1
|
Aghayeva A, Seker ME, Bayrakceken S, Kirbiyik E, Bagda A, Benlice C, Karahasanoglu T, Baca B. Comparison of Postoperative Outcomes and Long-Term Survival Rates between Patients Who Underwent Robotic and Laparoscopic Complete Mesocolic Excision for Right-Sided Colon Cancer. J Laparoendosc Adv Surg Tech A 2024. [PMID: 38899434 DOI: 10.1089/lap.2024.0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
Introduction: Right colon cancer often requires surgical intervention, and complete mesocolic excision (CME) has emerged as a standard procedure. The study aims to evaluate and compare the safety and efficacy of robotic and laparoscopic CME for patients with right colon cancer and 5-year survival rates examined to determine the outcomes. Materials and Methods: Patients who underwent CME for right-sided colon cancer between 2014 and 2021 were included in this study. Group differences of age, body mass index, operation time, bleeding amount, total harvested lymph nodes, and postoperative stay were analyzed by the Mann-Whitney U test. Group differences of sex, American Society of Anesthesiology, and tumor, node, and metastasis stage were analyzed by the Chi-squared test. Disease-free and overall survival were assessed using Kaplan-Meier curves with the log-rank Mantel-Cox test. Results: From 109 patients, 74 of them were 1:1 propensity score matched and used for analysis. Total harvested lymph node (P ≤ .001) and estimated blood loss (P = .031) were found to be statistically significant between the groups. We found no statistically significant difference between the groups in terms of disease-free and overall survival (P = .27, .86, respectively), and the mortality rate was 9.17%, with no deaths directly attributed to the surgery. Conclusions: Study shows that minimally invasive surgery is a feasible option for CME in right colon cancers, with acceptable overall survival rates. Although the robotic approach has a higher lymph node yield, there was no significant difference in survival rates. Further randomized trials are needed to determine the clinical significance of both approaches.
Collapse
Affiliation(s)
- Afag Aghayeva
- Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Mustafa Ege Seker
- School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Serra Bayrakceken
- Department of General Surgery, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - Ebru Kirbiyik
- Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Aysegul Bagda
- Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Cigdem Benlice
- Department of General Surgery, School of Medicine, Ankara University, Ankara, Turkey
| | - Tayfun Karahasanoglu
- Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Bilgi Baca
- Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| |
Collapse
|
2
|
Nguyen MT, Dang CT, Song Nguyen TB, Pham NC, Le DD, Pham MD, Nguyen HT, Dung Phan DT, Phu Nguyen DV, Nguyen TP, Doan PV, Nguyen DS, Pham AV. Lymph node harvesting after laparoscopic complete mesocolic excision colectomy in colon cancer with practical application of glacial acid, absolute ethanol, water, and formaldehyde solution: A prospective cohort study. SAGE Open Med 2024; 12:20503121241233238. [PMID: 38456163 PMCID: PMC10919137 DOI: 10.1177/20503121241233238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/23/2024] [Indexed: 03/09/2024] Open
Abstract
Objectives Quality of surgery has recently become an essential topic in the prognosis of colon cancer. Complete mesocolic excision for colon cancer has recently gained popularity with high-quality surgery. Patient specimens after complete mesocolic excision with central vessel ligation procedures have an integrity of the mesocolon and the yield of three fields of lymph node harvest. We apply the glacial acid, absolute ethanol, water, and formaldehyde solution to each specimen based on the Japanese classification of lymph node groups and station numbers. We aim to identify the distribution and status of lymph node metastasis according to each tumor site and some pathological characteristics related to this disease. Methods A prospective cohort study was performed on 45 laparoscopic complete mesocolic excision surgery patients. Results 2791 lymph nodes were harvested after complete mesocolic excision surgery. The average number was 62.0 ± 22.3 nodes. The mean tumor size (in the largest dimension) was 4.2 ± 1.8 cm. The average length of the resected bowel segments was 29.1 ± 7.7 cm. There are 63 (2.3%) node metastases in 2791 lymph nodes, in which 17/45 (37.8%) patients had pN(+). The minimum positive node size was 1 mm. The positive pericolic lymph nodes (station 1) accounted for the highest rate, with 53 nodes (1.9%). The number of lymph nodes in young age ⩽60 is more significant than in older. The results were similar, with a more significant node retrieval in the group with a tumor size >4.5 cm and specimen length >25 cm. The number of lymph nodes in lower tumor invasive (pT1,3) was smaller than pT4. Our research shows that the cecum, ascending, and descending colon had greater nodes than others, with a mean number of 78.6, 74.2, and 71.3, respectively. Conclusions The metastasis and harvested lymph nodes accounted for the highest rate of colon cancer in station 1 and the lowest rate in station 3. The number of retrieved lymph nodes was significantly associated with tumor location, size, specimen length, and patient age.
Collapse
Affiliation(s)
- Minh Thao Nguyen
- Anatomy and Surgical Training Department, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
- Department of Gastrointestinal Surgery, Hue University of Medicine and Pharmacy Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
| | - Cong Thuan Dang
- Pathology Department, Hue University of Medicine and Pharmacy Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
- Department of Histology, Embryology, Pathology and Forensic Medicine, University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
| | - Tran Bao Song Nguyen
- Pathology Department, Hue University of Medicine and Pharmacy Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
- Department of Histology, Embryology, Pathology and Forensic Medicine, University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
| | | | - Dinh Duong Le
- Faculty of Public Health, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
| | - Minh Duc Pham
- Department of Gastrointestinal Surgery, Hue University of Medicine and Pharmacy Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
- Department of Surgery, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
| | - Huu Tri Nguyen
- Anatomy and Surgical Training Department, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
- Department of Gastrointestinal Surgery, Hue University of Medicine and Pharmacy Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
| | - Dinh Tuan Dung Phan
- Department of Gastrointestinal Surgery, Hue University of Medicine and Pharmacy Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
- Department of Surgery, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
| | - Doan Van Phu Nguyen
- Department of Gastrointestinal Surgery, Hue University of Medicine and Pharmacy Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
- Department of Surgery, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
| | - Thanh Phuc Nguyen
- Anatomy and Surgical Training Department, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
- Department of Gastrointestinal Surgery, Hue University of Medicine and Pharmacy Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
| | - Phuoc Vung Doan
- Department of Gastrointestinal Surgery, Hue University of Medicine and Pharmacy Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
| | - Dinh Son Nguyen
- Anatomy and Surgical Training Department, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
- Department of Gastrointestinal Surgery, Hue University of Medicine and Pharmacy Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
| | - Anh Vu Pham
- Department of Gastrointestinal Surgery, Hue University of Medicine and Pharmacy Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
- Department of Surgery, Hue University of Medicine and Pharmacy, Hue University, Hue City, Vietnam
| |
Collapse
|
3
|
International survey among surgeons on the perioperative management of rectal cancer. Surg Endosc 2023; 37:1901-1915. [PMID: 36258001 DOI: 10.1007/s00464-022-09702-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/02/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Several pivotal studies and international guidelines on the perioperative management of rectal cancer have been published. However, little is known about the current state of perioperative management of rectal cancer patients in clinical practice worldwide. METHODS An online survey including 13 questions focusing on key topics related to the perioperative management of patients with rectal cancer was conducted among colorectal surgeons registered within the database of the Research Institute Against Digestive Cancer (IRCAD). RESULTS A total of 535 respondents from 89 countries participated in the survey. Most surgeons worked in the European region (40.9%). Two hundred and fifty-four respondents (47.5%) performed less than 25% of surgical procedures laparoscopically. The most commonly used definition of the upper limit of the rectum was a fixed distance from the anal verge (23.4%). Magnetic resonance imaging was used to define the upper limit of the rectum by 258 respondents (48.2%). During total mesorectal excision (TME), 301 respondents (56.3%) used a high-tie technique. The most commonly constructed anastomosis was an end-to-end anastomosis (68.2%) with the majority of surgeons performing a leak test intraoperatively (88.9%). A total of 355 respondents (66.4%) constructed a diverting ostomy, and the majority of these surgeons constructed an enterostomy (82%). A total of 208 respondents (39.3%) closed a stoma within 8 weeks. Lastly, 135 respondents (25.2%) introduced a solid diet on postoperative day 1. CONCLUSION There is considerable heterogeneity in the perioperative management of rectal cancer patients worldwide with several discrepancies between current international practice and recommendations from international guidelines. To achieve worldwide standardization in rectal cancer care, further research is needed to elucidate the cause of this heterogeneity and find ways of improved implementation of best practice recommendations.
Collapse
|
4
|
Zeng S, Wu W, Zhang X, Qiu T, Gong P. The significance of anatomical variation of the inferior mesenteric artery and its branches for laparoscopic radical resection of colorectal cancer: a review. World J Surg Oncol 2022; 20:290. [PMID: 36085239 PMCID: PMC9463869 DOI: 10.1186/s12957-022-02744-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
Currently, high or low ligation of the inferior mesenteric artery (IMA) is a controversial issue in laparoscopic radical surgery for colorectal cancer. High or low ligation of the IMA has both advantages and disadvantages, and the level of ligation during the left colon and/or rectum resection has been a dilemma for surgeons. One important factor influencing the surgeon's decision to ligate the IMA in a high or low position is the anatomical type of the IMA and its branches. Some studies confirm that the anatomy of the IMA and its branches is critical to the anastomotic blood supply and, therefore, influences the choice of surgical approach (level of ligation of the IMA). However, many vascular variations in the anatomy of the IMA and its branches exist. Herein, we have summarized the anatomical types of the IMA and its branches, finding that the classification proposed by Yada et al. in 1997 is presently accepted by most scholars. Based on Yada's classification, we further summarized the characteristics of the IMA's various anatomical types as a guide for high or low ligation in radical colorectal cancer surgery.
