A national strategic change in treatment policy for rectal cancer--implementation of total mesorectal excision as routine treatment in Norway. A national audit

INTRODUCTION: Rectal cancer surgery has been characterized by a high incidence of local recurrence, an occurrence which influences survival negatively. In Norway there was a growing recognition that local recurrence rates were related to surgeon performance and that surgeons applying a standardized surgical technique in the form of total mesorectal excision could achieve better results. This contrasts with the prevailing argument voiced by many opinion leaders that local recurrence rates and possibly survival rates can only be improved by adjuvant or neoadjuvant treatment strategies. The Norwegian Rectal Cancer Project—initiated in 1993—aimed at improving the outcome of patients with rectal cancer by implementing total mesorectal excision as the standard rectal resection technique. METHODS: This observational national cohort study covers all new patients (3,319) with rectal cancer from a population of 4.5 million treated between November 1993 and August 1997. The main outcome measures were local recurrence, survival, and postoperative mortality and morbidity rates. The technique of total mesorectal excision was compared with conventional surgery. RESULTS: The proportion of patients undergoing total mesorectal excision was 78 percent in 1994, increasing to 92 percent in 1997. The observed local recurrence rate for patients undergoing a curative resection was 6 percent in the group treated by total mesorectal excision and 12 percent in the conventional surgery group. Four-year survival rate was 73 percent after total mesorectal excision and 60 percent after conventional surgery. Postoperative mortality rate was 3 percent and the anastomotic dehiscence rate was 10 percent. Radiotherapy was given to 5 percent and chemotherapy to 3 percent of the patients in the curative resection group. CONCLUSION: A refinement of the surgical resection technique for rectal cancer can be achieved on a national level, the technique of total mesorectal excision can be widely distributed, and surgery alone can give good results.     

Technical feasibility of laparoscopic extended surgery beyond total mesorectal excision for primary or recurrent rectal cancer

Relatively little is known about the oncologic safety of laparoscopic surgery for advanced rectal cancer.Recently, large randomized clinical trials showed that laparoscopic surgery was not inferior to open surgery, as evidenced by survival and local control rates. However, patients with T4 tumors were excluded from these trials. Technological advances in the instrumentation and techniques used by laparoscopic surgery have increased the use of laparoscopic surgery for advanced rectal cancer. High-definition, illuminated, and magnified images obtained by laparoscopy may enable more precise laparoscopic surgery than open techniques, even during extended surgery for T4 or locally recurrent rectal cancer. To date, the quality of evidence regarding the usefulness of laparoscopy for extended surgery beyond total mesorectal excision has been low because most studies have been uncontrolled series, with small sample sizes, and long-term data are lacking. Nevertheless, laparoscopic extended surgery for rectal cancer, when performed by specialized laparoscopic colorectal surgeons, has been reported safe in selected patients, with significant advantages, including a clear visual field and less blood loss. This review summarizes current knowledge on laparoscopic extended surgery beyond total mesorectal excision for primary or locally recurrent rectal cancer.     

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide.Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy(total mesorectal excision).This has traditionally been performed transabdominally through an open incision.Over the last thirty years,minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach.There are currently three resective modalities that complement the traditional open operation:(1) Laparoscopic surgery;(2) Robotic surgery;and(3) Transanal total mesorectal excision.In addition,there are several platforms to carry out transluminal local excisions(without lymphadenectomy).Evidence on the various modalities is of mixed to moderate quality.It is unreasonable to expect a randomized comparison of all options in a single trial.This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks,recovery and complications,oncological and functional outcomes.     

Inferior rectal plexus is no longer isolated in no man’s land

Because of rapid technological progress, precision in rectal cancer therapy has assumed a new dimension. Thus, special attention can be given to the inferior rectal plexus. As a secondary plexus of the inferior hypogastric plexus, its nerve outflow is of great importance for proper pelvic floor function. Our leading question is what the transanal total mesorectal excision (TaTME) perspective could add to the topographical debate about the inferior rectal plexus. After TaTME cadaver training sessions and during TaTME in patients with rectal carcinoma, we can conclude that trained surgeons are capable of accessing the inferior rectal plexus in their operative field.     

