Total Mesorectal Excision, an erroneous anatomical term for the gold standard in rectal cancer treatment

Abstract

In 1986 Professor R J Heald published in The Lancet his new technique which he called Total Mesorectal Excision; today this is the gold standard for the surgical management of rectal cancer. In Total Mesorectal Excision (TME), the mesorectum is the term used to describe all the peri-rectal connective tissue including the posterior sheath of the endopelvic fascia containing the peri-rectal neurovascular structures. However, the mesenterium is a defined structure composed of a double layer of peritoneum which does not include the endopelvic fascia and the lateral rectal stalks, so these should not be included in the term 'mesorectum'. In our globalized medical culture it is important to use anatomic terms approved by the International Federation of Associations of Anatomists, as contained in the Terminologia Anatomica produced by the Federative International Programme for Anatomical Terminology (FIPAT). The term mesorectum is not listed in the Terminologia Anatomica.

Robotic total meso-rectal excision for rectal cancer: A systematic review following the publication of the ROLARR trial

“…With the introduction of the total meso-rectal excision (TME), developed in 1989 by Professor Heald, survival rates and the rates of local recurrence have significantly improved[ 3 , 4 ]. A TME is defined as an en bloc resection of the rectal tumour with endo-pelvic fascia to excise circumferential margins[ 5 ]. The decision to undertake a TME is influenced by several factors including distance of the cancer from the anal verge, degree of invasion into the pelvic walls, presence of metastases to regional lymph nodes, the patient’s co-morbidities and the ability to withstand trans-abdominal surgery[ 6 ].…”

“…Total mesorectal excision (TME) performed either by open or laparoscopic technique is an accepted gold standard treatment of rectal cancer worldwide. Laparoscopic TME (LTME) has apparent advantages and considered a preferred mode of surgery due to less tissue trauma[ 5 - 11 ]. Due to precision in dissection, stable base unit and better visualization in difficult areas like lower pelvis, the robotic TME (RTME) is also considered a possible alternative to LTME[ 12 , 13 ].…”

Tumour regression after radiotherapy for rectal cancer – Results from the randomised Stockholm III trial

“…38 Whether the mesorectum really is a true mesentery of the rectum or not has been questioned, but the surgical terminology of a mesorectum remains unthreatened. 39 The mesorectum is covered with the endopelvic fascia or the mesorectal fascia (MRF). The main arterial blood supply comes from the superior rectal artery (SRA) -the end branch of the inferior mesenteric artery (IMA), and the inferior rectal artery (IRA) -branch from the internal iliac arteries.…”

The burden of low anterior resection syndrome on quality of life in patients with mid or low rectal cancer

“…However, the risk of local recurrence is significant and has been shown to be as high as 30% in some studies. 2,3 Since its introduction by Heald, total mesorectal excision (TME), a surgical technique that respects the mesorectal fascial envelope containing the entire rectum with blood vessels and surrounding lymph nodes, has become the oncologic gold standard for curative resection of rectal cancer. While TME allows sphincter-sparing resections, the additional use of advanced sphincter preserving techniques has further reduced the rate of APR.…”

“…7 LARS has a negative impact on patient QoL in up to 80%, with major alterations in 40%. 3,7,[12][13][14] Many tools have been developed to assess the impact of LARS on QoL. 7,13,14 The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core Module (EORTC QLQ-C30) represents the most validated questionnaire to assess QoL of patients treated for rectal cancer.…”