Total Mesorectal Excision: The Gold Standard for Rectal Cancer Surgery

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• The Total Mesorectal Excision (TME) Technique
• Pathologist's Role in Surgical Quality Control
• Knowledge vs. Experience in a Surgeon
• Tailoring the Operation to the Patient and Tumor
• The Multidisciplinary Team (MD T) Approach
• Understanding R0, R1, and R2 Resection Margins
• Conclusion: The Path to a Cure

The Total Mesorectal Excision (TME) Technique

Total Mesorectal Excision (TME) is the gold standard surgical method for treating rectal cancer. Dr. Torbjorn Holm, MD, details that this precise technique involves surgery in the correct anatomical plane outside the mesorectal fascia. The surgeon must spare autonomic nerves, preserve the mesorectal fascia, and remove the rectum along with its complete surrounding mesorectum en bloc.

This method, introduced by Professor Heald in the early 1980s, took nearly two decades to gain widespread acceptance. It revolutionized rectal cancer treatment by drastically reducing local recurrence rates from 25-30% to much lower figures. The technique can be performed as open surgery or laparoscopically; the critical factor is achieving a perfect specimen with an intact mesorectal fascia down to the pelvic floor.

Pathologist's Role in Surgical Quality Control

Quality control of the rectal cancer surgery is essential and is performed by a pathologist. Dr. Torbjorn Holm, MD, stresses that the pathologist acts as a quality assessor. They must examine the surgical specimen, take photographs, and objectively grade its quality.

This collaboration is a critical feedback mechanism for the surgeon. A bad specimen indicates a need for the surgeon to improve their technique or, in severe cases, to stop performing these complex operations altogether. This rigorous assessment ensures that patients receive care that meets the highest standards.

Knowledge vs. Experience in a Surgeon

When choosing a rectal cancer surgeon, knowledge of the correct procedure is more important than years of experience alone. Dr. Torbjorn Holm, MD, explains a crucial paradox: a very experienced surgeon who performs the operation incorrectly will consistently yield poor results.

Therefore, patients must seek a well-educated surgeon who understands the principles of TME. While experience is beneficial, it is the surgeon's foundational knowledge of the correct anatomical planes and techniques that ultimately determines the success of the rectal cancer surgery and the patient's prognosis.

Tailoring the Operation to the Patient and Tumor

TME is the standard, but a skilled surgeon must tailor the operation to the individual patient and the specific characteristics of their tumor. Dr. Torbjorn Holm, MD, notes that for very elderly or frail patients, a less extensive operation might be appropriate to reduce surgical risk.

Conversely, for advanced rectal cancer that invades adjacent organs like the prostate, bladder, or sacrum, a standard TME is insufficient. In these cases, the surgeon must be prepared to perform more extensive procedures, such as pelvic exenteration or sacral resection, to achieve complete tumor removal.

The Multidisciplinary Team (MD T) Approach

A multidisciplinary team is extremely important for optimal rectal cancer treatment. Dr. Torbjorn Holm, MD, highlights the roles of each specialist. The radiologist provides a preoperative roadmap using MRI for rectal cancer or CT scans for colon cancer, detailing the tumor's precise location and extent.

The surgeon then uses this imaging as a guide during the operation. Finally, the pathologist provides the definitive assessment of the surgery's success. This team-based approach ensures every aspect of diagnosis, planning, and execution is handled by an expert, giving the patient the best chance for a cure.

Understanding R0, R1, and R2 Resection Margins

The quality of the resection margin is a primary determinant of patient survival. Dr. Torbjorn Holm, MD, defines the critical terms. An R0 resection means no tumor cells are found on the surface of the surgical specimen, indicating a complete removal and offering the highest chance of cure.

An R1 resection means microscopic tumor cells are present on the specimen margin, signaling an incomplete removal and a higher risk of recurrence. An R2 resection is the worst scenario, where macroscopic tumor is left behind in the patient, resulting in a very poor prognosis. Achieving an R0 resection is the primary goal of rectal cancer surgery.

Conclusion: The Path to a Cure

The quality of surgery is the most important factor in curing rectal cancer. Dr. Torbjorn Holm, MD, concludes that mastering the TME technique within a multidisciplinary framework is paramount. Patients should seek a second opinion to confirm their diagnosis and treatment plan, ensuring they are directed to a surgeon with the correct knowledge and skill to perform this life-saving operation.

Dr. Anton Titov, MD, underscores that this discussion highlights why surgical expertise and a team-based approach are non-negotiable for achieving the best possible outcomes in rectal cancer treatment.

Full Transcript

Dr. Anton Titov, MD: Leading Swedish rectal cancer surgeon discusses rectal cancer surgical treatment. Total Mesorectal Excision (TME) method is the best surgical treatment for rectal cancer. It took 20 years for TME to become accepted by colorectal surgeons.

