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PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY November 2016 | Archived Issues

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Education Schedule - November 2016 (PDF)

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Challenging the Rectal Cancer Standard

By Karen Zaghiyan, MD, and Phillip Fleshner, MD

Neoadjuvant chemoradiation followed by proctectomy with total mesorectal excision (TME) is the standard of care in the management of locally advanced rectal cancer. Unlike cancers of the colon, rectal cancer has always posed a unique challenge to the surgeon due to the narrow working space in the bony pelvis and the intimate relationship between the rectum and the pelvic autonomic nerves, vascular structures and the anal sphincter complex.

In the 19th century, survival from rectal cancer was nil. In 1908, Sir William Ernest Miles revolutionized the surgical management of rectal cancer when he published his experience with the simultaneous abdominoperineal approach. After this milestone in rectal cancer surgery, survival improved but remained under 50 percent. The next breakthrough in rectal cancer surgery was the concept of TME described by Bill Heald in 1982. Sharp dissection in the avascular plane between the mesorectum and the pelvic autonomic nerves significantly reduced local recurrence. In fact, completeness of the mesorectal envelope has become a key prognostic feature of quality rectal cancer surgery. Another important evolution in the management of rectal cancer was preoperative chemoradiation through a number of large trials showing reduced local recurrence and improved overall survival. In addition, sphincter preservation became more common, as the importance of the distal margin diminished with preoperative chemoradiation.

Despite these advances, surgeons continue to struggle with surgery for rectal cancer, especially low cancers in male or obese patients. Although development of minimally invasive techniques such as laparoscopy and robotic surgery have attempted to tackle these problems, four recent multicenter randomized trials have been unable to show any advantage of laparoscopy or robotic surgery to open TME for rectal cancer.

A recent innovation in the surgical management of rectal cancer is a natural orifice approach known as the bottom-up TME or transanal TME (taTME). In this technique, the surgeon works through a transanal access platform to insufflate the rectum, after which the tumor is identified and distal margin marked. Next a full-thickness, endoluminal transection of the rectum is performed using an endoscope and standard laparoscopic instruments, and the rectum is fully mobilized posteriorly in the TME plane, anteriorly, and laterally. This dissection is then carried circumferentially until the peritoneal cavity is entered. Working simultaneously, a second surgical team via abdominal laparoscopic ports performs a high ligation of the inferior mesenteric artery and mobilizes the colon and splenic flexure. At the time of peritoneal entry from below, the abdominal team helps complete the dissection to fully dismount the rectum and deliver it transanally, without making an abdominal incision for extraction. Potential benefits of taTME include precise determination of the distal margin, avoidance of multiple staple firings across the rectum, potentially better oncologic results and autonomic nerve preservation, reduced postoperative pain, and fewer wound complications including infections and hernias.

We have performed several taTME operations with good results over the past several months and recently attended a cadaver course in Orlando, Florida, to refine our technique. As we embark on this journey to improve surgical results after rectal cancer surgery, we are tracking our results through the OSTRiCh national registry that will allow multicenter quality analysis to assure patient safety. It appears that taTME has the potential to revolutionize the surgical management of rectal cancer, and we are excited to be among early adopters of this technique.

Photo information:

  1. Transanal access platform through which taTME is performed
  2. Full-thickness, endoluminal transection of the rectum
  3. Transanal development of the TME plane between mesorectum and pelvic floor
  4. Anterior plane between prostate and rectum
  5. Entry into peritoneal cavity completing the proctectomy
  6. Abdomen after taTME showing the temporary ileostomy with NO abdominal extraction site