeons (ASCRS) clinical practice guidelines. Together, NAPRC, ERAS®, and ASCRS provide complementary, evidence-based benchmarks for perioperative management and quality assurance in rectal cancer surgery [1, 6, 12]. In contrast, our approach focuses on patient-level key interventions—specific clinical actions within the preoperative, intraoperative, and postoperative phases (including 90-day outcomes) that can be incorporated into local care pathways and form the basis for future quality indicators. By identifying and implementing patient-centered key interventions, we aim to complement existing system-level interventions and contribute to their improvement from the base. This complementary perspective emphasizes the importance of aligning institutional standards with the individual patient journey.
The objective of this study was to identify and prioritize such essential clinical interventions for elective rectal cancer surgery through a structured, guideline-based development process as described by Kötter et al. [13], combined with a national expert consensus. While not all these key interventions are directly measurable as quality indicators, they form a clinically validated basis for future quality monitoring and improvement efforts.

Key message
This consensus-based framework provides clinicians and institutions with a practical, reproducible set of 37 patient-level interventions for rectal cancer surgery. It helps integrate evidence-based steps into local care pathways, supports consistent 90-day outcome monitoring, and offers a foundation for future quality indicators and care pathways.

Methods
A systematic and transparent approach is necessary to develop key interventions relevant to the quality of care in rectal cancer surgery. These key interventions need to be scientifically acceptable, feasible, clinically relevant, usable and allow for discrimination [14, 15]. We used the stepwise approach for a guideline-based development of key interventions as proposed by Kotter et al. [13]. They recommend six sequential steps: Topic selection, guideline selection, extraction of recommendations, quality-indicator selection, practice test and finally implementation. The present project reports on the first four steps, as testing and implementation will follow in future work. A visual summary of the process and article selection is provided in Fig. 1.
In the first step, a topic was selected and criteria for narrowing it down were identified by the research team and a group of faculty rectal cancer surgeons (AW, ADH, GB) in a tertiary referral center. In the second step, a selection of guidelines from peer-reviewed literature was made. Third, key interventions from the guidelines and literature were extracted. In the fourth step, we conducted a single-round Delphi consensus among 25 visceral surgeons involved in colorectal surgery, since colorectal surgery is not a distinct subspecialty in Belgium. The panel included surgeons from four Belgian university hospitals as well as peripheral hospitals, providing a balanced mix of academic and non-academic expertise. All invitees completed the survey (response rate 100%). All participants were senior staff colorectal surgeons, most of them heads of their colorectal units. Based on professional profiles, each had at least ~ 10 years of independent practice. Exact age and individual operative volumes were not collected. Each candidate intervention was rated on a 10-point Likert scale (1 = not relevant, 10 = indispensable). Consensus was predefined as ≥ 75% of experts scoring an item ≥ 8. Items scoring < 4 were excluded; items scoring 4–7 were discussed during a live video panel and included if consensus was reached. Panelists could also propose new interventions. No conflicts of interest were declared.

Results

Step 1: Topic selection
The topic, “Key interventions for best standard of care in patients undergoing rectal cancer surgery” was defined by the research team (CS, EC) together with three faculty colorectal surgeons in a tertiary referral center (AW, ADH, GB). The target population comprised adults scheduled for elective rectal cancer surgery, including total mesorectal excision (TME) and abdominoperineal resection (APR). The following research topics were excluded: patients with metastatic disease, patients with synchronous (colorectal) cancer and patients with underlying diseases like Familial Adenomatous Polyposis (FAP) or inflammatory bowel disease (IBD) specifically. While the focus was on identifying clinically relevant perioperative interventions, the potential impact on resource use and patient quality of life was considered when reviewing the literature and formulating candidate interventions.

Step 2: Literature review and selection of guidelines
To identify candidate interventions, the principal investigators (EC, CS) independently conducted an extensive literature review to determine key interventions for the best standard of care for all patients undergoing rectal cancer surgery. The primary database was PubMed/MEDLINE, searched on October 14th 2024 with the following MESH terms: ‘"Patient Reported Outcome Measures"[Mesh] OR ((("Guideline Adherence"[Mesh]) OR "Guideline" [Publication Type]) OR "Quality Indicators, Health Care"[Mesh]) AND "Rectal Neoplasms"[Mesh]’’. No duplicates or automation-based exclusions were identified. After title and abstract screening, 281 records from the initial 293 were excluded due to not focusing on rectal cancer surgery, lacking explicit clinical recommendations, or being non-English. Of the remaining 34 reports sought for retrieval, one could not be retrieved. Full-text assessment of 34 reports led to the exclusion of 21 other articles (no clinical recommendations, not within the scope of step 1). Ultimately, 12 key publications were included, from which the first set of key interventions was extracted (Fig. 1, Annex 1).

Step 3: Extraction of key interventions
A first set of key interventions (n = 56) was categorized into 5 sub-categories that cover the perioperative setting in rectal cancer surgery: pre-admission, anesthesia, surgery, postoperative course and clinical outcome. After elimination of duplicates, the list was reduced to 39 specific key interventions.

Step 4: Final selection of the relevant key interventions
From the 39 candidate interventions presented to the panel, three were excluded for low relevance (< 4). Twenty were included immediately (≥ 8), and twelve were retained after discussion of intermediate scores (4–7). The panel also proposed five new interventions, resulting in a final list of 37 key interventions. Highest consensus was reached for multidisciplinary team consultation (97%), preoperative patient counseling (89%), postoperative tumor board (94%), anastomotic leakage (89%), re-intervention (90%), and 90-day mortality (93%) (Tables 1 and 2). An illustrative mapping of interventions to possible quality indicators, evidence levels, and data sources is provided in Annex 3 to facilitate future indicator development.

