Total Mesorectal Excision: What Are We Doing?

David B. Stewart; David W. Dietz

doi:10.1055/s-2007-984863

Clinics in Colon and Rectal Surgery, Table of Contents

Clin Colon Rectal Surg 2007; 20(3): 190-202
DOI: 10.1055/s-2007-984863

Total Mesorectal Excision: What Are We Doing?

David B. Stewart¹ , David W. Dietz¹

¹Section of Colon and Rectal Surgery, Division of Surgery, Washington University School of Medicine, Barnes-Jewish-Christian Hospital, St. Louis, Missouri

Abstract

ABSTRACT

The introduction of total mesorectal excision (TME) for rectal cancer has reduced local recurrence rates and improved oncologic outcomes, although complication rates such as anastomotic leak have also been a consequence. With the advent of neoadjuvant therapy for rectal cancer, many are questioning how this development may change the role of TME. This review presents a history of how TME evolved and a description of this technique. Complication rates, the impact of neoadjuvant therapy on local recurrence, variations of TME such as nerve-sparing proctectomy and cancer-specific mesorectal excision, and a review of functional outcomes for various methods of reconstruction are presented.

KEYWORDS

Total mesorectal excision - rectal cancer - recurrence - surgical technique - review article

Full Text

References

REFERENCES

1 See the National Cancer Institute's Surveillance .Epidemiology, and end results (SEER). Available at: http://www.seer.cancer.gov Accessed September 2006
2 Heald R J, Husband E M, Ryall R D. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet. 1986; 1 1479-1482
3 Chapuis P, Bokey L, Fahrer M et al.. Mobilization of the rectum: anatomic concepts and the bookshelf revisited. Dis Colon Rectum. 2002; 45 1-9
4 Jonnesco T. Appareil digestif. In: Poirier P, Charpy A Traite d'anatomie Humaine. Vol. IV. 2nd ed. Paris; Masson et Cie 1901: 372-373
5 Gerota D. Die lymphgefasse des rectums und des anus. Archive fur Anatomie und Physiologie. Anatomische Abtheilung. 1895; 240-256
6 Waldeyer W. Das Becken. Bohn; Cohen 1899
7 Heald R J, Husband E M, Ryall R O. The mesorectum in rectal surgery: the clue to pelvic recurrence?. Br J Surg. 1982; 69 613-616
8 Abel A L. The modern treatment of cancer of the rectum. Milwaukee Proc. March 3-5, 1931; 296-300
9 Heald R J. A new approach to rectal cancer. Br J Hosp Med. 1979; 22 277-281
10 Isbister W H. Basingstoke revisited. Aust N Z J Surg. 1990; 60 243-246
11 Enker W E, Thaler H T, Cranor M L et al.. Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg. 1995; 181 335-346
12 Aitken R J. Mesorectal excision for rectal cancer. Br J Surg. 1996; 83 214-216
13 Martling A L, Holm T, Rutqvist L E, Moran B J, Heald R J, Cedemark B. Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group. Basingstoke Bowel Cancer Research Project. Lancet. 2000; 356 93-96
14 Hildebrandt U, Klein T, Feifel G et al.. Endosongraphy of pararectal lymph nodes. In vitro and in vivo evaluation. Dis Colon Rectum. 1990; 33 863-868
15 Tio T L, Coenne P P, van Delden O M et al.. Colorectal carcinoma: preoperative TNM classification with endosonography. Radiology. 1991; 179 165-170
16 Thaler W, Watzka S, Martin F et al.. Preoperative staging of rectal cancer by endoluminal ultrasound vs. magnetic resonance imaging. Preliminary results of a prospective, comparative study. Dis Colon Rectum. 1994; 37 1189-1193
17 Kwok H, Bissett I P, Hill G L. Preoperative staging of rectal cancer. Int J Colorectal Dis. 2000; 15 9-20
18 Rifkin M D, Ehrlich S M, Marks G. Staging of rectal carcinoma: prospective comparison of endorectal US and CT. Radiology. 1989; 170 319-322
19 Nagtegaal I D, Marijnen C A, Kranenbarg E K et al.. Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma. Not one millimeter but two millimeters is the limit. Am J Surg Pathol. 2002; 26(3) 350-357
20 Paty P B, Enker W E, Cohen A M et al.. Treatment of rectal cancer by low anterior resection with coloanal anastomosis. Ann Surg. 1994; 219 365-373
21 Vernava A M, Moran M. A prospective evaluation of distal margins in carcinoma of the rectum. Surg Gynecol Obstet. 1992; 175 333-336
22 Kirwan W O, Drumm J, Hogan J M, Keohane C. Determining safe margins of resection in low anterior resection for rectal cancer. Br J Surg. 1988; 75 720-721
23 Williams N S, Dixon M F, Johnston D. Reappraisal of the 5 centimetre rule for distal excision of carcinoma of the rectum: a study of distal intramural spread and of patients' survival. Br J Surg. 1983; 70 150-154
