Zusammenfassung
Die totale mesorektale Exzision (TME) hat in den letzten Jahren die chirurgische Therapie des Rektumkarzinoms, bei dem die Prognose durch die Lokalrezidivrate und die Inzidenz von Fernmetastasen bestimmt wird, revolutioniert. Durch die TME konnten die Lokalrezidivraten nach kurativer Rektumresektion zuverlässig auf unter 10 % gesenkt werden. Wird bei der Resektion in dem Raum, der zwischen viszeraler und parietaler Beckenfaszie liegt, präparariert und das Mesorektum komplett entfernt, kommt es bei zuverlässiger Lymphadenektomie zu keiner Affektion der autonomen Innervation, somit können Kontinenz- und Sexualfunktion weitestgehend erhalten bleiben. Rektumkarzinome im mittleren und unteren Drittel bedingen eine TME bis zum muskulären Beckenboden, während bei Karzinomen des oberen Rektums und rektosigmoidalen Übergangs eine partielle Mesorektumentfernung bis mindestens 5 cm distal des Tumors genügt. Der Entfernung eines intakten TME-Präparats und der pathologischen Untersuchung des lateralen Resektionsrands kommen entscheidende Bedeutung zu. Eine zusätzliche pelvine Lymphadenektomie führt bei erhöhter Morbidität zu keinem weiteren Überlebensvorteil. Da eine Tumorausbreitung nach distal selten und kurzstreckig ist, genügt ein distaler Sicherheitsabstand von 1 - 2 cm, um kontinenzerhaltend zu resezieren, ohne eine Prognoseverschlechterung in Kauf zu nehmen. Obwohl das Konzept der TME bisher in keiner prospektiv-randomisierten Studie überprüft wurde, sind die Ergebnisse der TME überzeugend und stellen das Dissektionsprinzip der Wahl bei Rektumkarzinomen der unteren zwei Drittel dar.
Abstract
Total mesorectal excision (TME) has gained a revolutionary impact on the surgical therapy of rectal cancer within the last years. Locoregional recurrence and distant metastases are the determinants of prognosis in rectal cancer. With the introduction of TME local recurrence rates have been reliably decreased below 10 % after curative resection. Surgical dissection along the connective tissue space between rectal and parietal pelvic fascia with complete mesorectal excision results in reliable excision of all relevant lymphatic pathways with preservation of continence and sexual function. Total mesorectal excision has to be performed in carcinomas of the middle and lower third of the rectum, while for tumors of the upper rectum or rectosigmoidal junction mesorectal excision has to proceed at least 5 cm distal to the primary tumor. Both removal of complete TME specimen and careful pathologic examination of the circumferential resection margin have decisive significance. An additional pelvic lymphadenenctomy with the potential risk of increased morbidity does not improve prognosis. As a spread of tumor distally along the bowel wall rarely exceeds a few centimeters, a distal resection margin of 1 - 2 cm is oncologically sufficient in sphincter-saving procedures without compromising prognosis. Taken together, the convincing results of TME provide a rationale for using TME as dissection policy of choice to resect rectal cancers in the distal two-thirds of the rectum, despite the absence of direct evidence from prospective randomized trials.
Schlüsselwörter
Totale mesorektale Exzision - TME - Rektumkarzinom - Lymphadenektomie - Lokalrezidiv - Überleben
Key words
Total mesorectal excision - TME - Rectal cancer - Lymphadenectomy - Local recurrence - Survival
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Prof. Dr. med. H.-P. Bruch
Klinik für Chirurgie, Universitätsklinikum Lübeck
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23538 Lübeck
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