Total Mesorectal Excision
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Total mesorectal excision (TME) is a common procedure used in the treatment of colorectal cancer in which a significant length of the bowel around the tumor is removed. TME addresses earlier treatment concerns regarding adequate local control of rectal cancer when an anterior resection is performed.
The term TME strictly applies in the performance of a low anterior resection for tumors of the middle and the lower rectum, wherein it is essential to remove the rectum along with the mesorectum up to the level of the levators.
The principles of TME (sharp mesorectal excision) are also applied during an abdominoperineal excision of the rectum and for tumors of the upper rectum, though these are considered distinct from standard TME. In an abdominoperineal excision of the rectum where the tumor exists below the level of the levators, the lateral margins of the tumor are inferior to the mesorectum, and the benefits of TME do not apply.
Anterior resections involving the upper rectum may be completed with mobilization of the rectum to beyond 5 cm of the lower margin of the tumor, and which is often above the level of the levator and is sometimes referred to as partial mesorectal excision.
The treatment of rectal cancers is multimodal, with adjuvant radiotherapy and chemotherapy having benefits in some settings. In addition, accurate preoperative staging is dependent on good radiologic support. It is therefore necessary to subject all rectal cancers to multidepartment conference and to design individualized treatment plans based on a well-defined protocol. This serves the dual purposes of maintaining a consistent evidence-based approach and creating a dataset for prospective analysis and feedback.
TME is indicated as a part of low anterior resection for patients with adenocarcinoma of the middle and lower rectum. It is now considered the gold standard for tumors of the middle and the lower rectum. [1]
The circumferential resection margin positivity rate is about 5% or less for low anterior resections with TME, whereas it is between 10% and 25% for abdominoperineal excision of the rectum. There is, understandably, a higher local recurrence rate following abdominoperineal excision of the rectum. The 5-year survival and disease-free survival rates are significantly lower with TME.
Evidence suggests that a circumferential resection margin of 1 mm or less adversely affects cancer-specific survival, local recurrence, and distant metastasis. [2]
Ridgway PF, Darzi AW. The role of total mesorectal excision in the management of rectal cancer. Cancer Control. 2003 May-Jun. 10(3):205-11. [Medline].
Lin HH, Lin JK, Lin CC, Lan YT, Wang HS, Yang SH, et al. Circumferential margin plays an independent impact on the outcome of rectal cancer patients receiving curative total mesorectal excision. Am J Surg. 2013 Nov. 206 (5):771-7. [Medline].
Kneist W, Kauff DW, Juhre V, Hoffmann KP, Lang H. Is intraoperative neuromonitoring associated with better functional outcome in patients undergoing open TME? Results of a case-control study. Eur J Surg Oncol. 2013 Sep. 39 (9):994-9. [Medline].
Acar HI, Kuzu MA. Important points for protection of the autonomic nerves during total mesorectal excision. Dis Colon Rectum. 2012 Aug. 55(8):907-12. [Medline].
Runkel N, Reiser H. Nerve-oriented mesorectal excision (NOME): autonomic nerves as landmarks for laparoscopic rectal resection. Int J Colorectal Dis. 2013 Oct. 28 (10):1367-75. [Medline].
Vennix S, Pelzers L, Bouvy N, Beets GL, Pierie JP, Wiggers T, et al. Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database Syst Rev. 2014 Apr 15. 4:CD005200. [Medline].
Chi P, Chen Z. [Comparison of robotic and laparoscopic total mesorectal excision]. Zhonghua Wei Chang Wai Ke Za Zhi. 2017 Jun 25. 20 (6):610-613. [Medline].
Morelli L, Di Franco G, Guadagni S, Rossi L, Palmeri M, Furbetta N, et al. Robot-assisted total mesorectal excision for rectal cancer: case-matched comparison of short-term surgical and functional outcomes between the da Vinci Xi and Si. Surg Endosc. 2017 Jul 21. [Medline].
Kang L, Chen WH, Luo SL, Luo YX, Liu ZH, Huang MJ, et al. Transanal total mesorectal excision for rectal cancer: a preliminary report. Surg Endosc. 2016 Jun. 30 (6):2552-62. [Medline].
Muratore A, Mellano A, Marsanic P, De Simone M. Transanal total mesorectal excision (taTME) for cancer located in the lower rectum: short- and mid-term results. Eur J Surg Oncol. 2015 Apr. 41 (4):478-83. [Medline].
Yao HW, Wu GC, Yang YC, Jin L, Zhang ZP, Chen N, et al. Laparoscopic-assisted Transanal Total Mesorectal Excision for Middle-Low Rectal Carcinoma: A Clinical Study of 19 Cases. Anticancer Res. 2017 Aug. 37 (8):4599-4604. [Medline].
Caycedo-Marulanda A, Jiang HY, Kohtakangas EL. Outcomes of a Single Surgeon-Based Transanal-Total Mesorectal Excision (TATME) for Rectal Cancer. J Gastrointest Cancer. 2017 Jul 13. [Medline].
Marks JH, Myers EA, Zeger EL, Denittis AS, Gummadi M, Marks GJ. Long-term outcomes by a transanal approach to total mesorectal excision for rectal cancer. Surg Endosc. 2017 Jun 22. [Medline].
Nanda Kishore Maroju, MRCS, MS, MBBS, DNB Additional Professor of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
Nanda Kishore Maroju, MRCS, MS, MBBS, DNB is a member of the following medical societies: Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.
Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine
Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.
Total Mesorectal Excision
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