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PubMed2006

Quality of life after total mesorectal excision for rectal cancer.

BACKGROUND: After total mesorectal excision for rectal cancer, many surgeons try to avoid an abdominoperineal resection (APR) by performing a transanally double stapled low colo-rectal anastomosis (LRA), frequently without a pouch. This policy is mainly based on the assumption that the quality of life after such LRA is higher than after APR. It has been suggested that a better functional outcome and therefore a higher quality of life might be achieved by a colo-anal J-pouch anastomosis (CPA). The aim of this study was to assess quality of life among disease-free survivors after APR, LRA and CPA. METHODS: The charts of 301 consecutive patients who had undergone surgery for cancer in the middle or lower third of the rectum were analysed. Two hundred four patients were eligible for inclusion. The quality of life among these patients was assessed using one generic (EQ-5D) and two disease-specific questionnaires (EORTC QLQ-C30 and EORTC QLQ-CR38). RESULTS: The response rate was 82%. The median follow-up was 31 months. Overall, quality of life was good but CPA patients had better quality of life scores than APR and LRA patients. This difference was not only due to the better functional outcome but also to the lower incidence of disturbed micturition and sexual problems in the CPA group. CONCLUSION: The quality of life after colo-anal J-pouch anastomosis is better than after abdominoperineal resection (APR) and low colo-rectal anastomosis (LRA). The quality of life after APR is similar to that after LRA.

Adult↗

PubMed2005

Laparoscopic total mesorectal excision for rectal cancer surgery.

The introduction of total mesorectal excision in the early 1980s has improved local control and survival in patients with rectal cancer. Laparoscopic resections for colonic malignancies are gaining acceptance in the light of the recent evidence of oncologic adequacy from randomized clinical trials. Technical difficulties and the difference in the natural history of the disease have excluded rectal cancer from major clinical trials comparing laparoscopic to conventional rectal surgery. This review examined the feasibility, safety and oncologic outcomes of reported laparoscopic total mesorectal excision for surgical treatment of operable rectal cancer.

Humans↗

PubMed2006

Female urogenital dysfunction following total mesorectal excision for rectal cancer.

BACKGROUND: The effect of Total Mesorectal Excision (TME) on sexual function in the male is well documented. However, there is little literature in female patients. The aim of this study was to review the pelvic autonomic nervous anatomy in the female and to perform a retrospective audit of urinary and sexual function in women following surgery for rectal cancer where TME had been performed. Urogenital dysfunction was assessed through interview and questionnaire. METHOD: Twenty-three questionnaires, eighteen returned, were sent to women with a mean age 65.5 yrs (range 34-86). All had undergone total mesorectal excision for rectal cancer between 1998-2001. Mean follow-up was 18.8 months (range 3-35). RESULTS: Preoperatively 5/18 (28%) were sexually active, 3/18 (17%) of patients described urinary frequency and nocturia and 7/18 (39%) described symptoms of stress incontinence prior to surgery. Postoperatively all sexually active patients remained active although all described some discomfort with penetration. Two of the patients sexually active described reduced libido secondary to the stoma. Postoperative urinary symptoms developed with 59% reporting the development of nocturia, 18% developed stress incontinence and one patient required a permanent catheter. Of those with symptoms, 80% persisted longer than three months from surgery. Symptoms were predominant in those patients with low rectal cancers, particularly those undergoing abdomino-perineal excision and in those who had previously undergone abdominal hysterectomy. CONCLUSION: The treatment of rectal cancer involves surgery to the pelvic floor. Despite nerve preservation this is associated with the development of worsening nocturia and stress incontinence. This is most marked in those patients who had previously undergone a hysterectomy. Further studies are warranted to assess the interaction with previous gynaecological surgery.

Journal Article↗

PubMed2002

Lymphoscintigraphy in patients with primary rectal cancer: the role of total mesorectal excision for primary rectal cancer--a lymphoscintigraphic study.