Collapse
Affiliation(s)
- Shun Zeng
- Department of General Surgery & Institute of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Shenzhen University General Hospital & Shenzhen University Clinical Medical Academy, Xueyuan Road 1098, Shenzhen, 518055, China.,Carson International Cancer Center & Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Shenzhen University Health Science Center, Xueyuan Road 1066, Shenzhen, 518060, China.,Shenzhen University Clinical Medical Academy, Xueyuan Road 1066, Shenzhen, 518060, China
| | - Wenhao Wu
- Department of General Surgery & Institute of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Shenzhen University General Hospital & Shenzhen University Clinical Medical Academy, Xueyuan Road 1098, Shenzhen, 518055, China.,Carson International Cancer Center & Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Shenzhen University Health Science Center, Xueyuan Road 1066, Shenzhen, 518060, China.,Shenzhen University Clinical Medical Academy, Xueyuan Road 1066, Shenzhen, 518060, China
| | - Xianbin Zhang
- Department of General Surgery & Institute of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Shenzhen University General Hospital & Shenzhen University Clinical Medical Academy, Xueyuan Road 1098, Shenzhen, 518055, China.,Carson International Cancer Center & Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Shenzhen University Health Science Center, Xueyuan Road 1066, Shenzhen, 518060, China
| | - Tong Qiu
- Shenzhen University Clinical Medical Academy, Xueyuan Road 1066, Shenzhen, 518060, China
| | - Peng Gong
- Department of General Surgery & Institute of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Shenzhen University General Hospital & Shenzhen University Clinical Medical Academy, Xueyuan Road 1098, Shenzhen, 518055, China. .,Carson International Cancer Center & Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Shenzhen University Health Science Center, Xueyuan Road 1066, Shenzhen, 518060, China.
| |
Collapse
|
5
|
Feng X, Wang H, Feng B, Chen X, Yi X, Zhang Q, Li E, Zhuang Y, Li H, Lu X, Chen Z, Wan J, Liao W, Wang J, Deng H, Chen C, Diao D. Risk factors of central area lymph nodes metastasis for guiding optimal right colon cancer surgery: A retrospective multicenter study.. [DOI: 10.21203/rs.3.rs-1991182/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract
Background: D3 or CME lymphadenectomy for right colon cancer (RCC) with lymph nodes metastasis (LNM) is strongly recommended but the anatomical landmark remains controversial. Central LNM predicted poor prognosis in RCC and determined the extent of lymphadenectomy. Methods: Data for 1712 RCC patients treated with D3/CME lymphadenectomy were reviewed. These patients had been treated in 9 centers. A total of 1023 RCC patients were enrolled in the derivation cohort while 689 patients were enrolled in the validation cohort. Results: The overall central LNM incidence was 12.58% (215/1712). In the derivation cohort, univariate and multivariate cox regression analyses revealed that preoperative N staging based on CT scan (OR=7.85, 95% CI, 4.53-14.51, p<0.001), tumor differentiation (OR=0.53, 95% CI, 0.33-0.86, p=0.01) and intraoperative view of tumor movability (OR=0.53, 95% CI, 0.33-0.86, p=0.02) were significant independent factors. Areas under receiver-operating characteristic curves (AUC) for assessing central LNM in the derivation and validation cohorts were 0.802 and 0.750, respectively. The risk-scoring system for patients with RCC was also established. A score of 0 points was the optimal cut-off value for central LNM. Compared to patients in the low-risk group, patients in the high-risk group exhibited worse overall survival outcomes (p<0.001).Conclusions: The established model can be used for preoperative assessment of the risk of central LNM in RCC patients, and for determining the landmark for D3/CME lymphadenectomy, therefore might contribute to decreased therapeutic complications and improved clinical outcomes.
Collapse
Affiliation(s)
- Xiaochuang Feng
- Guangdong Provincal Hospital of Chinese Medicine, University of Chinese Medicine
| | | | | | | | - Xiaojiang Yi
- Guangdong Provincal Hospital of Chinese Medicine, University of Chinese Medicine
| | | | - En Li
- Meizhou City People's Hospital
| | | | - Hongming Li
- Guangdong Provincal Hospital of Chinese Medicine, University of Chinese Medicine
| | - Xinquan Lu
- Guangdong Provincal Hospital of Chinese Medicine, University of Chinese Medicine
| | - Zhaoyu Chen
- Guangdong Provincal Hospital of Chinese Medicine, University of Chinese Medicine
| | - Jin Wan
- Guangdong Provincal Hospital of Chinese Medicine, University of Chinese Medicine
| | - Weilin Liao
- Guangdong Provincal Hospital of Chinese Medicine, University of Chinese Medicine
| | - Jiahao Wang
- Guangdong Provincal Hospital of Chinese Medicine, University of Chinese Medicine
| | - Haijun Deng
- Nanfang Hospital, Southern Medical, University
| | - Chuangqi Chen
- The First Affiliated Hospital of Sun Yat-sen University
| | - Dechang Diao
- Guangdong Provincal Hospital of Chinese Medicine, University of Chinese Medicine
| |
Collapse
|
6
|
Kim K, An S, Kim MH, Jung JH, Kim Y. High Versus Low Ligation of the Inferior Mesenteric Artery in Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1143. [PMID: 36143820 PMCID: PMC9506533 DOI: 10.3390/medicina58091143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/19/2022] [Accepted: 08/19/2022] [Indexed: 12/24/2022]
Abstract
Background and Objectives: This study aimed to compare the effects of high ligation (HL) versus low ligation (LL) in colorectal cancer surgery. Materials and Methods: We performed a comprehensive search using multiple databases (trial registries and ClinicalTrials.gov), other sources of grey literature, and conference proceedings, with no restrictions on the language or publication status, up until 10 March 2021. We included all parallel-group randomized controlled trials (RCTs) and considered cluster RCTs for inclusion. The risk of bias domains were "low risk," "high risk," or "unclear risk." We performed statistical analyses using a random-effects model and interpreted the results according to the Cochrane Handbook for Systematic Reviews of Interventions. We used the GRADE guidelines to rate the certainty of evidence (CoE) of the randomized controlled trials. Results: We found 12 studies (24 articles) from our search. We were very uncertain about the effects of HL on overall mortality, disease recurrence, cancer-specific mortality, postoperative mortality, and anastomotic leakage (very low CoE). There may be little to no difference between HL and LL in postoperative complications (low CoE). For short-term follow-up (within 6 months), HL may reduce defecatory function (constipation; low CoE). While HL and LL may have similar effects on sexual function in men, HL may reduce female sexual function compared with LL (low CoE). For long-term follow-up (beyond 6 months), HL may reduce defecatory function (constipation; low CoE). There were discrepancies in the effects regarding urinary dysfunction according to which questionnaire was used in the studies. HL may reduce male and female sexual function (low CoE). Conclusions: We are very uncertain about the effects of HL on survival outcomes, and there is no difference in the incidence of postoperative complications between HL and LL. More rigorous RCTs are necessary to evaluate the effect of HL and LL on functional outcomes.
Collapse
Affiliation(s)
- Kwangmin Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Korea
- Trauma Center, Wonju Severance Christian Hospital, Wonju 26426, Korea
| | - Sanghyun An
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Korea
- Division of Colorectal Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Korea
| | - Myung Ha Kim
- Yonsei Wonju Medical Library, Yonsei University Wonju College of Medicine, Wonju 26426, Korea
| | - Jae Hung Jung
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea
- Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul 03722, Korea
| | - Youngwan Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Korea
- Division of Colorectal Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Korea
| |
Collapse
|
7
|
Extended Lymphadenectomy for Proximal Transverse Colon Cancer: Is There a Place for Standardization? MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58050596. [PMID: 35630013 PMCID: PMC9145310 DOI: 10.3390/medicina58050596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 12/03/2022]
Abstract
Background and Objectives: Complete mesocolon excision and high vascular ligation have become a standard procedure in the treatment of colon cancer. The transverse colon has certain embryological and anatomical particularities which require special attention in case of oncological surgeries. Proximal transverse colon cancer (TCC) can metastasize to the lymph nodes in the gastrocolic ligament. The aim of this study is to assess the tumor involvement of these lymph nodes and to determine the applicability of gastrocolic ligament lymph nodes dissection as the standard approach for proximal transverse colon cancer. Materials and Methods: this study analyzes the cases of patients admitted to the Surgery Department, diagnosed with proximal transverse colon cancer, with tumor invasion ≥ T2 and for which complete mesocolon excision with high vascular ligation and lymphadenectomy of the gastrocolic ligament (No. 204, 206, 214v) were performed. Results: A total of 43 cases operated during 2015−2020 were included in the study. The median total number of retrieved central lymph nodes was 23 (range, 12−38), that had tumor involvement in 22 cases (51.2%). Gastrocolic ligament tumor involvement was found in 5 cases (11.6%). The median operation time was 180 min, while the median blood loss was 115 mL (range 0−210). The median time of hospitalization was 6 days (range, 5−11). Grade IIIA in the Clavien-Dindo classification was noticed in 3 patients, with no mortality. Upon Kaplan−Meier analysis, tumors > T3 (p < 0.016) and lymph node ratio < 0.05 (p < 0.025) were statistically significant. Conclusions: lymph node dissection of the gastrocolic ligament in patients with advanced proximal transverse colon cancer may improve the oncological outcome in T3/T4 tumors, and therefore standardization could be feasible
Collapse
|
8
|
Reconstructing topography and extent of injury to the superior mesenteric artery plexus in right colectomy with extended D3 mesenterectomy: a composite multimodal 3-dimensional analysis. Surg Endosc 2022; 36:7607-7618. [PMID: 35380284 PMCID: PMC9485098 DOI: 10.1007/s00464-022-09200-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 03/17/2022] [Indexed: 02/08/2023]
Abstract
Abstract
Background
Superior mesenteric artery plexus (SMAP) injury is reported to cause postoperative intractable diarrhea after pancreatic/colonic surgery with extended lymphadenectomy. This study aims to describe the SMAP microanatomy and extent of injury after right colectomy with extended D3 mesenterectomy for cancer.
