Total mesorectal excision - 40 years of standard of rectal cancer surgery.

Total mesorectal excision (TME) was first described 40 years ago by Richard Heald. The purpose of this article is to point out importance of this surgical procedure. Starting from first attempts to surgically cure rectal carcinoma in the nineteenth century through Miles' operation at the beginning of the twentieth century results were not satisfactory due to high number of local recurrences after resections for rectal cancer. Progress in surgical technique and knowledge of anatomy and embryology of the rectum led to development of TME. Principle of TME is surprisingly simple: removal of the rectum with complete embryonic space containing lymph nodes which are site of primary dissemination of the disease. Main advantages and drawbacks of TME as well as focus on newer procedures developed from the concept of TME are presented in the form of a review.

Abdominoperineal excision: evolution of a centenary operation.

During the last century, great improvements have been made in rectal cancer management regarding preoperative staging, pathologic assessment, surgical technique, and multimodal therapies. Surgically, there was a move from a strategy characterized by simple perineal excision to complex procedures performed by means of a laparoscopic approach, and more recently with the aid of robotic systems. Perhaps the most important advance is that rectal cancer is no longer a fatal disease as it was at the beginning of the 20th century. This achievement is definitely due in part to Ernest Mile's contribution regarding lymphatic spread of tumor cells, which helped clarify the natural history of the disease and the proper treatment alternatives. He advocated a combined approach with the rationale to clear "the zone of upward spread." The aim of the present paper is to present a brief review concerning the evolution of rectal cancer surgery, focusing attention on Miles' abdominoperineal excision of the rectum (APR) and its controversies and refinements over time. Although APR has currently been restricted to a small proportion of patients with low rectal cancer, recent propositions to excise the rectum performing a wider perineal and a proper pelvic floor resection have renewed interest on this procedure, confirming that Ernest Miles' original ideas still influence rectal cancer management after more than 100 years.

[Thomas Ionescu versus Wildhem von Waldeyer. Rectum sheath or fascia propria recti? The story of a wandering idea]. / Toma Ionescu sau Wilhelm von Waldeyer? Teaca rectului sau fascia propria recti? Istoria unei idei calatoare.

Anatomical knowledge of rectum and its fascial relationship is crucial in modem surgery and it represents the basis of total mesorectal excision. Most of the contemporary authors make reference to Waldeyer's description and use the name fascia propria recti. However, there are evidence regarding Thomas Jonnesco's priority in describing this fascial structure 5 years before Waldeyer. Thomas Jonnesco's description was published in a famous anatomy textbook: Traité d'Anatomie Humaine, Paris, Bataille, 1894, editor P. Poirier, where Thomas Jonnesco was the author of volume 4, fascicule 1, containing the anatomy of the digestive system. His description of the rectum sheath precedes Waldeyer's publication (Das Becken, Cohen, Bonn, 1899). The description of the rectum sheath is included also into the second edition of Traité d'Anatomie Humaine (editors P. Poirier and A. Charpy) published again in 1901 at Masson Publishing House. This second version, better known by contemporary authors (Chapuis et al. Dis Colon Rectum 2002;45:1), probably revised by Charpy, is no more so simple and so clear as the first one. In our paper Thomas Jonnesco's original description of rectal fascia (rectum sheath), published in 1894, is facsimiled, the two succesive editions of the book are compared and a comparison with Waldeyer's description of fascia propria recti is done. The priority of Thomas Jonnesco seems to be well proved. In this respect our own research is in line with the observations of Chapuis and Bell si colab.

[100 years of Miles' surgery--W. Ernest Miles 1869-1947]. / 100 let operace podle Milese--W. Ernest Miles 1869-1947.

Just 100 years ago Ernest Miles published his method of performing abdomino-perineal excision for rectal cancer in Lancet. According to detail anatomic studies he recognized the directions of lymphatic spread of this cancer. Based on these observations he suggested the surgery excising not only involved rectum, but also pelvic mesentery. The method is still current. E. Miles was excellent surgeon of peculiar personality; some of his statements and opinion are mentioned.

The evolution of pelvic dissection for rectal cancer from blunt dissection to total mesorectal excision.

"Modern" rectal cancer treatment began in the 18th century. However, initial results of the pioneer surgeons were very poor. During the next several decades, significant progress was made towards the cure of rectal cancer. Improvements have included lowering mortality, reducing recurrence, and optimizing functional outcomes. This article reviews the individuals and their advancements in rectal cancer treatment. It describes the changes in the surgical approach for tumor resection, the study of the lymphatic spread of rectal cancer and the advances in sphincter preservation procedures from the era of blunt dissection until the paradigm changing revolution of total mesorectal excision.

[The rectal carcinoma treatment history]. / Historie lécby karcinomu rekta.

The authors demonstrate a history of the rectal carcinoma surgical therapy, based on the available literature data or on oral information. Furthermore, they add their own experience with treatment of the rectal carcinoma, the disorder, which in the Czech Republic and, namely, in the Northern Moravian region, has one of the highest worldwide incidence rates.

[An outline of history of rectal surgery]. / Zarys rozwoju chirurgicznego leczenia raka odbytnicy.

