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Background: The purpose of this study was to determine whether sphincter preservation in patients undergoing elective radical excision of rectal cancer is associated with surgeon or hospital volume. We also sought to determine whether morbidity and mortality are affected by case-volume.Methods: Using the U.S. Nationwide Inpatient Sample database, we identified all adult patients who underwent elective rectal resection for cancer as their primary procedure between 2003 and 2007. Cases were divided into three groups according to the average number of resections performed annually by each surgeon: low-volume (≤2/year), intermediate volume (3-4/year), or high-volume (≥5/year). Annual hospital case-load was categorized as low-volume (≤8/year), intermediate-volume (9-18/year) and high-volume (≥19/year). Rates of sphincter preservation were determined for each group. Multiple regression models were used to identify differences in morbidity and mortality according to hospital and surgeon volume after adjusting for patient characteristics and tumor stage. The Elixhauser algorithm was used to adjust for comorbidities. Results: A total of 12,272 patients underwent radical excision of rectal cancer by 3667 surgeons in 1072 hospitals. There was a trend toward a higher rate of sphincter preservation among high-volume surgeons (74.4 vs. 71.9%; p=0.06). Neither morbidity nor mortality were associated with surgeon volume; however procedures perfomed by high-volume surgeons were associated with reduced length of stay (6.8%; 95%CI 4.9, 9.5) and decreased hospital charges (5.8%; 95% CI 2.0, 10.4). Patients who underwent surgery in high-volume hospitals had a higher rate of sphincter preservation (75.4 vs. 70.3%; p=0.0002), and a lower rate of pulmonary complications and blood transfusion. Hospital volume was associated with a reduced in-patient mortality in univariate analysis but not after adjustement for important patient-related covariates. In univariate analysis: resection by high volume-surgeons in high-volume hospitals had a 50% reduction in mortality rates compared to low-volume surgeons in low-volume hospitals (odds ratio: 0.48; 95% CI 0.26-0.48).Conclusions: In patients undergoing elective radical excison for rectal cancer, increased sphincter preservation is more frequent at high-volume centers. Morbidity and mortality are not significantly influenced by surgeon or hospital volume