BACKGROUND AND AIMS: Total mesorectal excision based operations is the gold standard of care in patients with middle and lower rectal cancer, but the extent of resection varies widely. In our view, extended lymphadenectomy is unnecessary with precise total mesorectal excision, i.e., anatomically correct and sharp surgery. PATIENTS AND METHODS: Sixteen patients with primary rectal cancer underwent rectal lymphoscintigraphy 1 day prior continence-preserving anterior resection with total mesorectal excision. The specimens were examined for integrity by postoperative angiography of the superior rectal artery in anteroposterior and lateral views. RESULTS: Twelve patients had only mesorectal lymph nodes, and four had additional extramesorectal iliac lymph nodes. The labeled lymph nodes were identified and removed perioperatively using a gamma probe. Activity was measured again in the preparations outside the situs. Histological examination showed tumor-free lymph nodes only. CONCLUSION: Lymph vessels can be divided anatomically into visceral and somatic, and detection of extramesorectal lymph nodes does not call for lateral lymphadenectomy. Primary rectal cancer confined to the organ metastasizes within the mesorectum and does not invade extraregional lymph nodes. The mesorectum is the major visceral route for caudocranial metastatic spread.

Aged↗

PubMed1996

Pathological evidence in support of total mesorectal excision in the management of rectal cancer.

Some 50 total mesorectal excision specimens were examined following rectal excision for cancer. Circumferential margin involvement was rare, but mesorectal tumour deposits were present in 17 of 44 patients with pT3 tumours, and 23 of 44 had mesorectal nodal involvement. No patient with a pT2 tumour had mesorectal involvement. Failure to excise the mesorectum completely has the potential to leave gross or microscopic residual disease that may in theory predispose to local failure. Total mesorectal excision is necessary to avoid incomplete pathological evaluation of the mesorectum and understaging of rectal cancer.

Adenocarcinoma↗

PubMed2003

Comparative evaluation of immune response after laparoscopical and open total mesorectal excisions with anal sphincter preservation in patients with rectal cancer.

AIM: The study of immune response of open versus laparoscopical total mesorectal excision with anal sphincter preservation in patients with rectal cancer has not been reported yet. The dissected retroperitoneal area that contacts directly with carbon dioxide is extensive in laparoscopic total mesorectal excision with anal sphincter preservation surgery. It is important to clarify whether the immune response of laparoscopic total mesorectal excision with anal sphincter preservation (LTME with ASP) in patients with rectal cancer is suppressed more severely than that of open surgery (OTME with ASP). This study was designed to compare the immune functions after laparoscopic and open total mesorectal excision with anal sphincter preservation for rectal cancer. METHODS: This study involved 45 patients undergoing laparoscopic (n=20) and open (n=25) total mesorectal excisions with anal sphincter preservation for rectal cancer. Serum interleukin-2 (IL-2), interleukin-6 (IL-6), tumor necrosis factor alpha (TNFalpha) were assayed preoperatively and on days 1 and 5 postoperatively. CD3+ and CD56+ T lymphocyte count, CD3- and CD56+ natural killer cell (NK) count and immunoglobulin (IgG/IgM/IgA) were assayed preoperatively and on day 5 postoperatively. The numbers of CD3+ and CD56+ T lymphocytes and CD3- and CD56+ NK cells were counted using flow cytometry. An enzyme-linked immunosorbent assay (ELISA) was used for IL-2, IL-6 and TNFalpha determination. And IgG, IgM, and IgA were assayed using immunonephelometry. RESULTS: The demographic data of the two groups had no difference. The preoperative levels of CD3+ and CD56+ T lymphocyte count, CD3- and CD56+ NK count, serum IgG, IgM, IgA, IL-2, IL-6 and TNFalpha also had no significant difference in the two groups (P>0.05). The CD3+ and CD56+ T lymphocyte counts had no obvious changes after surgery in laparoscopic (d=-0.79 +/- 3.83%) and open (d=0.42 +/- 2.09%) groups. The CD3- and CD56+ NK counts were decreased postoperatively in both laparoscopic (d=-7.23 +/- 11.33%) and open (d=-9.21 +/- 13.93%) groups. The differences of the determined values of serum IgG, IgM and IgA on the fifth day after operation subtracted those before operation were -2.56 +/- 2.14 g/L, -252.35 +/- 392.94 mg/L, -506.15 +/- 912.24 mg/L in laparoscopic group, and -1.81 +/- 2.10 g/L, -282.72 +/- 356.75 mg/L, -252.20 +/- 396.28 mg/L in open group, respectively. The levels of IL-2 were decreased after operation in both groups. However, the levels of IL-6 were decreased after laparoscopic surgery (d1=-23.14 +/- 263.97 ng/L and d5=-40.08 +/- 272.03 ng/L), and increased after open surgery (d1=27.38 +/- 129.14 ng/L and d5=21.67 +/- 234.31 ng/L). The TNFalpha levels were not elevated after surgery in both groups. There were no significant differences in the numbers of CD3+ and CD56+ T lymphocytes and CD3- and CD56+ NK cells, the levels of IgG, IgM, IgA, IL-2, IL-6 and TNFalpha between the two groups (P>0.05). CONCLUSION: There are no differences in immune responses between the patients having laparoscopic total mesorectal excision with anal sphincter preservation and those undergone open surgery for rectal cancer.

