Quality Still Counts

Abstract

total mesorectal excision (TME) is a dissection in the anatomic "holy plane, " where the rectal tumor is removed en bloc with the surrounding mesorectum containing the blood vessels, lymph nodes, and potential routes for cancer spread. Heald et al popularized TME as the optimal technique to ensure complete tumor resection while minimizing the risk of local recurrence and improving long-term outcomes. 1 Quirk et al then assigned a grading system to describe the completeness of the TME plane as a metric for the quality of the surgery performed. 2 At the time it was described, it was common to have a "V"-shaped specimen coned in on the rectal tube and local recurrence rates of 30% to 40%. There was widespread adoption of TME specimen completeness because innumerable studies with the highest level of evidence validated the independent predictive value of the TME grade for significantly reducing local recurrence. [3][4][5] Recently, the importance of the quality of TME excision on the patient's prognosis has been brought into question. Garoufalia et al 6 suggested that the grade of the TME may not be a critical factor impacting recurrence in rectal cancer surgery. This notion is simultaneously a potentially dangerous shift from the standard in rectal cancer care and a stimulating area for future research.Adjuvant chemotherapy cannot correct for an imprecise dissection. 7 The importance of the TME grade is further demonstrated as it serves as a key performance metric in the American College of Surgeons Commission on Cancer's National Accreditation Program for Rectal Cancer. Suggesting a shift away from this standard of care could potentially be dangerous.