Methods
Three groups (I) anatomical dissection, (II) postmortem histology, and (III) surgical specimen histology were included. Nerve count and area were compared between groups II and III and paravascular sheath thickness between groups I and II. 3D models were generated through 3D histology, nanoCT scanning, and finally through 3D printing.
Results
A total of 21 specimens were included as follows: Group (I): 5 (3 females, 80–93 years), the SMAP is a complex mesh surrounding the superior mesenteric artery (SMA), branching out, following peripheral arteries and intertwining between them, (II): 7 (5 females, 71–86 years), nerve count: 53 ± 12.42 (38–68), and area: 1.84 ± 0.50 mm2 (1.16–2.29), and (III): 9 (5 females, 55–69 years), nerve count: 31.6 ± 6.74 (range 23–43), and area: 0.889 ± 0.45 mm2 (range 0.479–1.668). SMAP transection injury is 59% of nerve count and 48% of nerve area at middle colic artery origin level. The median values of paravascular sheath thickness decreased caudally from 2.05 to 1.04 mm (anatomical dissection) and from 2.65 to 1.17 mm (postmortem histology). 3D histology models present nerve fibers exclusively within the paravascular sheath, and lymph nodes were observed only outside. NanoCT-derived models reveal oblique nerve fiber trajectories with inclinations between 35° and 55°. Two 3D-printed models of the SMAP were also achieved in a 1:2 scale.
Conclusion
SMAP surrounds the SMA and branches within the paravascular sheath, while bowel lymph nodes and vessels lie outside. Extent of SMAP injury on histological slides (transection only) was 48% nerve area and 59% nerve count. The 35°–55° inclination range of SMAP nerves possibly imply an even larger injury when plexus excision is performed (lymphadenectomy). Reasons for later improvement of bowel function in these patients can lie in the interarterial nerve fibers between SMA branches.
Collapse
|
9
|
Song WJ, Bae SU, Jeong WK, Baek SK. A propensity score-matched analysis of advanced energy devices and conventional monopolar device for colorectal cancer surgery: comparison of clinical and oncologic outcomes. Ann Surg Treat Res 2022; 103:290-296. [DOI: 10.4174/astr.2022.103.5.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/23/2022] [Accepted: 09/14/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Woo Jin Song
- Department of Surgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Sung Uk Bae
- Department of Surgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Woon Kyung Jeong
- Department of Surgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Seong Kyu Baek
- Department of Surgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| |
Collapse
|
10
|
Piozzi GN, Rusli SM, Baek SJ, Kwak JM, Kim J, Kim SH. Infrapyloric and gastroepiploic node dissection for hepatic flexure and transverse colon cancer: A systematic review. Eur J Surg Oncol 2021; 48:718-726. [PMID: 34893366 DOI: 10.1016/j.ejso.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 11/08/2021] [Accepted: 12/02/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The hepatic flexure and transverse colon have a complex intermingled lymphovascular anatomy crossing between mesocolon and mesogastrium. Few studies have investigated the oncological relevance of metastatic infrapyloric and gastroepiploic lymph nodes (IGLN) from hepatic flexure and transverse colon tumors. This study aimed to evaluate the incidence and risk factors for IGLN metastases, and the indications, surgical morbidities, and oncological outcome following extended lymphadenectomy. MATERIALS AND METHODS According to the PRISMA statement, a systematic review on IGLN lymphadenectomy for colon cancer was conducted into PubMed, Embase, and Cochrane databases. A critical appraisal of study was performed according to the Joanna Briggs Institute Tools. RESULTS Nine studies were included. IGLN metastases incidence ranged 0.7-22%. IGLN positivity for patients with metastatic mesocolic lymph nodes ranged 1.7-33.3%. Postoperative complication rate ranged 8.5-36.9%, mostly low grade according to Clavien-Dindo's classification. Postoperative mortality rate ranged 0-5.4% at 30-days. IGLN metastases were associated with advanced disease with a 5-year progression-free survival rate up to 33.9%. Two authors reported perineural invasion and N stage as risk factors, while another reported endoscopic obstruction, signet ring adenocarcinoma, CEA level ≥17 ng/ml, and M1 stage to be risk factors for IGLN involvement. Apart from one study, all other studies were of moderate/high quality. CONCLUSIONS Metastatic IGLNs are not uncommon and should be highly considered. IGLN metastases could be potentially associated with an aggressive disease. IGLN dissection is not associated with higher morbidity and mortality than standard CME. Preoperative risk factors of IGLN involvement could guide surgical indication for extended lymphadenectomy.
Collapse
Affiliation(s)
- Guglielmo Niccolò Piozzi
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Siti Mayuha Rusli
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Se-Jin Baek
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jung-Myun Kwak
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jin Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seon Hahn Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
11
|
Bergquist JR, Li AY, Javadi CS, Lee B, Norton JA, Poultsides GA, Dua MM, Visser BC. Regional lymph node sampling in hepatoma resection: insight into prognosis. HPB (Oxford) 2021; 23:1360-1370. [PMID: 33563547 DOI: 10.1016/j.hpb.2021.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/01/2020] [Accepted: 01/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The importance of regional lymph node sampling (LNS) during resection of hepatocellular carcinoma (HCC) is poorly understood. This study sought to ameliorate this knowledge gap through a nationwide population-based analysis. METHODS Patients who underwent liver resection (LR) for HCC were identified from Surveillance, Epidemiology and End Results (SEER-18) database (2003-2015). Cohort-based clinicopathologic comparisons were made based on completion of regional LNS. Propensity-score matching reduced bias. Overall and disease-specific survival (OS/DSS) were analyzed. RESULTS Among 5395 patients, 835 (15.4%) underwent regional LNS. Patients undergoing LNS had larger tumors (7.0vs4.8 cm) and higher T-stage (30.9 vs. 17.6% T3+, both p < 0.001). Node-positive rate was 12.0%. Median OS (50 months for both) and DSS (28 vs. 29 months) were similar between cohorts, but node-positive patients had decreased OS/DSS (20/16 months, p < 0.01). Matched patients undergoing LNS had equivalent OS (46 vs. 43 months, p = 0.869) and DSS (27 vs. 29 months, p = 0.306) to non-LNS patients. The prognostic impact of node positivity persisted after matching (OS/DSS 24/19 months, p < 0.01). Overall disease-specific mortality were both independently elevated (overall HR 1.71-unmatched, 1.56-matched, p < 0.01; disease-specific HR 1.40-unmatched, p < 0.01, 1.25-matched, p = 0.09). CONCLUSION Regional LNS is seldom performed during resection for HCC, but it provides useful prognostic information. As the era of adjuvant therapy for HCC begins, surgeons should increasingly consider performing regional LNS to facilitate optimal multidisciplinary management.
Collapse
Affiliation(s)
- John R Bergquist
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Amy Y Li
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Stanford University, Stanford, CA, USA; Department of Surgery, General Surgery Residency Program - Henry Ford Hospital, Detroit, MI, USA
| | - Christopher S Javadi
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Byrne Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Jeffrey A Norton
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - George A Poultsides
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Monica M Dua
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Brendan C Visser
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Stanford University, Stanford, CA, USA.
| |
Collapse
|
12
|
Bedzhanyan AL, Bredikhin MI, Galyan TN, Arutyunyants DE, Petrenko KN, Dolzhansky OV, Frolova YV, Linnik DV. [Metastasis of the right colon mucinous adenocarcinoma to aortocaval and retropancreatic space: case report and literature review]. Khirurgiia (Mosk) 2021:95-100. [PMID: 34032795 DOI: 10.17116/hirurgia202106295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Metastases of the right colon cancer to extra-regional lymph nodes are rarely observed. Available literature data cannot be a reliable guide to choose the optimal treatment strategy. Indeed, excision of extra-regional lymph nodes is a rare experience and its results are poorly represented. According to our clinical experience, surgical intervention following comprehensive examination may be radical in patients with right colon cancer if distant metastases are absent. Resection of extra-regional lymph nodes can be safely performed in these cases. We report a patient with the right colon cancer and lesion of extra-regional lymph nodes behind the pancreatic head, paracaval and paraaortic space, hepatoduodenal ligament. Standard laparoscopic right-sided hemicolectomy with D-3 lymph node dissection was accompanied by resection of a conglomerate of nodal metastases behind the pancreatic head and superficial resection of the pancreas. Extra-regional lymph node excision is a reasonable option for colon mucinous adenocarcinoma stage I-III. However, comprehensive preoperative examination is required. Technical difficulty of extra-regional lymph node excision it is not the reason for limitation of surgical intervention. However, safe and total resection requires an adequate surgical approach.
