Rectal Cancer and the Transanal Total Mesorectal Excision (TaTME) Procedure
Cleveland Clinic is a leading center in the United States for innovative cancer treatment methods. In this third and final episode of the 2020 Colorectal Cancer Awareness Month series, Dana Sands, MD joins Butts & Guts to discuss Transanal Mesorectal Total Excision (TaTME), an evolving procedure that is performed to treat rectal cancer.
Rectal Cancer and the Transanal Total Mesorectal Excision (TaTME) Procedure
Scott Steele: Butts & Guts, a Cleveland Clinic Podcast, exploring your digestive and surgical health from end to end.
So hi everybody and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery at Cleveland Clinic in beautiful Cleveland, Ohio. We're very pleased today to have one of our colleagues down South in Cleveland Clinic Florida, in Weston. That's Dr. Dana Sands, who's a Staff Surgeon in the Department of Colorectal Surgery and Director of the Colorectal Physiology Center at Cleveland Clinic Florida in Weston. Also, she’s the Director of the Summer Scholar Program down there in Cleveland Clinic Florida. Dana, welcome to Butts & Guts.
Dana Sands: Thanks. Great to be here.
Scott Steele: So today, we're going to talk a little bit about transanal total mesorectal excision to treat rectal cancer, who is essentially the new kid on the block. And just in a high volume way. As we know that March is Colorectal Cancer Awareness Month. And as you and I have known in past years, it’s the second or third leading cause of cancer related deaths in the United States alone. And what we're trying to make is a pathway that patients can have a great cancer operation for rectal cancer as well as good functional results.
So, that's going to be the topic of discussion today. And as you know, we like to jump in first with all of our guests and tell us a little bit about yourself, where you're from and where did you train and how did it come to the point that you wound up in Cleveland Clinic Florida?
Dana Sands: Thanks again, Scott, for having me. I am a Staff Surgeon as you said here at the Cleveland clinic, Florida. I'm originally from Philadelphia. I wound up down here at Cleveland Clinic Florida actually through a series of events that led me, 30 years ago almost, to be a patient's family member. And I got to experience the care that was offered by the Cleveland Clinic in Florida. And then pursued my training in general surgery at the University of Miami and ultimately in colorectal surgery back here on our Weston campus. And have been here really ever since practicing colorectal surgery. And as you said, the Director of our Physiology Center.
Scott Steele: Well, we've been great to have you here within the Cleveland Clinic enterprise for a long time. And before we jump into the topic of discussion today, TaTME, let's take a quick step back. We've had prior podcasts on rectal cancer in it of itself, but can you just give us the new listeners there and overview of rectal cancer. What is it, where is it and how might somebody develop it? Just in very global terms, how do we treat rectal cancer?
Dana Sands: Well, rectal cancer is probably the most complicated of the cancers that can occur in the large bowel. As we know, the rectum is the lower portion of the colon that terminates at the level of the anus where we evacuate. When cancers develop here, they can often be for other things like hemorrhoids, or other more benign pathologies because people just think that any signs of bleeding would be related to their hemorrhoids. And obviously nobody's expecting to have a rectal cancer. They develop through a variety of mechanisms, but there's certainly a genetic component. But oftentimes there's not. And it can be looser relations to our diet and exposure, but not always an exact genetic predisposition. And patients are often fairly surprised when they are diagnosed with rectal cancer.
Scott Steele: So, we talk about colorectal cancer all the time, those things are together. So in terms of treatment strategies, how is colon cancer different in many ways from rectal cancer?
Dana Sands: So colon cancer is usually a lot easier for us to manage, because all we really have to do is take out the piece of the colon. And you can certainly live without a lot of impact on your quality of life with missing a portion of the colon. The rectum, however, is really a much more important organ when it comes to functional aspects of life. The rectum is our reservoir that store's stool until it's an appropriate time to evacuate. And if we lose that reservoir, we potentially lose our ability to have control over when and where we evacuate. So taking out the rectum leads to a lot more impact on quality of life than taking out a portion of the colon.