An outline of the history of rectal surgery since the XIX century to the present day has been presented. Evolution of the opinions in rectal surgery have been recalled. Development of surgical technique has been presented. Technical achievements in surgery, which pushed possibilities of surgical treatment in rectal cancer patients, has been described.

Audit and the birth of the abdomino-perineal excision for carcinoma of the rectum.

Sir Ernest Miles first performed his radical abdomino-perineal excision for carcinoma of the rectum in 1907. This event was the culmination of almost a decade of audit in which he carefully studied the outcomes of patients with rectal carcinoma. Miles's interpretation of his audit led, in a stepwise manner, to gradual changes in his operative technique and the eventual development of the radical abdomino-perineal operation; the operation that bears his name. The Miles operation and the principles upon which it is based, would lead to an improved outcome for patients with rectal carcinoma.

[The contribution made by the 2nd Department of Surgery, Vienna University, to the treatment of colorectal cancer (author's transl)]. / Der Beitrag der II. Chirurgischen Universitätsklinik Wien zur Behandlung des kolorektalen Karzinoms.

The treatment of colorectal cancer was chosen as a significant example for the history of the second department of surgery of Vienna University. Not only was a considerable part of relevant surgical techniques developed here, but also the problem of cancer has always been one of the traditional fields of activity of this institution. After the foundation of modern abdominal surgery by Billroth, his pupil Czerny performed the first combined abdomino-perineal resection of the rectum, whilst Gussenbauer, his successor, carried out the first curative resection of a carcinoma of the colon. Hochenegg performed the first sphincter-saving resection of the rectum and devised his pull-through procedure. Moreover, he started to organize the general fight against cancer by a campaign to enlighten the public. Denk continued these activities. He founded the cancer research centre and initiated the present activities in the prevention and therapy of cancer in this country.

[Historical course of surgery in rectal cancer in Japan].

Rectal cancer surgery in Japan started to first step of Lisfranc type resection by T. Sato in 1887. Since H. Ito (1902) published in success of three cases of abdominosacral excision (ASE), ASE occupied the main position of rectal cancer surgery in Japan. In 1944, however, M. Kuru reported the superiority of abdominoperineal resection (APR), an orient of surgery had changed to APR from ASE with time. His operative mortality was 2.0% or less, and 5-year survival rate was more than 50%. D. Jinnai (1961) introduced endorectal pull-through operation, and in 1972 he exhibited an excellent survival and satisfying function following sphincter preserving operation, such as anterior resection and pull-through, for mid and upper rectal cancer. T. Kajitani (1975) and Y. Koyama (1977) improved the survivals through an extended pelvic nodes dissection. Today, the principle of rectal cancer surgery in Japan is a limited resection for early cancer, sphincter preserving operations for upper and mid-rectal cancer and extended pelvic nodes dissection for advanced lower rectal cancer.

[Historical review of colorectal cancer surgery].

The classical standard surgical technique for rectal carcinoma, abdominoperineal excision (Miles operation), has been gradually replaced by sphincter-saving surgery and more than 70% of rectal carcinomas are treated by anterior resection in which autosuture machines have played a major role in recent years. Wide lateral lymphadenectomy has been replaced by autonomic nerve preservation because of the high frequency of sexual and urinary dysfunction. Total mesorectal excision (TME) proposed by Heald et al which ignores the lateral nodes of the pelvic wall is the most popular technique in Western countries. The concept of TME is contradictory to that of wide lateral lymphadenectomy and the true merits of the latter should be examined in the near future. Minimally invasive surgery, including various procedures of local excision of low rectal tumors and colonoscopic polypectomy, has given great benefits to many patients. In Japan there seems to have been a lack of interest in adjuvant radiotherapy and chemoradiotherapy in the past, but they should be more seriously considered for the adjuvant treatment of advanced rectal carcinoma in the future.

Improvements in population-based survival of patients presenting with metastatic rectal cancer in the south of the Netherlands, 1992-2008.

We analysed population-based treatment and survival data of patients who presented with metastatic rectal cancer. All patients diagnosed with primary synchronous metastatic rectal cancer between 1992 and 2008 in the Eindhoven Cancer Registry area were included. Date of diagnosis was divided into three periods (1992-1999, 2000-2004, 2005-2008) according to the availability of chemotherapy type. We assessed treatment patterns and overall survival according to period of diagnosis. The proportion of patients diagnosed with stage IV disease increased from 16% in 1992-1999 to 20% in 2005-2008 (P < 0.0001). Chemotherapy use increased from 5% in 1992 to 61% in 2008 (P < 0.0001). Resection rates of the primary tumour decreased from 65% in 1992 to 27% in 2008 (P < 0.0001), while metastasectomy rates remained constant since 1999 (9%). Median survival increased from 38 weeks (95% confidence interval (CI) 32-44) in 1992-1999 to 53 weeks (95% CI 48-61) in 2005-2008. Among patients not receiving chemotherapy median survival remained approximately 30 weeks. Multivariable analysis confirmed the lower risk of death among patients diagnosed in more recent years. Increased use of chemotherapy went together with improved median survival among patients with metastatic rectal cancer in the last two decades. Stage migration as an effect of more effective imaging procedures is likely to be partly responsible for this improved survival.