Collapse
Affiliation(s)
- A L Bedzhanyan
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| | - M I Bredikhin
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| | - T N Galyan
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| | | | - K N Petrenko
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| | - O V Dolzhansky
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| | - Yu V Frolova
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| | - D V Linnik
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| |
Collapse
|
13
|
Andersen BT, Stimec BV, Edwin B, Kazaryan AM, Maziarz PJ, Ignjatovic D. Re-interpreting mesenteric vascular anatomy on 3D virtual and/or physical models: positioning the middle colic artery bifurcation and its relevance to surgeons operating colon cancer. Surg Endosc 2021; 36:100-108. [PMID: 33492511 PMCID: PMC8741724 DOI: 10.1007/s00464-020-08242-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022]
Abstract
Background The impact of the position of the middle colic artery (MCA) bifurcation
and the trajectory of the accessory MCA (aMCA) on adequate lymphadenectomy when
operating colon cancer have as of yet not been described and/or analysed in the
literature. The aim of this study was to determine the MCA bifurcation position to
anatomical landmarks and to assess the trajectory of aMCA. Methods The colonic vascular anatomy was manually reconstructed in 3D from
high-resolution CT datasets using Osirix MD and 3-matic Medical and analysed. CT
datasets were exported as STL files and supplemented with 3D printed models when
required. Results Thirty-two datasets were analysed. The MCA bifurcation was left to the
superior mesenteric vein (SMV) in 4 (12.1%), in front of SMV in 17 (53.1%) and right
to SMV in 11 (34.4%) models. Median distances from the MCA origin to bifurcation were
3.21 (1.18–15.60) cm. A longer MCA bifurcated over or right to SMV, while a shorter
bifurcated left to SMV (r = 0.457, p = 0.009). The main MCA direction was towards right in
19 (59.4%) models. When initial directions included left, the bifurcation occurred
left to or anterior to SMV in all models. When the initial directions included right,
the bifurcation occurred anterior or right to SMV in all models. The aMCA was found
in 10 (31.3%) models, following the inferior mesenteric vein (IMV) in 5 near the
lower pancreatic border. The IMV confluence was into SMV in 18 (56.3%), splenic vein
in 11 (34.4%) and jejunal vein in 3 (9.4%) models. Conclusion Awareness of the wide range of MCA bifurcation positions reported is
crucial for the quality of lymphadenectomy performed. The aMCA occurs in 31.3% models
and its trajectory is in proximity to the lower pancreatic border in one half of
models, indicating that it needs to be considered when operating splenic flexure
cancer. Supplementary information The online version of this article (10.1007/s00464-020-08242-8) contains supplementary material, which is available to authorized
users.
Collapse
Affiliation(s)
- Bjarte T Andersen
- Department of Gastrointestinal Surgery, Østfold Hospital Trust, PO Box 300, 1714, Grålum, Norway.,Institute for Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Bojan V Stimec
- Anatomy Sector, Teaching Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bjørn Edwin
- Intervention Centre and Department of Hepatopancreatobiliary Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.,Institute for Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Airazat M Kazaryan
- Department of Gastrointestinal Surgery, Østfold Hospital Trust, PO Box 300, 1714, Grålum, Norway. .,Intervention Centre and Department of Hepatopancreatobiliary Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway. .,Institute for Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway. .,Department of Faculty Surgery, I.M. Sechenov First Moscow State Medical University, Moscow, Russia. .,Department of Surgery N 2, Yerevan State Medical University After M.Heratsi, Yerevan, Armenia.
| | - Przemyslaw J Maziarz
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway.,Lancet Kirurgisk Praksis, Rolvsøy, Norway
| | - Dejan Ignjatovic
- Institute for Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.,Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
| |
Collapse
|
14
|
Zhang C, Chen L, Cui M, Xing J, Yang H, Yao Z, Zhang N, Tan F, Liu M, Xu K, Su X. Short- and long-term outcomes of rectal cancer patients with high or improved low ligation of the inferior mesenteric artery. Sci Rep 2020; 10:15339. [PMID: 32948817 PMCID: PMC7501289 DOI: 10.1038/s41598-020-72303-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/26/2020] [Indexed: 01/01/2023] Open
Abstract
The ligation site of the inferior mesenteric artery (IMA) during laparoscopic radical resection for rectal cancer has been controversial. Consecutive patients (n = 205) with rectal cancer who underwent laparoscopic-assisted low anterior resection from January 2009 to December 2015 were retrospectively analyzed. The patients were divided into high ligation (n = 126) and improved low ligation groups (n = 79). A total of 205 rectal cancer patients underwent laparoscopic assisted anterior resection: 126 patients in the high ligation group and 79 patients in the improved low ligation group. The improved low ligation group was better than the high ligation group in terms of postoperative flatus time and postoperative defecation time. There were no differences between the groups in terms of blood loss, operation time, total number of lymph nodes, anastomotic leakage, postoperative time to first liquid diet and postoperative hospital stay. There were also no differences in 5-year overall survival (OS). Compared to high ligation, the improved low ligation ensures the extent of lymph node dissection, and promotes the early recovery of postoperative gastrointestinal function, but does not increase the operation time, bleeding risk, or anastomotic leakage. A ligation site of the IMA in laparoscopic rectal cancer surgery may not influence oncological outcomes.
Collapse
Affiliation(s)
- Chenghai Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Lei Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Ming Cui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Jiadi Xing
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Hong Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Zhendan Yao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Nan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Fei Tan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Maoxing Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Kai Xu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Xiangqian Su
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China.
| |
Collapse
|
15
|
Naeem A, Shakeel O, Ashraf I, Riaz S, Haq I, Shah MF, Anwer AW, Nasir IUI, Amjad A, Khattak S, Syed AA. Laparoscopic Curative Resection for Right-Sided Colonic Tumors: Initial Experience From a Specialized Cancer Hospital of a Developing Country. Cureus 2020; 12:e9465. [PMID: 32874795 PMCID: PMC7455377 DOI: 10.7759/cureus.9465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introduction Laparoscopic colonic resection is increasingly becoming popular worldwide and aims to provide curative resection in addition to the inherent benefits of laparoscopic surgery. The aim of this study was to evaluate the long-term outcomes of laparoscopic right hemicolectomy in a Pakistani cohort of patients. Methods and procedures We retrospectively analyzed the medical records of all patients who presented to our hospital with the diagnosis of right-sided colon carcinoma from January 2010 to December 2018 and underwent laparoscopic right or extended right hemicolectomy. Demographics, operative findings, histopathology report, and follow-up of patients were recorded and the analysis was performed on Statistical Packages for the Social Sciences (SPSS) Version 20 (IBM Corp, Armonk, NY). Results Seventy-five patients were included, 56 (74.7%) of whom were males and 19 (25.3%) were females. The median age was 52 years (range 25-82 years). The median hospital stay was five days (Range 3-13 days). The median blood loss was 70 milliliters and the mean operative time was 195.5±77.6 minutes. Laparoscopic extended right hemicolectomy was performed in 23 (16.67%) patients and standard right hemicolectomy in 52 (83.33%) patients. Most (72%) of the patients had a pathological T3 tumor, and the majority (61.3%) of the patients had no nodal involvement (pN0). The mean number of lymph nodes removed was 20+8. The median numbers of involved lymph nodes were 1.14+2.19. All the patients had R0 resection. Postoperatively, two patients had pelvic collection, and there was no 30-day mortality. Local recurrence occurred in four patients and distant metastases were observed in nine patients. The median follow-up in our study was 40.5±18.35 months. The median disease-free survival was 42±2.17 months and the median overall survival was 44±2.16 months. Conclusion Our experience with laparoscopic right colon resections has confirmed the safety and feasibility of the procedure.
Collapse
Affiliation(s)
- Awais Naeem
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Osama Shakeel
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Ijaz Ashraf
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Sheryar Riaz
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Ihtisham Haq
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Muhammad F Shah
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Abdul Wahid Anwer
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Irfan Ul Islam Nasir
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Awais Amjad
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Shahid Khattak
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Aamir Ali Syed
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| |
Collapse
|
16
|
Meta-analysis and Trial Sequential Analysis of Randomized Controlled Trials Comparing High and Low Ligation of the Inferior Mesenteric Artery in Rectal Cancer Surgery. Dis Colon Rectum 2020; 63:988-999. [PMID: 32243350 DOI: 10.1097/dcr.0000000000001693] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite ongoing debates, there is still no consensus regarding where to divide the inferior mesenteric artery for oncological reasons in rectal cancer: at its origin from the aorta (high ligation) or distal to the origin of the left colic artery (low ligation). OBJECTIVES The purpose of this study was to compare the outcomes of high and low ligation of the inferior mesenteric artery in rectal cancer surgery. DATA SOURCES MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, and ISRCTN Register were searched. STUDY SELECTION andomized controlled trials investigating outcomes of curative anterior resection in patients with cancer of the rectum were included. INTERVENTIONS High ligation of the inferior mesenteric artery was compared with low ligation technique. MAIN OUTCOME MEASURES We measured the total number of lymph nodes harvested, anastomotic leak, postoperative complications, postoperative mortality, operative time, intraoperative blood loss, conversion to open surgery, overall survival, and disease-free survival. RESULTS Analysis of 1102 patients from 8 trials suggested no difference between high and low ligation of the inferior mesenteric artery in terms of total number of lymph nodes harvested (mean difference = -0.87; p = 0.26), anastomotic leak (OR = 1.39; p = 0.15), postoperative complications (OR = 1.39; p = 0.78), postoperative mortality (risk difference = -0.00; p = 0.48), operative time (mean difference = -1.99; p = 0.79), intraoperative blood loss (mean difference = -2.28; p = 0.77), conversion to open surgery (risk difference = 0.01; p = 0.48), 5-year overall survival (OR = 0.76; p = 0.32), 5-year disease-free survival (OR = 0.88; p = 0.58), overall survival at maximum follow up (OR = 0.80; p = 0.43), and disease-free survival at maximum follow-up (OR = 0.83; p = 0.35). LIMITATIONS Limited data were available on functional and long-term survival outcomes. CONCLUSIONS There is no difference between high and low ligation of the inferior mesenteric artery in terms of oncological outcomes or postoperative morbidity and mortality. The available evidence is subject to potential confounding by the use of neoadjuvant therapy, adjuvant therapy, disease stage, location of tumor, and use of protective stoma. Functional outcomes including postoperative bowel, urinary and sexual function, and long-term survival outcomes should be the outcome of study in future trials. PROSPERO registration number: CRD42019148626.
