Laparoscopic versus open complete mesocolic excision: a systematic review by updated meta-analysis

Complete mesocolic excision for right colon cancer: Is D3 lymphadenectomy necessary?

AIM

Although complete mesocolic excision (CME) for colon cancer is oncologically sound, to date, there has been no consensus on the extent of lymphadenectomy in radical right colectomy. This study essentially compared the perioperative and survival outcomes of CME with two templates of lymphadenectomy for right colon cancer.

METHOD

This was a propensity matched, retrospective analysis of a single centre, prospectively maintained database of all patients undergoing elective right colectomy for nonmetastatic, biopsy-proven adenocarcinoma from November 2013 to October 2018. CME + D3 was adopted selectively, documented prospectively, and compared with patients undergoing CME + central vascular ligation (CVL). The only technical difference between the groups was the excision of the surgical trunk of Gillot in the CME + D3 group. Postoperative, long-term outcomes and patterns of recurrence were compared between the groups.

RESULTS

Of the 244 eligible patients, 88 (36.1%) and 156 (63.9%) underwent CME + D3 and CME + CVL, respectively. Matched groups (72 [CME + D3] vs. 108 [CME + CVL]) showed no difference in histology, tumour grade, postoperative complications, mortality, and hospital stay. CME + D3 was preferentially performed laparoscopically (35.2% vs. 9%), was associated with lower blood loss (215 mL vs. 297 mL, p = 0.001), higher nodal yield (31 vs. 25 nodes, p = 0.003) and a higher incidence of chyle leak (4 vs. 0, p = 0.013). At a median follow-up of more than 57 months, there was no significant difference in local recurrence, disease-free or overall survival.

CONCLUSION

In this retrospective study, lymphadenectomy along the superior mesenteric vein, as a component of CME for right colon cancer, offered a higher nodal yield with no improvement in oncological outcome. Dissection of the SMV, over and above a D2 dissection, could therefore be restricted to specialized colorectal units until further studies establish the incremental oncological benefit of this extended lymphadenectomy or define a patient group in whom it is beneficial.

Computer-based multimodal training module facilitates standardization of complete mesocolic excision technique for right-sided colon cancer: Long-term oncological outcomes

AIM

The aim of this study is to demonstrate our video training tool developed to teach and standardize complete mesocolic excision (CME) for right-sided colon cancer and also to present our long-term oncological outcomes.

METHOD

Educational narrative videos were produced to demonstrate the technical steps of CME. First, a three-dimensional animation video was prepared. Then cadaveric dissections were recorded in a step-by-step fashion, following the sequences of open and minimally invasive surgery. These were followed by videos of real-life demonstrations of surgical procedures, enhanced by superimposed animations of key anatomical structures. In order to demonstrate the impact of this training module on outcomes of patients undergoing CME, we retrospectively queried data from before (2005-2010) and after (2011-2019) implementation of standardized CME in our practice.

RESULTS

A total of 180 consecutive patients underwent right hemicolectomy between 2005 and 2019. Fifty-four patients underwent surgery before and 126 patients after CME principles were elaborated and standardized. Of those patients who had surgery after the training module, 58 (46%) underwent open surgery and 68 (54%) underwent laparoscopic colectomy. Demographics, perioperative parameters and morbidity were comparable between the groups. The 5-year overall and disease-free survival rates were significantly improved after implementation of CME training (p = 0.059 and p = 0.041, respectively). Also, 5-year overall and disease-free survival rates for all patients were considerably better than our reported national outcomes.

CONCLUSION

Our comprehensive step-by-step training video module for the CME technique demonstrates surgical anatomical planes and important vascular structures and variations. The video also helps standardization of the CME technique and should contribute to improved histopathological and oncological outcomes.

Right-side colectomy with complete mesocolic excision vs conventional right-side colectomy in the treatment of colon cancer: a systematic review and meta-analysis

BACKGROUND

This meta-analysis aims to investigate the role of complete mesocolic excision (CME) in the treatment of right-side colon cancer when compared with standard right-side hemicolectomy, focusing on oncological outcomes, mortality and morbidity rates.

MATERIALS AND METHODS

A systematic literature search was performed on MEDLINE and EMBASE archives, including studies on CME in right-side colon cancer. Primary outcomes were five-year disease-free survival and five-year overall survival. Secondary outcomes investigated were mortality and morbidity rates, intraoperative blood loss, anastomotic leakage, postoperative ileus, day of postoperative flatus, pulmonary infection, duration of hospital stay and number of lymph nodes harvested.

RESULTS

Seventeen studies have been included in this meta-analysis for a total of 3918 patients. The five-year disease-free survival (DFS) and overall survival (OS) results improved in the CME group with respect to conventional right-side colectomy with an OR 1.88 (95% CI 1.02-3.45) and OR 2.77 (95% CI 1.33-5.74), respectively. The incidence of mortality and morbidity was comparable between the two groups. Moreover, conventional surgery time was faster than CME (MD 33.69 min, 95% CI 12.79-54.59), while no significant differences were reported in mean blood loss and hospital stay. Furthermore, the CME group showed a higher mean number of harvested lymph nodes (MD 7.08 lymph nodes 95% CI 4.90-9.27).

CONCLUSION

Complete mesocolic excision of the right-side colectomy improves oncological outcomes without increasing mortality and morbidity rates compared to standard right-side hemicolectomy. CME should therefore be routinely performed in the treatment of right-side colon cancer.