Adult↗

PubMed2002

Assessment of sexual and voiding function after total mesorectal excision with pelvic autonomic nerve preservation in males with rectal cancer.

PURPOSE: Total mesorectal excision with pelvic autonomic nerve preservation has been reported to be an optimal surgery for rectal cancer. It minimizes local recurrence and sexual and urinary dysfunction. The aim of this study was to assess the safety of total mesorectal excision with pelvic autonomic nerve preservation in terms of voiding and sexual function in males with rectal cancer. METHODS: We performed urine flowmetry using Urodyn and a standard questionnaire using the International Index of Erectile Function and the International Prostate Symptom Score before and after surgery in 68 males with rectal cancer. RESULTS: Significant differences in mean maximal urinary flow rate and voided volume were seen before and after surgery (18.9 +/- 5.7 13.7 +/- 7.0, 240 +/- 91.9 143 +/- 78; < 0.05, < 0.05, respectively), but no differences in residual volume before and after surgery were apparent (4.4 +/- 2.6 8.1 +/- 4.4; > 0.05). The total International Prostate Symptom Score was increased after surgery from 6.2 +/- 5.8 to 9.8 +/- 5.9 ( < 0.05). There were no changes of score for one of each of seven International Prostate Symptom Score items in 49 patients (73.5 percent) to 61 patients (89.7 percent). Five International Index of Erectile Function domain scores (erectile function, intercourse satisfaction, orgasmic function, sexual desire, and overall satisfaction) were significantly decreased after surgery (18.2 +/- 9.3 13.5 +/- 9, 8.4 +/- 4.2 4.4 +/- 2.9, 5.8 +/- 2.9 4.4 +/- 2.9, 6.1 +/- 2.4 4.8 +/- 2, 6.1 +/- 2.2 4.5 +/- 2.3, respectively; < 0.05). Erection was possible in 55 patients (80.9 percent); penetration ability was possible in 51 patients (75 percent). Complete inability for erection and intercourse was observed in three patients (5.5 percent). Retrograde ejaculation was noted in 9 patients (13.2 percent). International Index of Erectile Function domains such as sexual desire and overall satisfaction were greatly decreased in 39 patients (57.4 percent) and 43 patients (63.2 percent), respectively. Multiple regression analysis of factors affecting postoperative sexual dysfunction showed that age older than 60 years (sexual desire, P = 0.019), within six months (erectile function, P = 0.04; intercourse satisfaction, P = 0.011; orgasmic function, P = 0.03), lower rectal cancer (erectile function, P = 0.02; intercourse satisfaction, P = 0.036; orgasmic function, P = 0.027) were significant factors adversely affecting sexual function. CONCLUSION: Total mesorectal excision with pelvic autonomic nerve preservation showed relative safety in preserving sexual and voiding function. The International Prostate Symptom Score and International Index of Erectile Function questionnaires were useful in assessing urinary and sexual function.