Collapse
|
17
|
Sammour T, Malakorn S, Thampy R, Kaur H, Bednarski BK, Messick CA, Taggart M, Chang GJ, You YN. Selective central vascular ligation (D3 lymphadenectomy) in patients undergoing minimally invasive complete mesocolic excision for colon cancer: optimizing the risk-benefit equation. Colorectal Dis 2020; 22:53-61. [PMID: 31356721 DOI: 10.1111/codi.14794] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 07/07/2019] [Indexed: 12/16/2022]
Abstract
AIM Complete mesocolic excision (CME) with central vascular ligation (CVL) has been advocated for right colon adenocarcinoma (RC), but the radicality of vascular dissection remains controversial. Our aim is to report outcomes of selective CVL (D3 lymphadenectomy) during minimally invasive CME for RC. METHOD A prospective database identified patients who were treated for RC between 2009 and 2016. Minimally invasive CME was standard. The radicality of lymphadenectomy was defined as high ligation (HL) versus CVL based on operative reports and videos. Two blinded radiologists independently evaluated the pre- and postoperative CT scans for radiographically abnormal nodes. RESULTS Of 197 patients who underwent CME, HL was performed in 56 (28%) and CVL in 141 (72%). There were no baseline differences in age, sex, body mass index, American Society of Anesthesiologists score or pathological staging, and there were no major intra-operative complications in either group (including no major vascular injuries). The median total number of nodes retrieved was 27 and 31 (P = 0.011) in HL and CVL groups, resepctively, with pathologically positive nodes identified in 33.9% and 39.8% (P = 0.704), respectively. Preoperative imaging identified abnormal cN3 nodes in 1.5% of patients; all of whom underwent CVL. No abnormal cN2 or cN3 nodes remained on postoperative imaging. The 60-day mortality was 0.5%, and major morbidity was 4%. One patient (0.5%) had an anastomotic recurrence after a median follow-up of 22 months. CONCLUSION With imperfect preoperative clinical nodal staging, and in the absence of randomized data, the low morbidity and oncological outcomes observed support the approach of CME with HL as a minimum standard, with CVL (D3 lymphadenectomy) in selected cases.
Collapse
Affiliation(s)
- T Sammour
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - S Malakorn
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - R Thampy
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - H Kaur
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - B K Bednarski
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - C A Messick
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - M Taggart
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - G J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Y N You
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
18
|
Abstract
Total mesorectal excision (TME) has been the miracle surgical technique which has since allowed the outcomes of rectal cancer to surpass that of colon cancer. Complete mesocolic excision (CME) attempts to adopt the same principles as that of TME and apply it to colon cancer surgery. Initial retrospective case series and comparative studies have shown promising oncological outcomes. CME entails the en bloc removal of a sufficient length of colonic specimen within an intact peritoneal envelop with extended lymphadenectomy through a high central ligation of vessels. This technique, standardizing the method for resection of right sided colon cancer, has witness promising perioperative and oncological data for both open and laparoscopic methods. However, most data available are mostly retrospective with a glaring lack of level 1 evidence. Despite the technique showing similar outcomes to that of conventional colectomy, parts of the procedure put the patient (and surgeon) at risk of potentially catastrophic complications. As promising as the initial results of CME has been, more well-designed randomized control trials are necessary to justify the increased risks taken and effort to mount the learning curve for CME.
Collapse
Affiliation(s)
- Frederick H Koh
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, National University Health Systems, Singapore, Singapore
| | - Ker-Kan Tan
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, National University Health Systems, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| |
Collapse
|
19
|
Kudsi OY, Gokcal F. Totally robotic right hemicolectomy with the hanging technique for carcinoid tumour - a video vignette. Colorectal Dis 2019; 21:1335-1336. [PMID: 31389115 DOI: 10.1111/codi.14807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/23/2019] [Indexed: 02/08/2023]
Affiliation(s)
- O Y Kudsi
- Good Samaritan Medical Center, Tufts University School of Medicine, Brockton, MA, USA
| | - F Gokcal
- Good Samaritan Medical Center, Tufts University School of Medicine, Brockton, MA, USA
| |
Collapse
|
20
|
Bilgin IA, Yozgatli TK, Aytac E, Ozben V, Baca B, Hamzaoglu I, Karahasanoglu T. Standardized totally robotic complete mesocolic excision for right-sided colon cancer - a video vignette. Colorectal Dis 2019; 21:1335. [PMID: 31370101 DOI: 10.1111/codi.14800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/23/2019] [Indexed: 02/08/2023]
Affiliation(s)
- I A Bilgin
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - T K Yozgatli
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - E Aytac
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - V Ozben
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - B Baca
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - I Hamzaoglu
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - T Karahasanoglu
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| |
Collapse
|
21
|
Karachun A, Petrov A, Panaiotti L, Voschinin Y, Ovchinnikova T. Protocol for a multicentre randomized clinical trial comparing oncological outcomes of D2 versus D3 lymph node dissection in colonic cancer (COLD trial). BJS Open 2019; 3:288-298. [PMID: 31183444 PMCID: PMC6551411 DOI: 10.1002/bjs5.50142] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 12/14/2018] [Indexed: 12/13/2022] Open
Abstract
Background The extent of lymph node dissection in colonic cancer surgery remains arguable, and evidence from RCTs regarding extended lymph node dissection outcomes is lacking. This study aimed to compare the long‐term results of D3 lymph node dissection with those of D2 dissection. Methods This is a multicentre RCT. The aim is to enrol 768 patients with primary colonic cancer assigned randomly to D2 or D3 lymph node dissection. The trial is assessing the superiority of 5‐year overall survival as the primary endpoint in patients undergoing D3 lymph node dissection versus D2 dissection. Secondary endpoints include disease‐free survival, short‐term outcomes (30‐day morbidity and mortality), quality of complete mesocolic excision and lymph node dissection, pattern of lymph node metastasis and quality of life in patients following D2 and D3 lymph node dissection. Experience of 20 D3 and 20 D2 lymph node dissections is required for surgeons to participate in the trial. For surgical accreditation four non‐edited videos of procedures will be assessed. Patients will be followed up for 5 years after last patient enrolment. Intention‐to‐treat analysis will be performed. Discussion The results of this study will demonstrate whether extended lymph node dissection is superior to standard dissection in terms of oncological outcomes, and will also assess the impact of more extensive surgery on short‐term outcomes and quality of life.
Collapse
Affiliation(s)
- A Karachun
- Surgical Department of Abdominal Oncology National Medical Research Centre of Oncology named after N. N. Petrov St Petersburg Russia
| | - A Petrov
- Surgical Department of Abdominal Oncology National Medical Research Centre of Oncology named after N. N. Petrov St Petersburg Russia
| | - L Panaiotti
- Surgical Department of Abdominal Oncology National Medical Research Centre of Oncology named after N. N. Petrov St Petersburg Russia
| | - Y Voschinin
- Surgical Department of Abdominal Oncology National Medical Research Centre of Oncology named after N. N. Petrov St Petersburg Russia
| | - T Ovchinnikova
- Pathology Department National Medical Research Centre of Oncology named after N. N. Petrov St Petersburg Russia
| |
Collapse
|
22
|
Yozgatli TK, Aytac E, Ozben V, Bayram O, Gurbuz B, Baca B, Balik E, Hamzaoglu I, Karahasanoglu T, Bugra D. Robotic Complete Mesocolic Excision Versus Conventional Laparoscopic Hemicolectomy for Right-Sided Colon Cancer. J Laparoendosc Adv Surg Tech A 2019; 29:671-676. [PMID: 30807257 DOI: 10.1089/lap.2018.0348] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Robotic technique has been proposed to overcome the limitations of laparoscopic surgery. In this study, we aimed at determining whether robotic complete mesocolic excision (CME) for right-sided colon cancer can be safe and effective as conventional laparoscopic right hemicolectomy (CLRH). Materials and Methods: Between February 2015 and September 2017, patients undergoing robotic right CME and CLRH with curative intent for right-sided colon cancer were included. Patient characteristics, short-term and histopathological outcomes were compared between the groups. Results: Ninety-six patients (robotic, n = 35) were included in this study. The operative time (286 ± 77 versus 132 ± 40 minutes, P = .0001) was significantly longer in the robotic group. There were no conversions in either group. No significant differences existed between the groups regarding the mean estimated blood loss, time to first flatus, length of hospital stay (6 ± 3 versus 6 ± 3 days, P = .64), and follow-up times (robotic 15 ± 8 versus laparoscopic 16 ± 10 months P = .11). Overall complication rates (n = 10 [29%] versus n = 15 [25%], P = .67) were similar. In the robotic group, vascular injury occurred in 2 patients, and both were repaired robotically. The mean number of harvested lymph nodes was significantly higher (41 ± 12 versus 33 ± 10, P = .04) and length between the vascular tie and colonic wall was longer (13 ± 3.5 versus 11 ± 3, P = .02) in the robotic group. Conclusion: Although robotic right CME seems equally safe to CLRH in terms of short-term morbidity, future prospective randomized trials are needed to define its role for treatment of right colectomy.