Qualitative umbrella review of systematic reviews on complete mesocolic excision for colon cancer

BACKGROUND

Complete mesocolic excision (CME) of colon cancer with extended lymphadenectomy was suggested to improve radical resection of colon cancer. This comprehensive review aimed to assess the current literature for the outcomes of CME of colon cancer through an appraisal of the findings of published systematic reviews and meta-analyses.

METHODS

A systematic literature review searching for the studies that assessed the outcome of CME of colon cancer was conducted. Electronic databases were queried from 2009 through November 2020. The main objectives of this review were to illustrate the technical aspects and outcome of CME and to summarize the findings of the published systematic reviews.

RESULTS

Thirteen systematic reviews were retrieved. All reviews found CME to provide longer bowel, larger area of mesentery resected, and more lymph nodes (LNs) retrieved than standard colectomy. All systematic reviews except two found similar complication rates between CME and standard colectomy. Four systematic reviews documented the survival benefit of CME in regards to improved overall and disease-free survival. Using the laparoscopic approach for CME did not compromise the oncologic outcomes of the procedures, yet was associated with less intraoperative blood loss, faster recovery, and potential survival benefits.

CONCLUSIONS

CME is associated with better specimen quality, more LNs clearance, and potential survival benefits compared to standard colectomy. However, the lack of robust data from well-designed multicenter randomized trials may prevent drawing firm conclusions on the oncologic benefits of CME. Further high-quality studies are needed before recommending CME as the standard of care for colon cancer.

Robotic complete mesocolic excision versus conventional robotic right colectomy for right-sided colon cancer: a comparative study of perioperative outcomes

AIM

This study aims to compare the short-term outcomes of robotic complete mesocolic excision (RCME) versus conventional robotic right colectomy (RRC) for right-sided colon cancer.

METHODS

Consecutive patients who underwent robotic surgery for right-sided colon cancer in a public quaternary and a private tertiary healthcare centre between November 2018 and June 2020 were included. Clinical, perioperative and histopathological variables were collected and analysed.

RESULTS

Fifty-one patients were included; 25 (49%) of them had an RCME. The groups were evenly distributed in terms of demographic characteristics and tumour location. Operative time was similar between both groups, and no patients required conversion to open surgery. There were no differences in overall complications (16% in RCME vs. 26.9% in RRC; p = 0.499) or their profile between groups. There were no anastomotic leaks recorded, and the reoperation rates were similar (0% for RCME versus 3.8% for RRC; p = 1). In addition, the median length of hospital stay was similar in between the RCME and the RRC groups (4 [4-6] days versus 5 [3-8.5] days, respectively; p = 0.891). Whilst there were no differences in the TNM staging, the mean number of lymph nodes harvested with RCME was 37.7 (±12.9) compared to 21.8 (±7.5) with RCC (p < 0.001).

CONCLUSION

In our series, RCME was associated with a higher lymph node harvest and a similar morbidity profile compared to RCC. Further studies are required to validate these results and provide long-term oncologic outcomes.

Retrospective analysis of safety and efficacy of enhanced recovery pathways in stage II-III colorectal cancer patients submitted to surgery and adjuvant therapy

Background

The American Society of Colon and Rectal Surgeons is suggesting laparoscopic surgeries for colorectal cancer. Conventional perioperative procedures like long preoperative fasting and bowel procedures are not useful and harmful to patients undergoing surgeries for colorectal cancer. The objectives of the study were to compare surgery outcomes, hospital stays, and survival of patients who received fast-track (laparoscopy/open) surgical procedure followed by chemotherapy against those who received conventional (laparoscopy/open) surgical procedure followed by chemotherapy for colorectal cancer.

Methods

The study analyzes the outcomes of a total of 542 colorectal cancer (preoperative biopsies stage II or III) patients submitted to surgery and adjuvant chemotherapy. The study cohort is retrospectively subdivided in 4 groups submitted to open or laparoscopic resection with or without fast-track protocol appliance and two different chemotherapy regimens. Patients who ended up being TNM stage I have not received the adjuvant chemotherapy.

Results

The fast-track surgical procedure had shorter total hospital stays and postoperative hospital stays than the conventional surgical procedures. Flatus resumption time, the time until first defecation, and intraoperative blood loss were shorter for the fast-track surgical procedures than the conventional surgical procedures. Those surgery outcomes were also shorter for the fast-track laparoscopy than the open fast-track. Resumption of a fluid diet and ambulation onset time were shorter for the fast-track surgical procedures than the conventional surgical procedures. The surgical checkpoints that were compliance by patient of fast-track surgeries were significantly fewer than those of the conventional surgeries. Clinically significant difference for QLQ-C30/CR38 score after chemotherapy was reported between patients who received open conventional surgeries and those patients who received fast-track laparoscopy (59.63 ± 2.26 score/patient vs. 71.67 ± 5.19 score/patient). There were no significant differences for the number of patients with any grade adverse effects (p = 0.431) or with grade 3–4 adverse effects (p = 0.858), and the disease-free and overall survival among cohorts.

Conclusions

The fast-track surgical procedure is effective and safe even in a multidisciplinary scenario as colorectal cancer treatment in which surgery is only a part of management.

Level of evidence: III

Technical efficacy stage: 4.