Adult↗

PubMed2004

Oncologic and functional results of total mesorectal excision and autonomic nerve-preserving operation for advanced lower rectal cancer.

PURPOSE: Total mesorectal excision contains two different procedures: autonomic nerve preservation, and autonomic nerve sacrifice. It is unclear whether autonomic nerve preservation is suitable curative procedure. We clarify the significance of autonomic nerve preservation for an advanced lower rectal cancer. METHODS: All 403 patients curatively resected between 1975 and 1999 were clinicopathologically studied. Between 1975 and 1984, all patients routinely received total mesorectal excision without autonomic nerve preservation (TME-P(-) group). Since 1985, total mesorectal excision with autonomic nerve preservation has been performed in 81 percent of patients (TME-P(+) group). The remaining patients received TME-P(-) because of suspicious invasion to autonomic nerve plexus. All clinical and pathologic data were entered into a computer database. Long-term follow-up was used to analyze the oncologic and functional results of TME-P(+) group compared with TME-P(-) group. RESULTS: The follow-up rate was 98.1 percent. In either Dukes A+B or Dukes C disease, the TME-P(+) group did not increase local recurrence or decrease ten-year disease-free survival compared with the TME-P(-) group of Period 1975 to 1984. The TME-P(-) group of Period 1985 to 1999 had the highest distant metastasis and the lowest survival rates than any other groups. Urinary or sexual function was well preserved in the TME-P(+) group. CONCLUSIONS: Autonomic nerve preservation is oncologically and functionally excellent and suitable for almost all patients with advanced lower rectal cancer. Intensive chemotherapy is needed for patients whose autonomic nerves were killed in suspicion of nerve invasion.

Adult↗

PubMed2004

Preoperative radiotherapy combined with intraoperative radiotherapy improve results of total mesorectal excision in patients with T3 rectal cancer.

PURPOSE: The survival advantage of preoperative radiotherapy in patients with rectal cancer is still a matter of debate, because its incremental benefit in the total mesorectal excision setting is unclear. This study was designed to evaluate early and long-term results of preoperative radiotherapy plus intraoperative radiotherapy in a homogeneous population of T3 middle and lower rectal cancer patients submitted to total mesorectal excision. METHODS: A series of 113 patients with middle and lower T3 rectal cancer consecutively submitted to total mesorectal excision at a single surgical unit from 1991 to 1997 were divided into two groups according to type of neoadjuvant treatment: preoperative radiotherapy (38 Gy) plus intraoperative radiotherapy (10 Gy; n = 69), and no preoperative treatment (total mesorectal excision; n = 44). Standard statistical analyses were used to evaluate early (downstaging, intraoperative factors, hospital morbidity, and mortality rates) and long-term results (recurrence and survival). RESULTS: Overall, 68.2 percent of patients were downstaged by the preoperative regimens (T0 specimens in 3 cases). Postoperative complications were comparable in the two groups. Five-year, disease-specific survival was 81.4 and 58.1 percent in preoperative radiotherapy plus intraoperative radiotherapy group and total mesorectal excision group, respectively (P = 0.052). Corresponding figures for disease-free survival were 73.1 and 57.2 percent in the two groups, respectively (P = 0.096). The rates of local recurrence at five years were 6.6 and 23.2 percent in preoperative radiotherapy plus intraoperative radiotherapy and total mesorectal excision groups, respectively (P = 0.017). CONCLUSIONS: Preoperative radiotherapy plus intraoperative radiotherapy associated with total mesorectal excision reduce local recurrence rate and improve survival in T3 rectal cancer compared with total mesorectal excision alone.