Collapse
Affiliation(s)
- Tahir K Yozgatli
- Department of General Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Erman Aytac
- Department of General Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Volkan Ozben
- Department of General Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Onur Bayram
- Department of General Surgery, Koc University School of Medicine, Istanbul, Turkey
| | - Bulent Gurbuz
- Department of General Surgery, Koc University School of Medicine, Istanbul, Turkey
| | - Bilgi Baca
- Department of General Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Emre Balik
- Department of General Surgery, Koc University School of Medicine, Istanbul, Turkey
| | - Ismail Hamzaoglu
- Department of General Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Tayfun Karahasanoglu
- Department of General Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Dursun Bugra
- Department of General Surgery, Koc University School of Medicine, Istanbul, Turkey
| |
Collapse
|
23
|
Ho ML, Chong C, Yeo SA, Ng CY. Initial experience of laparoscopic right hemicolectomy with complete mesocolic excision in Singapore: a case series. Singapore Med J 2019; 60:247-252. [PMID: 30644524 DOI: 10.11622/smedj.2019008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Laparoscopic colorectal surgery is increasingly performed worldwide due to its multiple advantages over traditional open surgery. In the surgical treatment of right-sided colonic tumours, the latest technique is laparoscopic right hemicolectomy with complete mesocolic excision (lapCME), which aims to lower the rate of local recurrence and maximise survival as compared to standard laparoscopic right hemicolectomy (lapS). METHODS We conducted a retrospective analysis of our initial experience with lapCME in Singapore General Hospital between 2012 and 2015. All procedures were performed by a single surgeon. RESULTS Nine patients underwent lapCME and 16 patients underwent lapS. Indication for lapCME was cancer in the right colon. None of the patients required conversion to open surgery, and all were discharged well. The number of lymph nodes resected in the lapCME group was significantly greater than in the lapS group (29 ± 15 vs. 19 ± 6; p = 0.02) during the study period, and the mean operation time was significantly longer for lapCME (237 ± 50 minutes vs. 156 ± 46 minutes; p = 0.0005). There were no statistically significant differences in terms of demographics, tumour stage, time taken for bowel to open postoperatively, time taken for patient to resume a solid diet postoperatively and length of hospital stay. Two patients who underwent lapS were re-admitted for intra-abdominal collections - one patient required radiology-guided drainage, while the other patient was managed conservatively. CONCLUSION Our initial experience with lapCME confirms the feasibility and safety of the procedure.
Collapse
Affiliation(s)
- Ming Li Ho
- Department of Surgery, Sengkang Health, Singapore
| | - Cheryl Chong
- Department of General Surgery, Singapore General Hospital, Singapore
| | - Shen Ann Yeo
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Chee Yung Ng
- One Surgical Clinic and Surgery, Mount Elizabeth Novena Specialist Centre, Singapore
| |
Collapse
|
24
|
Willard CD, Kjaestad E, Stimec BV, Edwin B, Ignjatovic D. Preoperative anatomical road mapping reduces variability of operating time, estimated blood loss, and lymph node yield in right colectomy with extended D3 mesenterectomy for cancer. Int J Colorectal Dis 2019; 34:151-160. [PMID: 30386889 DOI: 10.1007/s00384-018-3177-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2018] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the impact of individual patient anatomy on operating time, estimated blood loss (EBL), and lymph node yield in right colectomy with extended D3 mesenterectomy, where surgeons have access to a preoperative 3-D reconstruction of the vascular anatomy of patients before surgery. Data on the impact of individual patient vascular anatomy when surgeons have an anatomical road map as a guide at surgery is still missing in the literature. METHOD Consecutive patients enrolled in an ongoing trial were classified into 4 groups and 2 subgroups using a 3-D vascular anatomy reconstruction derived from the staging CT. Outcome measures are operating time, EBL, vascular events, and D3 volume lymph node yield. SPSS was used for statistical analysis. RESULTS One hundred seventy-six (77 men) patients included. Mean operating time was 200 ± 50 min. Type 4b required significantly longer operating time (mean, 219 ± 59) compared to type 3 (mean, 188 ± 43) (p = 0.004). Vascular events occurred most often in anatomy type 4b (20.0%) and 3 (19.2%). No difference in EBL and lymph node yield was found (p = 0.102 and p = 0.803, respectively). CONCLUSION The use of a roadmap at surgery seems to even differences in operating time, EBL, and lymph node yield, independent of the complexity of the individual patient's central mesenteric vascular anatomy. The incidents of vascular events requiring hemostasis do not cause differences in EBL between the anatomy groups, suggesting that preoperative awareness of the anatomy is beneficial at surgery.
Collapse
Affiliation(s)
- Christer-Daniel Willard
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lorenskog, Norway
| | - Erik Kjaestad
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lorenskog, Norway
| | - Bojan V Stimec
- Anatomy Sector, Department of Cell Physiology and Metabolism, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bjorn Edwin
- Interventional Centre, Gastrointestinal and Pediatric Surgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Dejan Ignjatovic
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lorenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | | |
Collapse
|
25
|
Olofsson F, Buchwald P, Elmståhl S, Syk I. High Tie or not in Resection for Cancer in the Sigmoid Colon? Scand J Surg 2018; 108:227-232. [PMID: 30458672 DOI: 10.1177/1457496918812198] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The optimal extent of mesenteric resection in colon cancer surgery remains elusive. The aim was to assess the impact on perioperative morbidity and oncological outcome depending on the height of central vessel ligation in sigmoid resection for adenocarcinomas. MATERIAL AND METHODS All cases of stage I-III sigmoid cancers, operated on with locally radical resections (2007-2009), were identified in the Swedish Colorectal Cancer Registry and categorized according to the position of the vascular ligature, that is, ligation of the inferior mesenteric artery, ligation of the superior rectal artery, or ligation of the sigmoid branches. RESULTS In total, 999 cases were identified and possible to categorize. Although higher ligation level yielded a higher number of lymph nodes, 3- or 5-year overall survival, 5-year disease-free survival, or recurrence rate did not differ between the groups (p = 0.79, p = 0.41, p = 0.67, p = 0.51). No differences in survival were detected after multivariate analysis adjusted for age, sex, T-stage, N-stage, American Society of Anesthesiologists classification, and adjuvant therapy. CONCLUSION This large population-based study showed increased lymph node yield but no survival benefit or any decreased recurrence rate by high tie in resection of sigmoid cancer.
Collapse
Affiliation(s)
- F Olofsson
- 1 Division of Surgery, Department of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, Malmö, Sweden
| | - P Buchwald
- 1 Division of Surgery, Department of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, Malmö, Sweden
| | - S Elmståhl
- 2 Division of Geriatric Medicine, Department of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, Malmö, Sweden
| | - I Syk
- 1 Division of Surgery, Department of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, Malmö, Sweden
| |
Collapse
|
26
|
Fujii S, Ishibe A, Ota M, Watanabe K, Watanabe J, Kunisaki C, Endo I. Randomized clinical trial of high versus low inferior mesenteric artery ligation during anterior resection for rectal cancer. BJS Open 2018; 2:195-202. [PMID: 30079388 PMCID: PMC6069351 DOI: 10.1002/bjs5.71] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 03/16/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The optimal level for inferior mesenteric artery ligation during anterior resection for rectal cancer is controversial. The aim of this randomized trial was to clarify whether the inferior mesenteric artery should be tied at the origin (high tie) or distal to the left colic artery (low tie). METHODS Patients were allocated randomly to undergo either high- or low-tie ligation and were stratified by surgical approach (open or laparoscopic). The primary outcome was the incidence of anastomotic leakage. Secondary outcomes were duration of surgery, blood loss and 5-year overall survival. RESULTS Some 331 patients entered the trial between June 2006 and September 2012. The trial was stopped prematurely as recruitment was slow. Seven patients were excluded after randomization but before operation because of procedural changes. High tie and low tie were performed in 164 and 160 patients respectively. The incidence of anastomotic leakage was not significantly different (17·7 versus 16·3 per cent respectively; P = 0·731). The incidence of severe complications requiring intervention was 2·4 versus 5·0 per cent for high and low tie respectively (P = 0·222). In multivariable analysis, risk factors for anastomotic leakage included male sex (odds ratio 4·36, 95 per cent c.i. 1·56 to 12·18) and distance of the tumour from the anal verge (odds ratio 0·99, 0·98 to 1·00). At 5 years there were no significant differences in overall (87·2 versus 89·4 per cent respectively; P = 0·386) and disease-free (76·3 versus 77·6 per cent; P = 0·765) survival. CONCLUSION The level of ligation of the inferior mesenteric artery does not significantly influence the rate of anastomotic leakage. Registration number: NCT01861678 ( https://clinicaltrials.gov).
