Interaction Between Operator and Assistant Certification Is Associated With Local Recurrence After Laparoscopic Rectal Cancer Surgery: An Ancillary Analysis of the EnSSURE Study

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Background: Local recurrence (LR) after laparoscopic rectal cancer surgery remains a major clinical concern. While surgical expertise is important, the impact of combined operator and assistant certification on local recurrence remains unclear. Methods: This retrospective multicenter study analyzed 2825 patients with stage II-III rectal cancer who underwent laparoscopic resection in the EnSSURE cohort. The primary endpoint was the 3-year cumulative incidence of LR, treating death and distant metastasis as competing events. The primary analysis used a Fine-Gray model including an interaction term between operator and assistant certification based on the Endoscopic Surgical Skill Qualification System. Secondary analyses included a four-group Fine-Gray analysis (qualified operator and assistant [QQ], qualified operator only [QN], qualified assistant only [NQ], and neither qualified [NN]). A cause-specific Cox model was used for sensitivity analysis. Results: = 0.038), whereas neither was independently associated with LR. In the four-group analysis, the risk of LR was significantly higher in the QN, NQ, and NN groups compared with the QQ group (QN: sHR 2.37; NQ: sHR 2.12; NN: sHR 2.18). Results were consistent in sensitivity analyses. Conclusions: A significant interaction between operator and assistant certification was associated with a lower risk of LR, suggesting that surgical outcomes may depend on team composition rather than individual qualifications alone. Trial Registration: UMIN Clinical Trials Registry System: UMIN000040645 (June 3, 2020).

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