Adult↗

PubMed1997

Evaluation of a policy of total mesorectal excision for rectal and rectosigmoid cancers.

BACKGROUND: Total mesorectal excision (TME) is advocated for rectal cancer but the indications and extent of resection vary widely between surgeons. METHODS: Seventy-six consecutive patients (61 elective, 15 acute admission) with rectal or rectosigmoid cancer were admitted to a unit where TME was the preferred surgical option for potentially curative cancer at all levels of the rectum. RESULTS: Procedures undertaken were anterior resection (38 patients), abdominoperineal resection (18), Hartmann's procedure (ten) and transanal excision (one). Six patients had proximal faecal diversion alone and surgery was withheld in three. Anastomotic leaks occurred in six of 37 patients who had anterior resection with primary anastomosis, resulting in one early death. The presence of a proximal stoma did not influence the rate or seriousness of anastomotic dehiscence. After potentially curative TME in 45 patients, there have been eight local recurrences, four associated with systemic metastases and four which occurred in isolation (median follow-up 34 months). CONCLUSION: Curative TME was deemed appropriate in 59 per cent of unselected patients with rectal cancer. It was associated with few local recurrences but a morbidity rate that questions its role in treatment of upper third tumours.

Adult↗

PubMed2002

[Comparison of local recurrence of rectal cancer after two radical operations using total mesorectal excision].

OBJECTIVE: To compare the difference in local recurrence Dixon and Miles groups after total mesorectal excision. METHODS: One hundred and seventy-three patients with rectal cancer were divided into two groups (Dixon group, 123 patients; Miles group 50 patients). Total mesorectal excision was made according to Heald's method. RESULTS: The local recurrence in the Dixon and Miles groups was 4.8% (6/123) and 18.0% (9/50) respectively (P < 0.05), and in the Miles group before and after 1997 was 36.8% (7/19) and 6.5% (2/31) respectively (P < 0.05), 4.8% in LRR (P < 0.01). No significant difference was observed in the local recurrence between the two groups (P > 0.05). CONCLUSION: Total mesorectal excision is an important factor reducing local recurrence after radical operation for rectal cancer.

Adult↗

PubMed2004

Total mesorectal excision with the water-jet-dissection. Technique and results.

BACKGROUND: The introduction of total mesorectal excision (TME), in particular, has resulted in a dramatic decrease in postoperative functional disorders. Strict adherence to the dissection planes described above, is the prerequisite for good oncological and functional outcome. To facilitate dissection, we have introduced the high-pressure water jet dissector into our surgical routine for the treatment of rectal cancer. Below, we describe the technique of total mesorectal excision we employ in our department and present our perioperative surgical results. METHODS: We performed total mesorectal excision for rectal cancer on 49 patients, comprising 32 males and 17 females aged between 34 and 88 years. 38 patients underwent low anterior resection of the rectum and 11 patients abdominoperineal resection. RESULTS: The mean operating time was 282 min, mean intraoperative administration of red cell concentrates was 0.55 units. The mean postoperative stay in the ICU was 1.92 days. Anastomotic leakage occurred in 6.1%, wound healing disturbances in 12.2%, urinary tract infection in 12.2% intra-abdominal infection in 4.1% and faecal fistula in 4.1%. Urinary tract infections occurred in 12.2%. Postoperative temporary neurogenic voiding disturbances occurred in 14.3%. Persistent neurogenic bladder dysfunction after three months could be observed in 6.1%. CONCLUSIONS: The perioperative results are comparable to those of centres of excellence in the international literature. The Hydro-Jet dissector significantly facilitated TME. The particular feature of this technical aid is that it permits the rapid early development of the embryological plane between the pelvic nerves and the mesorectal fascia, without doing damage to either of them. This leads to optimal radicality and 1 maximum preservation of the autonomic nerves. Before a definitive pronouncement on voiding disturbances can be made, however, we consider it necessary to carry out a prospective randomised study with preoperative and postoperative urodynamic investigations.