24 Grinnell R S. Distal intramural spread of carcinoma of the rectum and rectosigmoid. Surg Gynecol Obstet. 1954; 99 421-430
25 Bass E M, Del Pino A, Tan A et al.. Does preoperative stoma marking and education by the enterostomal therapist affect outcome?. Dis Colon Rectum. 1997; 40 440-442
26 Colwell JC, Sartor RB, Sandborn W Care of the patient with a fecal diversion. In: Kirsner's Inflammatory Bowel Disease. 6th ed. Philadephia, PA; WB Saunders 2004: 631-638
27 Polk Jr H C, Lopez-Mayer J F. Postoperative wound infection: a prospective study of determinant factors and prevention. Surgery. 1969; 66 97-103
28 Mauermann W J, Nemergut E, Warltier D. The anesthesiologists role in the prevention of surgical site infections. Anesthesiology. 2006; 105(2) 413-421
29 Geerts W H. Prevention of venous thromboembolism. Chest. 2001; 119(1 Suppl) 132S-175S
30 Raskob G E. Controversies in timing of the first dose of anticoagulant prophylaxis against venous thromboembolism after major orthopedic surgery. Chest. 2003; 124(6 Suppl) 379S-385S
31 Breukink S O, Pierie J P, Grand A J, Hoff C, Wiggers T, Meijerink W J. Laparoscopic versus open total mesorectal excision: a case-control study. Int J Colorectal Dis. 2005; 20 428-433
32 Tsang W W, Chung C C, Kwok S Y, Li M K. Laparoscopic sphincter-preserving total mesorectal excision with colonic j-pouch reconstruction: five-year results. Ann Surg. 2006; 243(3) 353-358
33 Heald R J, Moran B J, Brown G et al.. Optimal total mesorectal excision for rectal cancer is by dissection in front of Denonvilliers' fascia. Br J Surg. 2004; 91 121-123
34 Lindsey I, Warren B, Mortensen N. Denonvilliers' fascia lies anterior to the fascia propria and rectal dissection plane in total mesorectal excision. Dis Colon Rectum. 2005; 48 37-42
35 Leong A F. Selective mesorectal excision for rectal cancer. Dis Colon Rectum. 2000; 43 1237-1240
36 Heald R J, Moran B, Ryall R DH et al.. Rectal cancer: The Basingstoke experience of total mesorectal excision, 1978-1997. Arch Surg. 1998; 133 894-899
37 Law W L, Chu K W. Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients. Ann Surg. 2004; 240 260-268
38 Kapiteijn E, Marijnen C, Nagtegaal I et al.. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001; 345(9) 638-646
39 Sauer R, Fietkau R, Wittekind C et al.. Adjuvant vs. neoadjuvant radiochemotherapy for locally advanced rectal cancer: the German trial CAO/ARO/AIO-94. Colorectal Dis. 2003; 5 406-415
40 Kapiteijn E, Putter H, van de Velde C JH et al.. Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in the Netherlands. Br J Surg. 2002; 89 1142-1149
41 Law W L, Chu K W. Impact of total mesorectal excision on the results of surgery of distal rectal cancer. Br J Surg. 2001; 88 1607-1612
42 Carlsen E, Schlichting E, Guldvog I, Johnson E, Heald R J. Effect of the introduction of total mesorectal excision for the treatment of rectal cancer. Br J Surg. 1998; 85 526-529
43 Bruce J, Krukowski Z H, Al-Khairy G, Russell E M, Park K G. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg. 2001; 88 1157-1168
44 Heald R J, Karanjia N D. Results of radical surgery for rectal cancer. World J Surg. 1992; 16 848-857
45 Pakkastie T E, Luukkonen P E, Jarvinen H J. Anastomotic leakage after anterior resection of the rectum. Eur J Surg. 1994; 160 293-297
46 Rullier E, Lauren C, Garrelo J L, Michel P, Saric J, Parneix M. Risk factors for anastomotic leakage after resection of rectal cancer. Br J Surg. 1998; 85 355-358
47 Karanjia N D, Corder A P, Bearn P et al.. Leakage from stapled low anastomoses after total mesorectal excision for carcinoma of the rectum. Br J Surg. 1994; 81 1224-1226
48 Eriksen M T, Wibe A, Norstein J et al.. Anastomotic leakage following routine mesorectal excision for rectal cancer in a national cohort of patients. Colorectal Dis. 2005; 7(1) 51-57
49 Scott N, Jackson P, al-Jaberi T, Dixon M F, Quirke P, Finan P J. Total mesorectal excision and local recurrence: a study of tumour spread in the mesorectum distal to rectal cancer. Br J Surg. 1995; 82 1031-1033
50 Karanjia N D, Schache D J, Heald R J. Function of the distal rectum after low anterior resection for carcinoma. Br J Surg. 1992; 79 114-116
51 Graf W, Ekstrom K, Glimelius B, Pahlman L. A pilot study of factors influencing bowel function after colorectal anastomoses. Dis Colon Rectum. 1996; 39 744-749
52 Ho P, Law W L, Chan S C, Lam C K, Chu K W. Functional outcome following low anterior resection with total mesorectal excision in the elderly. Int J Colorectal Dis. 2003; 18 230-233
