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Introduction {#Sec1} ============ Total mesorectal excision (TME) as described by Heald et al. in 1982 has \[[@CR1]\] become the gold standard of rectal cancer surgery. When performed meticulously, it yields low rates of local recurrence (LR) and improved survival \[[@CR1]\]. In Norway, a national rectal cancer project was launched in 1993 in order to improve outcome for rectal cancer patients. Of several interventions, TME was introduced as the preferred surgical technique and an educational programme, which included training courses and master classes, was implemented throughout Norway \[[@CR2]\]. As a result, the risk of LR was decreased by 50% \[[@CR3]\]. At Levanger Hospital, the modern principles of rectal cancer surgery were introduced in 1980, and a prospective protocol for operative strategy, radiotherapy and surveillance was established. Although excellent results were reported \[[@CR4]\], an offer to participate in the TME educational programme was rejected by Levanger Hospital because it was a common belief among our staff that we had mastered this technique. However, the first biannual report from the Cancer Registry of Norway in 1997 revealed an unacceptably high rate of LR at Levanger hospital, and actions had to be taken. The protocol was regarded as sufficient and left unchanged, but the focus on adequate preoperative assessment to assign the right patients to neoadjuvant therapy was increased. In addition, the team of surgeons who performed TME surgery was strengthened by having specialists in colorectal surgery present during operation. In this study, a complete cohort of patients who were treated for rectal cancer at Levanger Hospital during 1980--2004 was analyzed to assess temporal trends in treatment and oncologic outcomes. We examined every case of LR in this time period in search of possible protocol violations. Patients and methods {#Sec2} ==================== A complete cohort was assured by using data from the Norwegian Cancer Registry. The hospital health records of all patients treated for rectal cancer at Levanger Hospital from 1980 to the end of 2004 were reviewed. The patients were assigned into three separate periods, which depended on their date of surgery: 1980--1989, 1990--1999 and 2000--2004. The hospital served a defined patient catchment area with a population that increased slightly from 85,741 in 1980 to 88,858 in 2004. The upper limit for rectal cancer was defined as 15 cm from the anal verge measured on rigid proctoscopy. The surgery was performed by sharp dissection under visual guidance in the avascular plane surrounding the mesorectal fascia. A major resection with curative intent implied resection of the tumour bearing segment of rectum with no signs of metastases on preoperative investigations or by intraoperative examination, but included patients with microscopically involved margin and intraoperative perforations. The operation was considered curative if a microscopically free margin was confirmed and there was no bowel perforation. Circumferential resection margin (CRM) was defined as the shortest distance from the periphery of the tumour or tumour deposits to the resection margin. Residual tumour stage (R stage) was registered where no residual tumour locally was classified as R0 resection, microscopically involved margin as