Discussion
This study defined a contemporary set of 37 key interventions for rectal cancer surgery through a literature review and a single-round national Delphi process. The resulting framework provides a reproducible basis for integrating evidence-based steps into rectal cancer care pathways and for developing future quality indicators.

Alignment with international standards
High consensus on pre- and postoperative multidisciplinary team (MDT) consultation (97% and 94%, respectively) underscores the central role of coordinated decision-making in rectal cancer care. MDTs comprising surgeons, radiologists, pathologists, and (radiation) oncologists enable comprehensive treatment planning and have been associated with reduced recurrence and improved survival. These findings are consistent with the standards of the NAPRC, which mandates multidisciplinary evaluation and systematic quality monitoring [6, 16]. Surgical and postoperative outcomes, such as anastomotic leakage (89%), re-intervention (90%), and 90-day mortality (93%), were given high scores by the expert panel. Additionally, postoperative complications often necessitate re-interventions, leading to prolonged hospital stays and negatively affecting long-term survival. Therefore, vigilant monitoring of these indicators is essential to promptly identify and address complications, ultimately enhancing patient outcomes [17]. These findings are consistent with ERAS ® and ASCRS guidelines emphasizing perioperative optimization and robust 90-day outcome monitoring [1, 12].

Excluded or reclassified items
In our study, several key interventions were excluded due to limited or inconsistent evidence regarding their effectiveness. Prehabilitation was not retained, largely because current programs differ widely in duration, intensity, and multimodal components, making standardization and outcome evaluation difficult. Nevertheless, emerging trials show potential benefit, indicating a need for further high-quality studies to clarify its role [18, 19]. Similarly, high versus low tie of the inferior mesenteric artery/vein was ultimately retained, although current literature shows no clear survival benefit, likely serving more as a data-collection item or technical variable than as a true key intervention [20]. Perioperative fluid balance and soberness were excluded by the experts due to varying recommendations and a lack of consensus on optimal management strategies in the perioperative setting [21]. The practice of reinforcing anastomosis with additional sutures was also excluded, as recent studies have not demonstrated a clear benefit in reducing anastomotic leaks, making its routine use debatable [22]. Additionally, multimodal prevention of ileus was not included, given the heterogeneous approaches and insufficient high-quality evidence supporting its effectiveness in enhancing recovery after surgery [23]. Routine pelvic drains and nasogastric tubes were discouraged, consistent with both ERAS and ASCRS recommendations, with explicit allowance for selective use under documented clinical indications. These exclusions highlight the need for robust clinical trials to establish the efficacy of such interventions before their integration into standard care protocols.

Strengths and limitations
Whereas existing international frameworks largely specify institutional or system-level requirements for accreditation and quality assurance, our framework focuses on patient-level interventions that translate such standards into daily clinical practice. By incorporating detailed intraoperative practices and early postoperative milestones, our framework complements organizational metrics with process measures that are directly actionable within care pathways, supporting consistent bedside implementation across both academic and peripheral hospitals. Strengths of this study include a transparent, guideline-anchored methodology, full expert panel participation, and explicit consensus thresholds (≥ 75% agreement) consistent with recommended Delphi practice.
Several limitations merit consideration. First, our framework focuses strongly on clinical process indicators—internal procedures and organizational aspects of care delivery While essential for maintaining consistency and quality, these elements are often not directly visible to patients. To achieve a more integrated and multidimensional understanding of quality, future efforts should combine such process measures with patient-facing components, including communication, education, and shared decision-making [24]. Second, the Delphi design involved a single round with 25 national colorectal surgeons. Although this approach achieved full participation and rapid consensus (≥ 75% agreement), literature indicates that panel composition can shape the resulting key interventions [25]. Third, the literature search was restricted to MEDLINE. While this was judged sufficient to capture major international colorectal guidelines (e.g., NAPRC, ERAS®, ASCRS) and suited the scoping purpose of identifying guideline-based interventions, it may have omitted relevant studies indexed only in Embase or Cochrane.

Implications and next steps
Integrating the 37 identified key interventions into institutional care pathways is crucial for ensuring consistent, evidence-based implementation of international colorectal surgery standards such as ERAS® and ASCRS guidelines. Embedding these interventions provides a practical foundation for benchmarking and quality improvement, supporting both internal audits and external accreditation efforts. The value of such integration is illustrated by a recent healthcare system-wide collaborative that successfully reduced hospital stays after elective colectomy for cancer through a structured, multi-center pathway approach [26]. Future research should include practice testing (Kotter steps 5–6), international validation, and the incorporation of patient-reported outcomes to complement process indicators. These steps will help transform key interventions into measurable quality indicators and ensure a multidimensional, patient-centered quality framework.

Conclusion
This study identifies 37 key interventions for rectal cancer surgery, providing a structured framework to strengthen quality of care across the preoperative, intraoperative, and postoperative phases. High expert consensus on critical steps—such as pre- and postoperative multidisciplinary team consultation—underscores their central role in optimizing outcomes. While conceived as candidate quality indicators, many of these elements are best regarded as core clinical or process interventions that form the foundation for future indicator development. Next steps include validation in real-world settings, refinement into measurable indicators where feasible, and integration of patient-centered outcomes. Consistent implementation of these interventions within institutional care pathways will be essential to enhance surgical results and patient satisfaction. 10.7326/M18-0850