Total Mesorectal Excision
Most of the Cancer diagnosed has found many cures in modern world based on various factors such as stage of the cancer, organ affected, age of the patient, treatment protocols etc.
Thanks to the advanced technology and life sciences, new treatment methods and innovations, surgical procedures, chemotherapy and radiation protocols and numerous research studies, given a cancer diagnosis is no longer considered getting a death sentence. As a doctor I would like to share some of my thoughts on Total Mesorectal Excision.
What is TME?
TME or Total Mesorectal Excision involves a surgery to remove a major part of the bowel around the tumor and is used to treat colorectal cancer. Earlier, the traditional surgical method to treat colorectal cancer was to have a blunt dissection that was not very successful as it left behind residue that could progress to metastatic disease.
Whereas, the TME involves complete removal of the mesorectum to enable mobilization of the rectum post the procedure. The decision to have a TME done for a patient is after determining the staging of the cancer by performing an MRI, ensuring the effectiveness of radiation therapy followed by surgery with Total Mesorectal Excision. The removed part is then sent for pathological testing to determine the nature and extent of the cancer.
The crucial aspect of this surgery is to remove the entire rectum along with the blood vessels and adjacent lymph nodes by still keeping the visceral facial envelope intact and a clear margin. This is very important to lessen the chances of a recurrence of the disease. Along with the rectum, all pararectal lymph nodes are also removed.
While performing a total mesorectal excision, a proximal bowel margin of at least 5 cm or longer needs to be achieved for the best outcome. TME lessens usage of permanent stoma in patients post surgically and resection can be done sparing sphincter and the nerves. It is very important to identity the autonomic nervous system in the pelvis region so as to not impact the patient’s sexual and urination functions after Total Mesorectal Excision.
During the TME
It is very important for me to consider various factors that determine the success of the surgery. If the tumor is located anterior, it is a cause to worry about due to its nearness to the adjacent viscera and the slimness of the mesorectum i.e. if it is not thick enough to allow for more space for resection. If the tumor itself has invaded surrounding causing adhesions, it is more complicated.
The size of the tumor is also crucial as if it does rupture during the surgery, it will be a very risky surgical situation. The third cause of concern could be if any of the nerves in that area get damaged or scarred, the outcome will not be funny as the patient could lose their sensitivity for voiding and sexual functions.
Right after the surgery, the removed rectum now called as the specimen is carefully studied and categorized to appraise the surgical proficiency of the surgeon and the success of the outcome. This is very important as it directly correlates to survival rates and that can be quite scary. Well, as per statistics an incomplete mesorectal specimen could translate to a 60% survival chance whereas a complete and intact mesorectal specimen could mean around 80% survival chance.
That is a huge variation and so in this kind of surgery it can be said to ‘Watch before you Cut’. Well, I just made that up but it is just not enough to stress on the fact that achieving clear margins as per standard procedure under variant surgical environments and variables still is very crucial to achieve best results for the cancer treatment. The reconstruction method after the TME is also very important and needs to be done using a colon pouch, end to end anastomosis or coloplasty.
As Total Mesorectal Excision is a standardized surgical procedure to treat colorectal cancers, it does come with its share of problems and disadvantages. Many patients that I performed this surgery did report fecal incontinence, bowel dysfunction, blood loss, morbidity etc. at some point of time after the recovery phase or many years later.
Just like most other cancers, Total Mesorectal Excision has best outcome with pre operation radiation therapy followed up with neo-adjuvant therapy to reduce chances of recurrence and enhance patient survival rates.