Scott Steele: Dana, one of the questions' that comes up that gets at the heart of what we're talking about today is essentially, do patients with rectal cancer always have to wear a bag?
Dana Sands: Not necessarily. There are many different ways that we go about treating rectal cancer, some as minimally invasive as just taking out a small piece of the rectum with a local excision in very select early types of tumors. Then when we do remove the rectum, there is often a temporary ostomy bag, but many, many times we can avoid a permanent colostomy in these patients.
Scott Steele: Okay, so that gets us into the topic of today, TaTME, or the transanal total mesorectal excision. First of all, let's start very, very 5,000 foot view. What is a mesorectum? And why within rectal cancer are we talking about a mesorectal excision?
Dana Sands: The first thing any patient ever asks me when they're diagnosed with cancer is, "Did it spread?" And the mesorectum is the envelope of fatty tissue that surrounds the rectum and is filled with the lymph nodes that drain the rectal area. And that is typically the first place that tumors will spread. And it's so important in rectal cancer surgery, because if we leave portions of the mesorectum behind in the patient, then we increase their chance of having recurrence of their cancer at a later date.
Scott Steele: So on the technical aspect, give us a little history behind this transanal total mesorectal excision. What is it? What does it involve in terms of the technique and how does it differ from traditional ways about which we typically surgically manage rectal cancer?
Dana Sands: So transanal total mesorectal excision, aside from being a mouthful, we'll call it the TaTME if that's okay. Transanal total mesorectal excision is, I think, the newest innovation in the treatment of rectal cancer. We've been looking at ways to treat rectal cancer with smaller incisions and the same approach by going through the abdomen for the last 20 years. But this is really the first real, significant change in the way we do rectal cancer surgery.
Dana Sands: The challenge for rectal cancer surgery, especially through small incisions, is to be able to perform a perfect total mesorectal excision, to be able to remove all of that fatty tissue from the pelvis with the rectum, so that the patient has a lower chance of recurrence. And when you're going from above, through the abdomen, how we traditionally do this, it can be very, very difficult in the low pelvis.
What's happened with TaTME is we said, "Let's take that hardest part of the operation, the most critical part of the operation, often where the tumor is sitting and let's put that right close to our fingertips by going through the anus. And being right on top of that area with a straight shot to be able to see and dissect that area perfectly. Rather than going from the abdomen where things can be much, much more challenging."
Scott Steele: So what are the advantages of this surgery over a procedure like laparoscopy?
Dana Sands: So the advantage of, and not to be confused, we use laparoscopy in conjunction with TaTME, because we need to perform the abdominal portion of the surgery still laparoscopically, still minimally invasive, avoiding those huge incisions that we used to make for patients. But the advantages in the pelvic dissection and the rectal cancer portion of the operation are that we can see better, our instruments work better in that area. With laparoscopic instruments going from above, we're often over a foot away from the area that we're trying to work, and the instruments don't have the right angles on them. And that can cause great difficulty in trying to perform that perfect TaTME, that perfect total mesorectal excision operation.
Whereas when we do TaTME, we're able to again, be about two inches away from where we're working with a straight shot with our instruments, working exactly in the direction that they were made to move in. And again with perfect visualization, so that we can really find that challenging plane much, much easier.
Scott Steele: So Dana, full disclosure, you're one of the more busy TaTME surgeons, not only in America but in the world. So you have extensive experience with this. And I think it's important that we address right now, can TaTME impact above other minimally invasive surgery patients’ quality of life? Or how does this exactly fit into that aspect of it? And does a TaTME mean that if you can have a TaTME don't have to have a permanent bag?
Dana Sands: One of the things about TaTME that is so important and in all of rectal cancer surgery is what we call the distal margin. Being able to get a clear rim of normal tissue below the area where the tumor was. And when you're going from above and the standard, traditional rectal cancer surgery, it can be very difficult to figure out where that margin is, where that line is that we need to cut through to be able to take the tumor out with normal tissue. TaTME allows us to control and define that distal margin, that area below the tumor as the first step in the operation.