Collapse
Affiliation(s)
- S. Fujii
- Department of Gastroenterological Surgery, Ichikawa HospitalInternational University of Health and WelfareChibaJapan
- Department of Surgery, Gastroenterological CentreYokohama City UniversityYokohamaJapan
| | - A. Ishibe
- Department of Surgery, Gastroenterological CentreYokohama City UniversityYokohamaJapan
| | - M. Ota
- Department of Surgery, Gastroenterological CentreYokohama City UniversityYokohamaJapan
| | - K. Watanabe
- Department of Gastroenterological Surgery, Graduate School of MedicineYokohama City UniversityYokohamaJapan
| | - J. Watanabe
- Department of Gastroenterological Surgery, Graduate School of MedicineYokohama City UniversityYokohamaJapan
| | - C. Kunisaki
- Department of Surgery, Gastroenterological CentreYokohama City UniversityYokohamaJapan
| | - I. Endo
- Department of Gastroenterological Surgery, Graduate School of MedicineYokohama City UniversityYokohamaJapan
| |
Collapse
|
27
|
Fujii S, Ishibe A, Ota M, Suwa H, Watanabe J, Kunisaki C, Endo I. Short-term and long-term results of a randomized study comparing high tie and low tie inferior mesenteric artery ligation in laparoscopic rectal anterior resection: subanalysis of the HTLT (High tie vs. low tie) study. Surg Endosc 2018; 33:1100-1110. [DOI: 10.1007/s00464-018-6363-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 07/10/2018] [Indexed: 12/11/2022]
|
28
|
Zurleni T, Cassiano A, Gjoni E, Ballabio A, Serio G, Marzoli L, Zurleni F. Surgical and oncological outcomes after complete mesocolic excision in right-sided colon cancer compared with conventional surgery: a retrospective, single-institution study. Int J Colorectal Dis 2018; 33:1-8. [PMID: 29038964 DOI: 10.1007/s00384-017-2917-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of the study was whether complete mesocolic excision (CME) with central vascular ligation (CVL) is associated with a survival benefit compared with traditional procedure in right-sided colon cancer. METHODS Overall, 251 consecutive patients underwent surgery for right colon cancer between 2007 and 2012. After exclusion, 95 subjects received non-CME surgery before 2010, and 97 subjects received CME surgery after January 2010, when we started to perform CME systematically. The number of lymph nodes, morbidity, and mortality was analyzed. Overall survival (OS) and disease-specific survival (DSS) were investigated. RESULTS The median number of examined lymph nodes was 33.28 in the CME group and 26.92 in the non-CME group, p < 0.001. Postoperative complications were 21.6% in the CME group and 17.8% in the non-CME group, without significant difference. One out of 192 patients died. Three-year OS was 88% in the CME group and 71% in the non-CME group (p = 0.003). In stage II, 3-year DSS was 97% in the CME group and 86% in the non-CME group. In stage III, the 3-year DSSs in the CME and in the non-CME groups were 86 and 67%, respectively (p < 0.001). Cox's regression showed that CME (p = 0.0012), the number of lymph nodes (p = 0.029), and TNM stage (p < 0.001) were significant independent predictors of DSS at 3 years. CONCLUSION Surgical standardization of CME with CVL for right-sided colon cancer is associated with better staging and prognosis, particularly in UICC stage II and III. This study shows that CME is safe and reproducible with acceptable morbidity.
Collapse
Affiliation(s)
- Tommaso Zurleni
- Department of General Surgery, Hospital of Busto Arsizio (Va), Piazzale Solaro 3, 21052, Busto Arsizio, Italy.
| | - Alberto Cassiano
- Department of General Surgery, Hospital of Busto Arsizio (Va), Piazzale Solaro 3, 21052, Busto Arsizio, Italy
| | - Elson Gjoni
- Department of General Surgery, Hospital of Busto Arsizio (Va), Piazzale Solaro 3, 21052, Busto Arsizio, Italy
| | - Andrea Ballabio
- Department of General Surgery, Hospital of Busto Arsizio (Va), Piazzale Solaro 3, 21052, Busto Arsizio, Italy
| | - Giovanni Serio
- Department of Anatomical Pathology, Hospital of Busto Arsizio, Busto Arsizio, Italy
| | - Luca Marzoli
- Department of Medical Physics, Hospital of Busto Arsizio, Busto Arsizio, Italy
| | - Francesco Zurleni
- Department of General Surgery, Hospital of Busto Arsizio (Va), Piazzale Solaro 3, 21052, Busto Arsizio, Italy
| |
Collapse
|
29
|
Bilgin IA, Aytac E, Erenler I, Atasoy D, Ozben V, Akpunarli B, Baca B, Hamzaoglu I, Karahasanoglu T. Robotic mesocolic excision with a 'top to down no-touch' technique for right colon cancer - a video vignette. Colorectal Dis 2017; 19:866-867. [PMID: 28710846 DOI: 10.1111/codi.13819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/24/2017] [Indexed: 02/08/2023]
Affiliation(s)
- I A Bilgin
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - E Aytac
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - I Erenler
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - D Atasoy
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - V Ozben
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - B Akpunarli
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - B Baca
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - I Hamzaoglu
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - T Karahasanoglu
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| |
Collapse
|
30
|
Liska D, Stocchi L, Karagkounis G, Elagili F, Dietz DW, Kalady MF, Kessler H, Remzi FH, Church J. Incidence, Patterns, and Predictors of Locoregional Recurrence in Colon Cancer. Ann Surg Oncol 2016; 24:1093-1099. [PMID: 27812826 DOI: 10.1245/s10434-016-5643-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Locoregional recurrence (LR) in colon cancer is uncommon but often incurable, while the factors associated with it are unclear. The purpose of this study was to identify patterns and predictors of LR after curative resection for colon cancer. METHODS All patients who underwent colon cancer resection with curative intent between 1994 and 2008 at a tertiary referral center were identified from a prospectively maintained institutional database. The association of LR with clinicopathologic and treatment characteristics was determined using univariable and multivariable analyses. RESULTS A total of 1397 patients were included with a median follow-up of 7.8 years; 635 (45%) were female, and the median age was 69 years. LR was detected in 61 (4.4%) patients. Median time to LR was 21 months. On multivariable analysis, the independent predictors of LR were disease stage [hazard ratio (HR) for Stage II 4.6, 95% confidence interval (CI) 1.05-19.9, HR for Stage III 10.8, 95% CI 2.6-45.8], bowel obstruction (HR 3.8, 95% CI 1.9-7.4), margin involvement (HR 4.1, 95% CI 1.9-8.6), lymphovascular invasion (HR 1.9, 95% CI 1.06-3.5), and local tumor invasion (fixation to another structure, perforation, or presence of associated fistula, HR 2.2, 95% CI 1.1-4.5). Adjuvant chemotherapy was not associated with reduced LR in patients with either Stage II or Stage III tumors. CONCLUSIONS Adherence to oncologic surgical principles in colon cancer resection results in low rates of LR, which is associated with tumor-dependent factors. Recognition of these factors can help to determine appropriate postoperative surveillance.
Collapse
Affiliation(s)
- David Liska
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA.
| | - Luca Stocchi
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - Georgios Karagkounis
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - Faisal Elagili
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - David W Dietz
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - Matthew F Kalady
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - Feza H Remzi
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - James Church
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| |
Collapse
|
31
|
Merkel S, Weber K, Matzel KE, Agaimy A, Göhl J, Hohenberger W. Prognosis of patients with colonic carcinoma before, during and after implementation of complete mesocolic excision. Br J Surg 2016; 103:1220-9. [DOI: 10.1002/bjs.10183] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 03/02/2016] [Accepted: 03/07/2016] [Indexed: 01/08/2023]
Abstract
Abstract
Background
The implementation of complete mesocolic excision (CME) for colonic cancer was accompanied by other important changes, including more patients with early diagnosis by screening and the introduction of adjuvant chemotherapy in patients with stage III disease. The contribution of CME remains unclear.
Methods
In this observational study, data from patients with stage I–III colonic carcinoma were analysed by comparing five time intervals: 1978–1984 (pre-CME), 1985–1994 (CME development), 1995–2002 (CME implementation), 2003–2009 (CME) and 2010–2014 (CME), with a special focus on indicators of process and outcome quality.
Results
During the observed periods, the median age of patients increased (from 65 to 67 years), there were more right-sided carcinomas (from 17·0 to 32·4 per cent), more stage I disease (from 14·0 to 27·7 per cent) and fewer patients with regional lymph node metastases (from 42·7 to 32·0 per cent). The proportion of patients with pN0 disease and at least 12 examined regional lymph nodes increased (from 84·8 to 100 per cent) as did the R0 resection rate (from 97·0 to 100 per cent). Overall morbidity increased, whereas the in-hospital mortality rate was stable (range 1·8–3·7 per cent). Use of adjuvant chemotherapy in stage III colonic carcinoma increased from 0 to 79 per cent. The improvement in outcome quality was more evident in stage III than in stage I–II tumours. In stage III, the 5-year locoregional recurrence rate decreased from 14·8 to 4·1 per cent (P = 0·046) and the 5-year cancer-related survival rate increased from 61·7 to 80·9 per cent (P = 0·010).
Conclusion
With CME, the quality indicators of process and outcome quality improved, especially in stage III colonic carcinoma. Adjuvant chemotherapy in stage III and multidisciplinary approaches in patients with metachronous distant metastases contributed to further outcome improvement.
Collapse
Affiliation(s)
- S Merkel
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - K Weber
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - K E Matzel
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - A Agaimy
- Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - J Göhl
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - W Hohenberger
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| |
Collapse
|
32
|
Emmanuel A, Haji A. Complete mesocolic excision and extended (D3) lymphadenectomy for colonic cancer: is it worth that extra effort? A review of the literature. Int J Colorectal Dis 2016; 31:797-804. [PMID: 26833471 DOI: 10.1007/s00384-016-2502-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Recent interest in complete mesocolic excision (CME) with central vascular ligation (CVL) or extended (D3) lymphadenectomy (EL) for curative resection of colon cancer has been driven by published series from experienced practitioners showing excellent survival outcomes and low recurrence rates. In this article, we attempt to clarify the role of CME or EL in modern colorectal surgery. METHODS A narrative review of the evidence for CME and EL in the curative treatment of colon cancer. RESULTS The principal of CME surgery, similar to total mesorectal excision (TME) for rectal cancer, is the removal of all lymphatic, vascular, and neural tissue in the drainage area of the tumour in a complete mesocolic envelope with intact mesentery, peritoneum and encasing fascia. Extended (D3) lymphadenectomy (EL) is based on similar principles. Sound anatomical and oncological arguments are made to support the principles of removing the tumor contained within an intact mesocolic facial envelope together with an extended lymph node harvest. Excellent oncological outcomes with minimal morbidity and mortality have been reported. This has led to calls for the standardisation of surgery for colon cancer using CME. However, there is conflicting evidence regarding the prognostic benefit of greater lymph node harvests and the evidence for an oncological benefit of CME is limited by methodology flaws and several potential confounding factors. CONCLUSIONS Although there is a reasonable anatomical and oncological basis for these techniques, there are no randomised controlled trials from which to draw confident conclusions and there is insufficient consistent high quality evidence to recommend widespread adoption of CME.