53 Dehni N. Effects of aging on the functional outcome of coloanal anastomoses with colonic J-pouch. Am J Surg. 1998; 175 209-212
54 Kollmorgen C F, Meagher A P, Wolf B G et al.. The long-term effect of adjuvant postoperative chemoradiotherapy for rectal carcinoma on bowel function. Ann Surg. 1994; 220 676-682
55 Yamana T, Oya M, Komatsu J et al.. Preoperative anal sphincter high-pressure zone, maximal tolerable volume, and anal mucosal electrosensitivity predict early postoperative defecatory function after low anterior resection for rectal cancer. Dis Colon Rectum. 1999; 42 1145-1151
56 Jones T E. Complications of one-stage abdominoperineal resection of the rectum. JAMA. 1942; 120 104-107
57 Havenga K, Enker W E, McDermott K et al.. Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J Am Coll Surg. 1996; 182 495-502
58 Shirouzu K, Ogata Y, Araki Y. Oncologic and functional results of total mesorectal excision and autonomic nerve-preserving operation for advanced lower rectal cancer. Dis Colon Rectum. 2004; 47 1442-1447
59 Kim N K, Aahn T W, Park J K et al.. Assessment of sexual and voiding function after total mesorectal excision with pelvic autonomic nerve preservation in males with rectal cancer. Dis Colon Rectum. 2002; 45 1178-1185
60 Camma C, Giunta M, Fiorica F et al.. Preoperative radiotherapy for respectable rectal cancer: a meta-analysis. JAMA. 2000; 284 1008-1015
61 Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N Engl J Med. 1997; 336 980-987
62 Martling A, Holm T, Bremmer S, Lindholm J, Cedermark B, Blomqvist L. Prognostic value of preoperative magnetic resonance imaging of the pelvis in rectal cancer. Br J Surg. 2003; 90 1422-1428
63 Mathur P, Smith J J, Ramsey C et al.. Comparison of CT and MRI in the pre-operative staging of rectal adenocarcinoma and prediction of circumferential resection margin involvement by MRI. Colorectal Dis. 2003; 5 396-401
64 Beets-Tan R G. MRI in rectal cancer: the T stage and circumferential resection margin. Colorectal Dis. 2003; 5 392-395
65 Hiotis S P, Weber S M, Cohen A M et al.. Assessing the predictive value of clinical complete response to neoadjuvant therapy for rectal cancer: an analysis of 488 patients. J Am Coll Surg. 2002; 194 131-135
66 Marijnen C A, van de Velde C J, Putter H et al.. Impact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol. 2005; 23 1847-1858
67 Peeters K C, van de Velde C J, Leer J W et al.. Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients - A Dutch Colorectal Cancer Group Study. J Clin Oncol. 2005; 23 6199-6206
68 Lazorthes F, Fages P, Chiotasso P, Lemozy J, Bloom E. Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum. Br J Surg. 1986; 73 136-138
69 Berger A, Tiret E, Frileux P et al.. Excision of the rectum with colonic J pouch-anal anastomosis for adenocarcinoma of the low and mid rectum. World J Surg. 1992; 16 470-477
70 Williams N, Seow-Choen F. Physiological and functional outcome following ultra-low anterior resection with colon pouch-anal anastomosis. Br J Surg. 1998; 85(8) 1029-1035
71 Ho Y H, Brown S, Heah S M et al.. Comparison of J-pouch and coloplasty patch for low rectal cancers: a randomized, controlled trial investigating functional results and comparative anastomotic leak rates. Ann Surg. 2002; 236 49-55
72 Z'graggen K, Maurer C A, Birrer S et al.. A new surgical concept for rectal replacement after low anterior resection: the transverse coloplasty pouch. Ann Surg. 2001; 234(6) 780-787
73 Remzi F H, Fazio V W, Gorgun E et al.. Quality of life, functional outcome, and complications of coloplasty pouch after low anterior resection. Dis Colon Rectum. 2005; 48(4) 735-743
74 Koperna T. Cost-effectiveness of defunctioning stomas in low anterior resections for rectal cancer. a call for benchmarking. Arch Surg. 2003; 138 1334-1338
75 Dehni N, Schlegel R D, Cunningham C et al.. Influence of a defunctioning stoma on leakage rates after low colorectal anastomosis and colonic J pouch-anal anastomosis. Br J Surg. 1998; 85(8) 1114-1117
76 O'Leary D P, Fide C J, Foy C, Lucarotti M R. Quality of life after low anterior resection with total mesorectal excision and temporary loop ileostomy for rectal cancer. Br J Surg. 2001; 88(9) 1216-1220

David W DietzM.D.

Washington University School of Medicine

660 S. Euclid Ave., Campus Box 8109, St. Louis, MO 63110

Email: dietzd@wudosis.wustl.edu