And in order to be able to avoid a colostomy, we need to be able to get below the tumor to have a complete resection and then be able to restore the patient and hook them back up again with a piece of colon that we bring down. So with TaTME, I think that we can get better what we call distal margin control, better control of that lower end of the tumor, define it, choose the spot we're going to transact and then be able to leave a place to hook the patient up to avoid a colostomy.
Scott Steele: Yeah. And I think it's important to clarify here that the appropriately selected patients will undergo a TaTME, but if the tumor's too low, or we have underlying incontinence or something like that, that the patients out there that may be listening, you may not be a candidate for this TaTME procedure. So a little bit more background on this, how was this treatment developed and been available for patients? And is this something that's widely practiced along the United States?
Dana Sands: Well, I think that the TaTME really evolved through a convergence of multiple different issues happening at the same time. As we as surgeons got better at laparoscopy, minimally invasive surgery through the abdomen, we started to tackle the more challenging cases of rectal cancer. And that's when we realized that it was very, very difficult in the lower pelvis. At the same time, the transanal surgical platforms, the technology and the instruments that we used for transanal surgery also evolved to be more user-friendly, and able to be obtained by larger numbers of surgeons.
So I think the combination of doing harder laparoscopic surgery and recognizing that it was difficult in the low pelvis, the addition of better transanal instrumentation and technology, and then also the recognition of how important it was to provide a perfect TME dissection. And to have our pathologists look at those specimens and determine that we in fact indeed removed all of the mesorectum that we had talked about in the beginning here.
So those three things together, coming at the same time, really led surgeons to look for a better way to take out the rectum from the lower pelvis. We had better instruments in our hand, transanally, and we recognize how important it was. I think those things happening at the same time was what really brought about the evolution of rectal cancer surgery to TaTME.
And you're right, not a lot of people do this. It's a hard operation to begin with and then you turn it into a hard operation, which is backwards and upside down from the way that we have traditionally learned and understood it. So, no, it's not something that's practiced widely by many, many people. And I think part of that is that whoever is going to embark on doing TaTME, really needs to have a high rectal cancer volume of patients that they have a lot of experience and ability to do this operation often. It's not something that people should dabble in.
Scott Steele: Yeah. I try to tell all my patients that whether it's robotic, or open, or laparoscopic, or even TaTME, the inside part of the operation is the same, it's a matter of how we get there. One of the scariest things and something that we'd like to address here on Butts & Guts is, patients listen to this and you're newly diagnosed with a rectal cancer. They're going to come into your clinic. Walk through that patient journey, what they can expect during that office visit for somebody who has just recently been told they have a rectal mass, or they have a concerning examination, or even if they have a rectal cancer.
Dana Sands: One of the most important things I think in treating any patient, and certainly any patient with cancer, is that we have to develop a rapport. We have to develop a trust and understanding between the doctor and the patient. So the first thing that I do when a patient comes in the office is we have to get to know each other a little bit. And we're going to talk about their medical history, their family history, other things that have gone on that would be relevant to their medical care, obviously. And then we're going to look at where this tumor is.
So oftentimes the patient will need an examination actually in the office, a rectal examination, either with just a digital exam, a finger examination. Sometimes if the patient can tolerate it and they're okay, we can do a sigmoidoscopy and actually look at that tumor in the office. And that's one of the most important things that we need to know first is, where is that tumor exactly? And how much of how much room below the tumor do we have before we get to those anal sphincter muscles? Because that's really the determination of if a patient is going to need a permanent colostomy or not. If we have room to hook up below where the tumor is and still preserve the anal sphincter muscle.