Collapse
Affiliation(s)
- Andrew Emmanuel
- Department of Colorectal Surgery, King's College Hospital, King's College Hospital NHS Foundation Trust, 2nd Floor Hambelden Wing, Denmark Hill, London, SE5 9RS, UK.
| | - Amyn Haji
- Department of Colorectal Surgery, King's College Hospital, King's College Hospital NHS Foundation Trust, 2nd Floor Hambelden Wing, Denmark Hill, London, SE5 9RS, UK
| |
Collapse
|
33
|
Duraker N, Civelek Çaynak Z, Hot S. The prognostic value of the number of lymph nodes removed in patients with node-negative colorectal cancer. Int J Surg 2014; 12:1324-7. [PMID: 25448653 DOI: 10.1016/j.ijsu.2014.10.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 10/24/2014] [Accepted: 10/28/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND To investigate the prognostic significance of the number of lymph nodes removed in colorectal cancer (CRC) patients with no metastatic lymph node. PATIENTS AND METHODS The clinicopathological data of 461 CRC patients was analyzed. In order to compare the survival of patients who had fewer lymph nodes removed versus the survival of patients who had 1-3 metastatic lymph node(s), a separate group of 74 N1 disease patients were also included in the study. All patient data were collected prospectively. Kaplan-Meier method was used for calculation and plotting of the survival curves of the patient groups, and log-rank test was used for the comparison of the survival curves. RESULTS Cancer-specific survival (CSS) rates of patients who had 1-7 lymph node(s) and 8-11 lymph nodes removed were significantly worse than those who had 12 or more lymph nodes removed (p = 0.006 and p = 0.037, respectively), while CSS was not significantly different between those who had 1-7 versus 8-11 lymph node(s) removed (p = 0.647); this grouping had independent prognostic significance in Cox analysis (p = 0.006). CSS of patients with N1 disease was not significantly different from those who had 1-7 and 8-11 lymph node(s) removed (p = 0.312 and p = 0.165, respectively), while it was significantly worse than CSS of patients who had 12 or more lymph nodes removed (p = 0.001). CONCLUSION In colorectal cancer patients whose removed lymph nodes are non-metastatic, removal of at least 12 lymph nodes will determine the lymph node status reliably.
Collapse
Affiliation(s)
- Nüvit Duraker
- Department of Surgery, SB Okmeydanı Training and Research Hospital, İstanbul, Turkey.
| | | | - Semih Hot
- Department of Surgery, SB Okmeydanı Training and Research Hospital, İstanbul, Turkey
| |
Collapse
|
34
|
Abstract
BACKGROUND Long-term survival after colorectal cancer may be improved by more extensive resection of the primary tumor and lymph nodes. Resection of the gastroepiploic and infrapyloric lymph nodes in the gastrocolic ligament has been proposed as a standard procedure when resecting tumors located in the proximity of the flexures or in the transverse colon. OBJECTIVE The purpose of this work was to present our findings of metastases in the gastrocolic ligament in a consecutive series of patients. DESIGN This was a single-center retrospective study. SETTINGS The study was conducted in a colorectal cancer center. PATIENTS All of the colon adenocarcinoma resections with relevant tumor location from June 1, 2008, to December 31, 2012 were included in this study. MAIN OUTCOME MEASURES The presence of lymph node metastases in the gastrocolic ligament in colon adenocarcinomas located in the proximity of the flexures or in the transverse colon was measured. RESULTS Gastrocolic resection was performed in 130 patients. Thirty-two patients were excluded because of a lack of information about gastrocolic lymph node status in the pathology reports. Median age of the remaining 98 patients was 70 years (range, 30-90 years), and 57% were men. Gastrocolic lymph nodes were found in 86 specimens (88%) with a median number of 4 lymph nodes (range, 0-16 lymph nodes). Thirty-four patients (35%) had mesocolic lymph node metastases. Gastrocolic lymph node metastases were found in 4 (12%) of these 34 patients and in 4% of all 98 included patients. Gastrocolic lymph node metastases were related to perineural invasion (p > 0.001). LIMITATIONS Limitations of this study include the retrospective design, size of material, and lack of gastrocolic ligament lymph node status in the pathology report in some patients. CONCLUSIONS Metastases in the gastroepiploic or infrapyloric lymph nodes can be found in patients with tumors located in the proximity of the flexures or in the transverse colon. Further studies are needed to reveal the clinical relevance of this finding, with special focus on recurrence risk and long-term survival.
Collapse
|
35
|
Vennix S, Pelzers L, Bouvy N, Beets GL, Pierie J, Wiggers T, Breukink S. Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database Syst Rev 2014; 2014:CD005200. [PMID: 24737031 PMCID: PMC10875406 DOI: 10.1002/14651858.cd005200.pub3] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Colorectal cancer including rectal cancer is the third most common cause of cancer deaths in the western world. For colon carcinoma, laparoscopic surgery is proven to result in faster postoperative recovery, fewer complications and better cosmetic results with equal oncologic results. These short-term benefits are expected to be similar for laparoscopic rectal cancer surgery. However, the oncological safety of laparoscopic surgery for rectal cancer remained controversial due to the lack of definitive long-term results. Thus, the expected short-term benefits can only be of interest when oncological results are at least equal. OBJECTIVES To evaluate the differences in short- and long-term results after elective laparoscopic total mesorectal excision (LTME) for the resection of rectal cancer compared with open total mesorectal excision (OTME). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2013, Issue 2), MEDLINE (January 1990 to February 2013), EMBASE (January 1990 to February 2013), ClinicalTrials.gov (February 2013) and Current Controlled Trials (February 2013). We handsearched the reference lists of the included articles for missed studies. SELECTION CRITERIA Only randomised controlled trials (RCTs) comparing LTME and OTME, reporting at least one of our outcome measures, was considered for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality according to the CONSORT statement, and resolved disagreements by discussion. We rated the quality of the evidence using GRADE methods. MAIN RESULTS We identified 45 references out of 953 search results, of which 14 studies met the inclusion criteria involving 3528 rectal cancer patients. We did not consider the risk of bias of the included studies to have impacted on the quality of the evidence. Data were analysed according to an intention-to-treat principle with a mean conversion rate of 14.5% (range 0% to 35%) in the laparoscopic group.There was moderate quality evidence that laparoscopic and open TME had similar effects on five-year disease-free survival (OR 1.02; 95% CI 0.76 to1.38, 4 studies, N = 943). The estimated effects of laparoscopic and open TME on local recurrence and overall survival were similar, although confidence intervals were wide, both with moderate quality evidence (local recurrence: OR 0.89; 95% CI 0.57 to1.39 and overall survival rate: OR 1.15; 95% CI 0.87 to1.52). There was moderate to high quality evidence that the number of resected lymph nodes and surgical margins were similar between the two groups.For the short-term results, length of hospital stay was reduced by two days (95% CI -3.22 to -1.10), moderate quality evidence), and the time to first defecation was shorter in the LTME group (-0.86 days; 95% CI -1.17 to -0.54). There was moderate quality evidence that 30 days morbidity were similar in both groups (OR 0.94; 95% CI 0.8 to 1.1). There were fewer wound infections (OR 0.68; 95% CI 0.50 to 0.93) and fewer bleeding complications (OR 0.30; 95% CI 0.10 to 0.93) in the LTME group.There was no clear evidence of any differences in quality of life after LTME or OTME regarding functional recovery, bladder and sexual function. The costs were higher for LTME with differences up to GBP 2000 for direct costs only. AUTHORS' CONCLUSIONS We have found moderate quality evidence that laparoscopic total mesorectal excision (TME) has similar effects to open TME on long term survival outcomes for the treatment of rectal cancer. The quality of the evidence was downgraded due to imprecision and further research could impact on our confidence in this result. There is moderate quality evidence that it leads to better short-term post-surgical outcomes in terms of recovery for non-locally advanced rectal cancer. Currently results are consistent in showing a similar disease-free survival and overall survival, and for recurrences after at least three years and up to 10 years, although due to imprecision we cannot rule out superiority of either approach. We await long-term data from a number of ongoing and recently completed studies to contribute to a more robust analysis of long-term disease free, overall survival and local recurrence.
Collapse
Affiliation(s)
- Sandra Vennix
- Academic Medical CenterDepartment of SurgeryMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Loeki Pelzers
- Maastricht University Medical CentreDepartment of SurgeryPO Box 5800MaastrichtNetherlands6202 AZ
| | - Nicole Bouvy
- Maastricht University Medical CentreDepartment of SurgeryPO Box 5800MaastrichtNetherlands6202 AZ
| | - Geerard L. Beets
- Maastricht University Medical CentreDepartment of SurgeryPO Box 5800MaastrichtNetherlands6202 AZ
| | - Jean‐Pierre Pierie
- Medical Centre LeeuwardenDepartment of SurgeryH. Dunantweg 2LeeuwardenNetherlands8934 AD
| | - Theo Wiggers
- University Medical Centre GroningenDepartment of Surgical OncologyPostbox 30.001RG GroningenNetherlands9700
| | - Stephanie Breukink
- Maastricht University Medical CentreDepartment of SurgeryPO Box 5800MaastrichtNetherlands6202 AZ
| | | |
Collapse
|