Tumor pathologist must check the result of rectal cancer surgeon’s work. Did the cancer surgeon achieve R0 or R1 or R2 margin of tumor resection? Patient’s survival depends on surgery technique and cancer surgeon’s skill.

What method does your cancer surgeon plan to use? Rectal cancer surgery treatment. Surgery for colorectal cancer treatment. Total Mesorectal Excision is the best method of surgical treatment for rectal cancer.

Leading colorectal cancer surgeon from Stockholm explains best treatment options for rectal cancer. What is best surgical treatment for rectal cancer? Surgeon must be able to do Total Mesorectal Excision to resect rectal cancer tumor en bloc.

Surgeon must not only have a lot of experience but know how to do the correct operation to resect colorectal cancer. Rectal cancer treatment. Advanced rectal cancer surgery.

Medical second opinion confirms that rectal cancer diagnosis is correct and complete. Medical second opinion also confirms that rectal cancer surgery is required. Best treatment for rectal cancer is Total Mesorectal Excision.

Medical second opinion helps to choose the best surgical treatment for rectal cancer. Get medical second opinion on rectal cancer and be confident that your treatment is the best. Best rectal cancer treatment center and cancer surgeon.

Video interview with leading expert in rectal cancer treatment surgery and minimally invasive rectal cancer treatment. Rectal cancer surgery treatment. Total Mesorectal Excision for rectal cancer.

Surgical treatment is the primary treatment for colorectal cancer. Multimodality therapy for rectal cancer is very important. But surgical treatment for rectal cancer is the first and foremost treatment method.

You have a lot of experience with rectal cancer surgical treatment in Sweden and elsewhere. What are the principles of surgical treatment for colorectal cancer? What is the preferred surgical treatment method for rectal cancer correct now?

Dr. Torbjorn Holm, MD: We have to remember that there has been a very interesting historical development in the surgery for colorectal cancer. Years ago colorectal cancer treatment results were significantly worse than now. It was especially true for rectal cancer.

There was higher risk of local failure. Local recurrence of rectal cancer was about 25% to 30%. Patients with rectal cancer had poor survival. But then Professor Heald introduced the Total Mesorectal Excision for rectal cancer surgery treatment.

He started doing Total Mesorectal Excision (TME) already in early 1980s. But Total Mesorectal Excision method of rectal cancer surgery was not accepted until mid-1990s or even late 1990s.

Surgical treatment of rectal cancer by total mesorectal excision technique is a precise surgery. It is rectal cancer surgery in the correct anatomical plane outside of mesorectal fascia. Surgeon should see exactly where he or she is going.

Surgeon should spare autonomic nerves. Surgeon should save mesorectal fascia. Surgeon should take out the rectum with a complete mesorectum. This is called Total Mesorectal Excision, TME.

TME is the method of choice for surgical treatment of rectal cancer today. It is the golden standard. Every cancer surgeon who operates on rectal cancer has to be able to do a good Total Mesorectal Excision surgery technique.

It could be open technique of rectal cancer surgery treatment or laparoscopic technique. It does not matter. Specimen of the rectum with cancer tumor should be perfect.

Mesorectal fascia should be intact all the way down to the pelvic floor. This is extremely important. For colon cancer surgery Prof. Hohenberger developed the same concept.

It is called total mesocolic excision. Surgeon follows the correct and well-defined anatomical planes outside the mesocolic fascia. To treat colon cancer surgeon removes the whole mesocolon with all lymph nodes.

Lymph nodes are removed all the way up to the superior mesenteric artery and vein. Colon is removed up to the aorta if it's a left-sided tumor. So again, good surgical practice to treat rectal cancer is to remove the whole mesorectum.

Or remove the whole mesocolon in the correct plane and close to the tumor. This rectal cancer surgery method is the gold standard. Total Mesorectal Excision of rectal cancer has to be required of all rectal cancer surgeons.

Sometimes rectal cancer surgeon cannot do total mesorectal excision well. This cancer surgeon should stop doing colorectal cancer surgery. You have to have quality control of rectal cancer surgery by the pathologists.

This is why the collaboration between surgeons and the pathologists is so important. The pathologist should be a quality assessor of rectal cancer surgery. Pathologists should look at rectal cancer specimen.

They should take photographs of rectal cancer specimen. They should say this. This is a good specimen or this is a bad rectal cancer surgery specimen.

Sometimes you have a bad rectal cancer surgery specimen. You have to learn how to get a good specimen. You have to improve surgical technique to treat rectal cancer.

Or you have to stop doing rectal cancer surgery.

