Rectal Cancer: Most Important Decision

Rectal Cancer: Most Important Decision

A few weeks ago, my mom told me that she had per rectal bleeding.

Expecting the worst, I maintained composure and remembered the first thing that I did.

Actually, I was planning few things simultaneously for her such as getting an appointment for my mom for colonoscope and asking around my colleagues for good colorectal surgeon who can operate the soonest.

Yes, the most important decision is finding the right surgeon, specifically colorectal surgeon.

To get a good colorectal surgeon.

One who is skilful in total mesolectal excision (TME) surgery.

Actually, most colorectal surgeons are now trained in TME technique for rectal cancer.

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Standard surgical technique for rectal cancer: Total mesorectal excision (TME)

How important is TME?

Since it was introduced by Heald in 1979, it had gained wide acceptance and is generally the standard when it comes to colorectal surgery.

Heald’s first series of 112 patients showing a cumulative 5-year local recurrence rate of 2.7% and an overall corrected 5-year survival of 87.5%.

The results were unheard of at that time and even today, it’s a result that is only achievable by a selected few colorectal surgeon.

If the surgery was done badly or not optimally, further subsequent treatments (chemotherapy, radiotherapy, etc) won’t compensate for the poor surgery.

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Selected clinical trials from 1980s to 2000s. Improvement in surgical technique (higher percentage of good TME) reflected in better local control and lower local recurrence (LR)

Of course, prior to surgery, other considerations such as pre-operative radiotherapy, pre-op chemo-radiotherapy, post-op radiotherapy, post-op chemo-radiotherapy, short course radiotherapy, long course radiotherapy and adjuvant chemotherapy all need to be discussed with your oncologist in order to get the best outcome.

What happened to my mom? Anyway, I brought my mom to a private hospital for colonoscope. It wasn’t the big C, to my relief.


Association of Plane of Total Mesorectal Excision With Prognosis of Rectal Cancer. Secondary: Analysis of the CAO/ARO/AIO-04 Phase 3 Randomized Clinical Trial (J Kitz, 2018)

The TME quality (mesorectal, intramesorectal, and muscularis propria plane) was prospectively assessed in 1152 operation specimens.

  • TME plane quality was an independent prognostic factor for local recurrence (mesorectal vs muscularis propria)
    • 2.6 times local recurrence risk for poor quality surgery – TME resection plane at muscular propria
  • Circumferential resection margin (CRM) involvement (>1 mm vs ≤1 mm) or how much clearance from the surgery. If margin small meaning distance from cancer tissue from the resection plane was close.
    • 3.6 times higher risk of local recurrence when CRM <1 mm/ close/ threatened

The above study again proved the importance of a good colorectal surgery by an excellent colorectal surgeon.


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