Laparoscopic ultralow anterior resection combined with<Emphasis Type="Italic">Per Anum</Emphasis> intersphincteric rectal dissection for lower rectal cancer

Rectal resection with total mesorectal excision is perhaps the most technically challenging of laparoscopic procedures, and the purpose of this study was to show that laparoscopic ultralow anterior resection is feasible for lower rectal cancer. Seven patients with lower rectal cancer were treated in this way with a satisfactory outcome in each case, and on the basis of this limited study, we suggest that extension of laparoscopy to the treatment of very low rectal lesions may be of advantage.     

中日韩中低位直肠癌术前放化疗的理念与策略

关于术前放化疗在中低位直肠癌治疗中选择的理念和策略,中日韩三个国家的医生有些不同。中国的指南接近于美国国立综合癌症网络（National Comprehensive Cancer Network,NCCN）指南,建议对于T3和（或）N＋以上的可切除直肠癌患者,推荐术前放化疗;日本大多数医生对可切除的中低位直肠癌并不积极推荐术前放化疗,根据日本指南推荐,对于腹膜返折下局部进展期直肠癌的标准治疗方式为全直肠系膜切除术＋侧方淋巴结清扫术;韩国的结直肠癌临床实践指南对术前放化疗的推荐与中国和美国指南类似,与中国不同的是,源于韩国政府的法定政策,韩国医生针对直肠癌患者术前放化疗开展的更为积极。     

Decision-making in rectal cancer surgery

PURPOSE: Although rectal cancer is common in the United States, there is significant variation in management and outcome of this disease. The aim of this study is to measure the amount of variability that exists in the way colorectal surgeons investigate and manage patients with rectal cancer. METHODS: A detailed questionnaire covering preoperative assessment, operative technique, and follow-up of primary rectal cancer was sent to all colorectal surgeons associated with colorectal residency programs throughout North America. RESULTS: One hundred ten responses were obtained (response rate, 71 percent). Surgeons were in broad agreement (>75 percent agree) on the routine preoperative use of endorectal ultrasound and carcinoembryonic antigen and the postoperative use of endorectal ultrasound. There was also broad agreement about the use of adjuvant therapy and radical resection for a poorly differentiated uT2,N0 cancer, the use of total mesorectal excision for a mid rectal cancer, and for the choice of loop ileostomy if diversion is necessary. Two-thirds of the surgeons used adjuvant therapy and radical resection for a uT3,N0 cancer and preferred a follow-up schedule of three monthly visits for two years with six monthly visits for the next three years. Opinion was divided (<63 percent agreement) on the use of a preoperative liver scan, the approach to a moderately differentiated uT2,N0 cancer, the use of rectal irrigation before resection, the timing of colonoscopy in a patient with stenosing rectal cancer, and the frequency of postoperative colonoscopies. CONCLUSIONS: There is considerable variation in the management of low rectal cancer advocated by colorectal surgeon educators. For each histologic and pathologic stage, opinion is divided about which operation is best. Careful outcomes analysis is required to clarify the situation.Presented at the meeting of the Ohio Valley Society of Colon and Rectal Surgeons, Columbus, Ohio, June 7, 1997.     

Prospective study of sexual dysfunction in men with rectal cancer: feasibility and results of nerve sparing surgery

Purpose  

Rectal cancer surgery is impaired by a high rate of postoperative sexual dysfunction cause of frequent nerve injuries. The aim of this study was to prospectively evaluate sexual function in a group of male patients after total mesorectal excision (TME) for rectal cancer, using an autonomic nerve sparing technique.     