Dr. Anton Titov, MD: So it's important for patients to seek the cancer surgeon with the most experience in rectal cancer surgery.

Dr. Torbjorn Holm, MD: Not necessarily the most experienced cancer surgeon is most important. Because there is a problem that some rectal cancer surgeons are very experienced. But those rectal cancer surgeons do the operation in the wrong way.

Experience is not everything. Knowledge is the most important thing. Surgeon has to know how to do rectal cancer surgery properly.

Then, of course, surgical experience helps. But if you don't know how to do correct method of rectal cancer surgery, it doesn't matter how many cancer patients you operate on.

Because if you do rectal cancer surgery wrong every time, the results of surgery will not be good. So you have to find a well-educated cancer surgeon. Preferably this will be a cancer surgeon with a long experience.

The knowledge of cancer surgeon is much more important that the surgical experience.

Dr. Anton Titov, MD: This is very important point. You could do the same surgical operation very well, but it's not the correct operation for the patient.

Dr. Torbjorn Holm, MD: Also you have to tailor the operation to the patient. For example the Total Mesorectal Excision surgery is good for most patients. But it is not good for all patients with rectal cancer.

Sometimes you have an advanced rectal cancer case. The tumor may be going into the prostate, or into the urinary bladder, or the sacrum. Total Mesorectal Excision surgery alone is not sufficient to treat such rectal cancer patient.

The cancer surgeon should not only be able to do a Total Mesorectal Excision or Total Mesocolic Excision. Good colorectal cancer surgeon should also tailor the extent of the surgical operation to the rectal cancer or colon cancer tumor and to the patient.

So we must not forget the rectal cancer patient! Total Mesorectal Excision surgery for rectal cancer or Total Mesocolic Excision for colon cancer is the standard operation for normal patient with rectal cancer or colon cancer.

But you may have a very sick patient or very old patient. Then maybe you could do a little less extensive operation to keep the surgery time down. It is not necessary to do extensive rectal cancer surgical operation.

On the other hand, if you have a more extensive rectal cancer or colon cancer tumor, then maybe cancer surgeon needs to do more than the standard TME or CME operation for rectal cancer or colon cancer. Surgeon may have to take out the urinary bladder or do pelvic exenteration.

Colorectal cancer surgeon may have to take the sacrum out. Sometimes there is an extensive colon cancer. You may have to remove the tail of the pancreas or the spleen or part of the abdominal wall or the kidney.

So you have to tailor the rectal cancer or colon cancer operation according to the stage of the tumor. Surgery planning should be assessed for rectal cancer on MRI and for colon cancer on a good CT scan.

This is extremely important. The collaboration with a radiologist is very important. Radiologist will tell the surgeons how the tumor is growing.

Using the radiology (CT or MRI) as a roadmap for rectal cancer surgery or colon cancer surgery is very important. After rectal cancer surgery or colon cancer operation it is important to have the pathologist.

Pathologist will assess the quality of the surgical specimen. Pathologist must tell the cancer surgeon the truth. He should confirm that the cancer surgeon has done a good job to remove rectal cancer or colon cancer.

Did the cancer surgeon remove the rectum or colon with the growing cancer with good margins?

Dr. Anton Titov, MD: Did cancer surgeon achieve what we call the R0 margins? It is complete rectal cancer or colon cancer tumor resection. This is extremely important for successful surgical treatment of rectal cancer.

Dr. Torbjorn Holm, MD: It is obvious that multidisciplinary team (MD T) is extremely important to treat rectal cancer or colon cancer patients. Because the radiologist should do a good and proper preoperative evaluation with CT scan of colon or MRI of the rectum with tumor.

The colorectal cancer surgeon should use that tumor staging as a roadmap for the rectal cancer surgery. Because then cancer surgeon can know what tumor to take out or what tissue to leave in.

The pathologist should assess if the tumor was completely removed with free circumferential margins. Removal of rectal cancer or colon cancer specimen with free margins implicates that the patient has a great chance to be cured.

Of course the radicality of the rectal cancer surgery or colon cancer operation is crucial. Sometimes you have an R0 resection, this means there is no tumor on the surfaces of the specimen.

In R0 resection the chance of rectal cancer cure is much higher than if there is R1 margin after rectal cancer resection. R1 margin means that there are tumor cells on the surface of the surgical specimen.

R2 margin is worst. Because R2 margin means that the cancer surgeon left the tumor inside the patient. Then rectal cancer prognosis or colon cancer prognosis is very poor.

The quality of the surgery is extremely important for curing the patient with colorectal cancer.

Dr. Anton Titov, MD: Rectal cancer treatment by surgery. Video interview with leading Swedish cancer surgeon. Total Mesorectal Excision is a gold standard for rectal cancer surgery.