Adult↗

PubMed2000

[Total mesorectal excision with ultrasonic coagulation knife ("UltraCision") in surgery of rectal cancer].

The authors report a total of 62 middle and low third rectal cancer cases operated on by total mesorectal excision by the method of Heald. The oncological basis of this procedure is the horizontal regional metastatization of rectal cancer. The total mesorectal excision facilitates, the low anterior resections and preservation of sphincter with an ultra-low colorectal, or coloanal anastomosis using the double stapling technique. In the authors' experience, the "UltraCision" cutting-coagulating device permits an atraumatic, bloodless and oncologically correct dissection. Using the double stapling technique, we succeeded in 60% of our middle- and low-third rectal cancer patients to perform a sphincter preserving low anterior resection. In 9 (28%) of the low third rectal cancer patients, preservation of the sphincter was possible with oncologically correct anterior resection and an ultra-low colo-anal anastomosis. Three anastomotic insufficiencies occurred, two of them healed on lotion-suction drainage, and one on the application of transient protective ileostomy. The literature data suggest a lower local recurrency rate after radical rectal cancer surgery, if total mesorectal excision is performed.

Adult↗

PubMed2004

Total mesorectal excision for rectal cancer: the truth lies underneath.

The surgical technique itself has emerged as a crucial factor for local recurrence since the popularization of total mesorectal excision for the treatment of rectal cancer. This procedure is associated with lower local recurrence rates after "curative" surgery compared to traditional dissection of the rectum. The aim is to remove an intact mesorectal envelope from the promontorium down to the pelvic floor by sharp dissection with tumor-free margins and without causing injury to the pelvic nerves. However, the description of total mesorectal excision has been confusing. Moreover, the implication that total excision of all the perirectal fat contained within the perirectal fascia en bloc in all patients with rectal cancer can minimize local recurrence remains contentious. Therefore a critical appraisal of the procedure is required. Nonrandomized clinical studies have shown that total mesorectal excision reduces the local recurrence rate and increases disease-free survival in patients with adenocarcinoma of the middle and distal third of the rectum. Circumferential resection margins of 2 mm or more are associated with a lower local recurrence rate. Additional benefits in local control can be obtained with neoadjuvant treatment. Thus the modern treatment of rectal cancer combining total mesorectal excision with neoadjuvant chemoradiation results in excellent local tumor control. However, it is achieved at the cost of significant functional sequelae and impaired quality of life. The development of therapeutic alternatives that can achieve similar rates of local and distant tumor control without the mortality, morbidity, and functional consequences of radical surgery is a major challenge for colorectal surgeons.

Adenocarcinoma↗

PubMed2003

Prospective evaluation of laparoscopic total mesorectal excision with colonic J-pouch reconstruction for mid and low rectal cancers.

BACKGROUND: Results of laparoscopic sphincter-preserving total mesorectal excision and colonic J-pouch reconstruction are few. The aim of this study was to examine outcomes after this procedure. METHODS: Patients with mid or low rectal cancer underwent laparoscopic total mesorectal excision with construction of a colonic J pouch, performed by a single surgeon. The patients were evaluated prospectively. RESULTS: From March 1999 to January 2002, 44 patients underwent laparoscopic total mesorectal excision with colonic J-pouch reconstruction. There were 21 men and 23 women of median age 65.5 years. The median operating time was 180 min and median blood loss 80 ml. There was no conversion to an open procedure. The median distance of the anastomosis from the anal verge was 4 cm. No procedure-related death occurred. Four patients developed significant complications that required reoperation. With a median follow-up period of 15 months, no port-site recurrence was noted. Five patients developed distant metastases, and two had local recurrence in the pelvis. Bowel function was satisfactory at 6, 12 and 18 months after ileostomy closure. CONCLUSION: Laparoscopic total mesorectal excision with colonic J-pouch reconstruction is safe, with a reasonable operating time. Early results suggest satisfactory oncological control and functional outcomes.