Selective total mesorectal excision for rectal cancer

PURPOSE: Total mesorectal excision has been advocated for rectal cancer, but its use in upper rectal and rectosigmoid tumors remains a point of debate. METHODS: One hundred seventeen patients with rectal cancers were subjected to a prospective policy of total mesorectal excision for mid and low rectal cancers and a wide (5 cm) distal margin mesorectal excision for upper rectal and rectosigmoid cancers. RESULTS: Forty-one patients underwent ultralow anterior resection, 10 underwent abdominoperineal excision, 64 had anterior resection and 2 had Hartmann's procedure. The median follow-up was 39 months. Forty-three patients had a defunctioning ileostomy. Three patients (7.3 percent) had anastomotic leaks after ultralow anterior resection with total mesorectal excision. Ninety-three patients had palliative resections. There were four locoregional recurrences in this group, giving an actuarial locoregional recurrence rate of 9.3 percent at five years. The actuarial locoregional recurrence rate after anterior resection was 6.5 percent at five years. The actuarial five-year cancer-specific survival rate was 81.4 percent at five years. CONCLUSION: These results demonstrate that a policy of wide excision of the mesorectum for upper rectal and rectosigmoid cancer and total mesorectal excision for mid and low rectal cancer is associated with a low locoregional recurrence rate and may be as efficacious as routine total mesorectal excision for all rectal cancers.     

Technique for laparoscopic autonomic nerve preserving total mesorectal excision

With the introduction of total mesorectal excision (TME) for treatment of rectal cancer, the prognosis of patients with rectal cancer is improved. With this better prognosis, there is a growing awareness about the quality of life of patients after rectal carcinoma. Laparoscopic total mesorectal excision (LTME) for rectal cancer offers several advantages in comparison with open total mesorectal excision (OTME), including greater patient comfort and an earlier return to daily activities while preserving the oncologic radicality of the procedure. Moreover, laparoscopy allows good exposure of the pelvic cavity because of magnification and good illumination. The laparoscope seems to facilitate pelvic dissection including identification and preservation of critical structures such as the autonomic nervous system. The technique for laparoscopic autonomic nerve preserving total mesorectal excision is reported. A three- or four-port technique is used. Vascular ligation, sharp mesorectal dissection and identification and preservation of the autonomic pelvic nerves are described.     

The pathological assessment of mesorectal excision: implications for further treatment and quality management

BACKGROUND AND AIMS. Most clinical practice guidelines today recommend total mesorectal excision (TME) for carcinoma of the middle and lower rectal thirds and partial mesorectal excision (PME) for the upper rectal third. However, these procedures may not always fulfill the oncological requirements. The pathological examination of resected rectal carcinomas should always include a visual assessment of the mesorectal excision to ensure oncological adequacy and appropriate quality. The clinical practice guideline of the German Cancer Society recommends reporting of the distal extent of mesorectal excision (total or partial without coning) and the excision in an inviolate fascial envelope. PATIENTS AND METHODS. Reporting schemas of assessment and documentation for daily use and for studies are presented. RESULTS. Careful macroscopic evaluation of the resection specimen should be standardized. This may be supplemented by stain marking after postoperative filling the inferior mesenteric or superior rectal artery with ink or methylene blue solution. Photodocumentation is highly desirable. The pathological assessment of adequacy of mesorectal excision should be taken into account in selection for adjuvant radiotherapy. Objective macro- and microscopic assessment of mesorectal excision by pathologists is essential for quality management throughout patient care and in clinical trials.     

Transanal total mesorectal excision:Towards standardization of technique

AIM: To describe the role of Transanal total mesorectal excision(Ta TME) in minimally invasive rectal cancer surgery, to examine the differences in patient selection and in reported surgical techniques and their impactson postoperative outcomes and to discuss the future of Ta TME. METHODS: MEDLINE(Pub Med), EMBASE, and The Cochrane Library were systematically searched through the 1st of March 2015 using a predefined search strategy. RESULTS: A total of 20 studies with 323 patients were included. Most studies were single-arm prospective studies with fewer than 100 patients. Multiple transanal access platforms were used, and the laparoscopic approach was either multi- or single port. The procedure was initiated transanally or transabdominally. If a simultaneous approach with 2 operating surgeons was chosen, the operative time was significantly reduced. CONCLUSION: Ta TME was also associated with better TME specimens and a longer distal resection margin. Ta TME is thus feasible in expert hands, but the learning curve and safety profile are not well defined. Longterm follow-up regarding anal function and oncological outcomes should be performed in the future.     