So I like to try to figure that out in the office and sometimes the patients are very uncomfortable, or nervous, or upset about doing that. We can schedule that as a test that's done, a sigmoidoscopy that's done with some sedation. But most often patients are really eager to know the answer to that question and tolerate the exam in the office just fine. After the examination in the office, then we certainly need to do more staging. And that's where we do some X-rays and studies to see if the tumor has spread anywhere else in the pelvis, just outside the rectum and also throughout the body. So an MRI would be very important in the staging process. An MRI of the pelvis and also, I like to use a CT scan of the chest and the abdomen to look for any evidence of spread of disease anywhere else.
One of the next things that we do routinely in the treatment of rectal cancer is we take all of that information with the biopsy results, the MRI, the X-rays, the surgeons, interpretation of the physical examination. And we go to our multidisciplinary tumor board, which is where we once a week sit down with all of our radiologist, oncologists, medical oncologists, radiation oncologists, pathologists, and we all look at all of the information together with the surgeons and determine the next steps in treatment.
Scott Steele: So as we go on with this, and it comes to the point where the patient eventually gets surgery and whether or not they get a TaTME, what do you think is on the horizon in terms of continued innovation into either this particular procedure, or rectal cancer treatment as a whole?
Dana Sands: Well, I think two things would be looking forward to the future. Number one is instrumentation. There are some robotic platforms that may just make that TaTME surgery even easier with articulating instruments and visualization techniques. So robotic platforms certainly would be an exciting innovation from the technological standpoint. And then as we get better and better at chemotherapy and radiation, who needs surgery. Sometimes we can have patients who have complete responses. And who can we avoid surgery altogether in? And I think those are really the two things on the forefront of rectal cancer surgery.
Scott Steele: Yeah, I think that both Dana and I would agree for all the listeners out there, if you're having some of these symptoms and they're concerning. And I know that it's a part of the body that we often don't talk about, but these are important things that you need to bring up to your doctor and make sure that they get investigated properly.
Dana Sands: Agree. For sure.
Scott Steele: So a final take home messages for our listeners regarding rectal cancer in general, or this particular TaTME procedure?
Dana Sands: Well, I think first of all, you said it perfectly. Never ignore any symptoms. This is colorectal cancer awareness month. And I have many, many patients who come into my office that thought they just had a little bit of rectal bleeding from their hemorrhoids. And perhaps even other people would have told them, "Oh it's just your hemorrhoids, don't worry about it." And I think that's probably one of the most important take home messages is always, always, always get that checked out by a specialist in the area. And make sure that it's not anything more sinister than hemorrhoids, number one.
And number two, I think that if you are diagnosed or with a rectal cancer, or are found to have one, I think it's really, really important that you seek out medical care with a surgeon, and a team of doctors who have significant amounts of experience. And are really at the forefront of innovation and technology and the medical forefront with the chemotherapy and different techniques, so that you can get the state-of-the-art care that you need for rectal cancer.
Scott Steele: Fantastic information and wisdom there. And Dana, we'd like to end with all of our guests here on Butts & Guts with a couple of quick hitters. So number one, what's your favorite food?
Dana Sands: Pizza.
Scott Steele: Number two, what's your favorite sport?
Dana Sands: Weightlifting.
Scott Steele: And number three, what's the last nonmedical book that you've read?
Dana Sands: When Breath Becomes Air was sort of medical, but that was the last one.
Scott Steele: Great book. Great book, but that's a little bit medical. I'll let that one pass. And then finally a twist on my last question, since where you live. I always ask all of our guests about what's something they like about being in beautiful Cleveland, Ohio. But I'll transition it today. So what's something that you like about living in beautiful Western Florida?
Dana Sands: No winter.
Scott Steele: Fantastic. Dually appropriate. Well, Dana, we truly appreciate you taking the time out here. So to learn more about colorectal cancer prevention and treatment, please visit clevelandclinicflorida.org/coloncancer. That's clevelandclinicflorida.org/coloncancer. And for more information, or to speak with a specialist about Cleveland Clinic Florida's Digestive Disease Center, please call (877) 463-2010. That's (877) 463-2010. Dana, thanks for joining us on Butts & Guts.
Dana Sands: Thanks for having me.
Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.