Adult↗

PubMed1998

Effect of the introduction of total mesorectal excision for the treatment of rectal cancer.

BACKGROUND: Total mesorectal excision (TME) has been reported to reduce local recurrence and improve survival rates in patients with rectal carcinoma. This paper reports the problems that have arisen with the introduction of this new surgical technique. METHODS: This was a prospective study of two consecutive groups of patients: one who underwent TME (n = 76) and one who did not (non-TME, n = 76). RESULTS: Postoperative mortality rate in the non-TME and TME group was 5 and 7 per cent respectively, and the rate of anastomotic failure was 8 and 16 per cent respectively. Anastomotic leaks in TME patients were located in the mid and lower rectum. TME patients with anastomotic failure had lower anastomoses and a longer duration of operation than non-TME patients. Intraoperative problems were encountered in 71 per cent of the failures. All TME patients who had a leak required reoperation compared with 25 per cent of non-TME patients. TME patients without postoperative complications stayed significantly longer in hospital than non-TME patients. CONCLUSION: Anastomotic dehiscence increased after introduction of the TME technique but this improved with experience.

Adult↗

PubMedDate not supplied

The role of total mesorectal excision in the management of rectal cancer.

BACKGROUND: Total mesorectal excision (TME) was described 20 years ago and is now being established as the therapeutic gold standard for middle and lower third rectal cancers in a number of countries worldwide. METHODS: The authors reviewed published data regarding TME since its first description in 1982. Emphasis was placed on basic principles, achievable recurrence rates, evidence for use of adjunctive strategies, and the potential of TME. RESULTS: Local recurrence rates following TME approximate 6.6% from published series, accounting for more than 5,000 patients. The available evidence for TME is largely composed of retrospective series, although benefits of TME compare favorably to established conventional controls. Recent studies have clarified the benefit of adjunctive radiotherapy with TME. There is considerable scope for development of TME within the minimal access setting, providing first principles are observed. CONCLUSIONS: Despite initial controversy, TME is now a feasible, reproducible, adjunctive surgical therapy in the management of rectal cancer.

Anastomosis, Surgical↗

PubMed2003

Total mesorectal excision (TME)--twenty years on.

INTRODUCTION: The results of total mesorectal excision (TME) for rectal cancer were first reported 20 years ago. The superior outcome in the original two papers was attributed to the complete excision of the mesorectum, preference for anterior resection over abdominoperineal resection, application of cytotoxic solutions to eradicate exfoliated tumour cells and specialisation in rectal cancer surgery. A review was conducted to examine the evidence from the literature accumulated over the past 20 years in support of this thesis. METHODS: A Medline search of all studies was carried out pertaining to the issues of mesorectal metastases, anterior resection versus abdominoperineal resection, exfoliated tumour cells in rectal cancer and specialisation in rectal cancer surgery. RESULTS: Mesorectal metastases can be found up to 5 cm from the apparent distal edge of a rectal cancer. They occur in pT3 and pT4 tumours. Their presence indicates a poorer prognosis. There is evidence that TME improves outcomes in mid- and low-rectal cancers but its role in upper rectal and rectosigmoid cancers is controversial. It has been difficult to demonstrate the superiority of anterior resection over abdominoperineal resection as comparative studies report similar outcomes. Exfoliated tumour cells have been demonstrated to contribute to anastomotic recurrence and this probability may be reduced by the use of cytotoxic agents to irrigate the rectal stump. Multiple studies have shown that specialisation in rectal cancer surgery result in lower postoperative morbidity and mortality, local and distant recurrence rates and higher rates of sphincter saving resections. CONCLUSION: The majority of tenets espoused in the original papers on TME have found support in follow-up studies since their publication.

Disease-Free Survival↗