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.     

Laparoscopic total mesorectal excision

This article describes the operative technique that my colleagues and I apply to total mesorectal excision in patients with rectal cancer. A body of data support improvement of short-term outcomes over open resection. Although long-term data remain scarce, several ongoing trials may clarify this deficiency. The appropriateness of laparoscopy in the treatment for rectal cancer should be carefully weighed with consideration of patient preferences, surgeon experience, and available infrastructure.     

Recent progress in diagnosis and treatment of rectal cancer]

Rectal cancer is an emerging health issue in Korea because its incidence is rapidly increasing with changes in life styles and diets. The optimal treatment of rectal cancer is based on multimodality. Among them, surgical treatment is the corner-stone. In the past, local recurrence rate has been reported as high as 30-40%, but the concept of total mesorectal excision (TME) lowered the rate of local recurrence down to less than 10%. TME focuses on sharp pelvic dissection and complete removal of rectal cancer with surrounding mesorectum inside the rectal proper fascia. TME is now considered as a standard procedure for surgical treatment of mid and low rectal cancer. With the introduction of pelvic magnetic resonance imaging (MRI) for preoperative staging of rectal cancer, risk factors for local recurrence can be predicted before surgery to distinguish patients who are in high risk for recurrence that requires preoperative neoadjuvant chemoradiation therapy. Early rectal cancer was assessed by transrectal ultrasonography (TRUS) and endorectal MRI with coil. Transanal local excision can be applied with anal sphincter preservation safely. Neoadjuvant chemoradiation therapy was performed in patients with locally advanced rectal cancer, and this resulted in tumor size reductions and histopathologic downstaging effect. As far as the quality of life is concerned, sexual and voiding function are much improved by techniques preserving nerve. Many experts have dealt with challenging practical problems of managing rectal cancer from diagnosis to quality of life. This issue contains recent progresses in the diagnosis and treatment of rectal cancer which will serve as a comprehensive reference for those who manage rectal cancer in their medical practice.     

Role of total mesorectal excision and of circumferential resection margin in local recurrence and survival of patients with rectal carcinoma

Rectal cancer is a common disease with poor prognosis because of local recurrence and metastases. Local recurrence arises mainly as a result of incomplete surgical resection. Evaluation of completeness of the mesorectum provides significant information about prognosis. Total mesorectal excision (TME) has become the surgical treatment of choice for rectal cancer because adopting the principles of TME achieves very low local recurrence rates. The adoption of the TME principles along with the estimation of the circumferential resection margin on the non-peritonealized surface of the resected rectal specimen are the most important predictors of local recurrence.     

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.     

Combined transanal total mesorectal excision (taTME) with laparoscopic instruments and abdominal robotic surgery in rectal cancer

Laparoscopic surgery for rectal cancer can be technically challenging. We describe a hybrid technique combining abdominal robotic dissection and transanal total mesorectal excision. This procedure was performed in a 50-year-old man with rectal adenocarcinoma at 5 cm from the dentate lane. Preoperative staging was T2N0M0. Surgery went well without complications, and estimated blood loss was less than 50 mL. Robotic surgical time was 90 min, and total operative time was 160 min. The patient was discharged on postoperative day 3. Pathology analysis revealed an intact mesorectum (TME grade 3) and a T2N0 tumor with negative margins. Hybrid surgery with pelvic robotic dissection and transanal total mesorectal excision was feasible, quick and safe in this patient and may be a method that can be developed further.     

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.