Laparoscopic vs open complete mesocolic excision with central vascular ligation for right-sided colon cancer

Robot-assisted versus laparoscopic short- and long-term outcomes in complete mesocolic excision for right-sided colonic cancer: a systematic review and meta-analysis

BACKGROUND

Complete mesocolic excision (CME) surgery is increasingly implemented for the resection of right-sided colonic cancer, possibly resulting in improved 5-year overall and disease-free survival compared to non-CME surgery. However, it is not clear what surgical platform should be used. The aim of this study was to compare the following outcomes between robot-assisted and laparoscopic CME-surgery for right-sided colonic cancer: (i) short-term clinical outcomes, (ii) pathological specimen quality, and (iii) long-term oncological outcomes.

METHODS

Medline, Embase, and Cochrane Database of Systematic Reviews were searched from inception until August 2021. Pooled proportions were calculated by applying the inverse variance method. Heterogeneity was explored by I-square and supplemented by sensitivity- and meta-regression analyses. The risk of bias was evaluated by either MINORS or Cochrane's risk-of-bias tool (RoB 2).

RESULTS

Fifty-five studies with 5.357 patients (740 robot-assisted and 4617 laparoscopic) were included in the meta-analysis. Overall postoperative morbidity was 17% [95% CI (14-20%)] in the robot-assisted group and 13% [95%CI (12-13%)] in the laparoscopic group. Robot-assisted CME was associated with a shorter hospital stay, lower intraoperative blood loss, a higher amount of harvested lymph nodes, and better 3-year oerall and disease-free survival. MINORS and RoB2 indicated a serious risk of bias across studies included.

CONCLUSIONS

This review which includes predominantly non-randomized studies suggests a possible advantage of the robot-assisted CME compared with a laparoscopic technique for several short-term outcomes.

Definition and reporting of lymphadenectomy and complete mesocolic excision for radical right colectomy: a systematic review

BACKGROUND

Several procedures have been proposed to reduce the rates of recurrence in patients with right-sided colon cancer. Different procedures for a radical right colectomy (RRC), including extended D3 lymphadenectomy, complete mesocolic excision and central vascular ligation have been associated with survival benefits by some authors, but results are inconsistent. The aim of this study was to assess the variability in definition and reporting of RRC, which might be responsible for significant differences in outcome evaluation.

METHODS

PRISMA-compliant systematic literature review to identify the definitions of RRC. Primary aims were to identify surgical steps and different nomenclature for RRC. Secondary aims were description of heterogeneity and overlap among different RRC techniques.

RESULTS

Ninety-nine articles satisfied inclusion criteria. Eight surgical steps were identified and recorded as specific to RRC: Central arterial ligation was described in 100% of the included studies; preservation of mesocolic integrity in 73% and dissection along the SMV plane in 67%. Other surgical steps were inconstantly reported. Six differently named techniques for RRC have been identified. There were 35 definitions for the 6 techniques and 40% of these were used to identify more than one technique.

CONCLUSIONS

The only universally adopted surgical step for RRC is central arterial ligation. There is great heterogeneity and consistent overlap among definitions of all RRC techniques. This is likely to jeopardise the interpretation of the outcomes of studies on the topic. Consistent use of definitions and reporting of procedures are needed to obtain reliable conclusions in future trials. PROSPERO CRD42021241650.

Sağ kolon tümörlerinde laparoskopik komplet mezokolik eksizyon ve santral vasküler ligasyon öğrenme eğrisi için kümülatif toplam analizi

Amaç: Her prosedürün, ne kadar zor olursa olsun, bir öğrenme eğrisi vardır. Ancak, hiç kimse basit işlemler için öğrenme eğrisinden bahsetmez. Bu kavram alışkanlıklara meydan okuyan zorlu bir cerrahi yöntem söz konusu olduğunda karşımıza çıkar. Bu çalışmanın amacı, sağ taraflı kolon kanseri için zorlayıcı bir yöntem olan laparoskopik komplet mezokolik eksizyon ve santral vasküler ligasyon tekniğinin kümülatif toplam analizi ile öğrenme eğrisinin belirlenmesidir. Gereç ve Yöntem: Bu retrospektif çalışmada Ocak 2015-Haziran 2022 tarihleri arasında Ankara Üniversitesi Tıp Fakültesi Genel Cerrahi Anabilim Dalı'na başvuran 18 yaşından büyük sağ kolon kanserli hastalar dahil edilmiştir. Ameliyat süresi ve lenf nodu miktarına göre kümülatif toplam (CUSUM) analizi kullanılarak öğrenme eğrisi belirlenmiştir. Bulgular: 53 hasta çalışmaya dahil edildi. Operasyon süresine göre yapılan CUSUM analizi, cerrahın 21 vakadan sonra öğrenme aşamasını geçtiğini ve yeterlik kazandığını göstermiştir. Lenf nodlarına göre yapılan CUSUM analizi ise cerrahın 25. vakada yeterlik kazandığını ortaya koymuştur. CUSUM analizlerine göre yeterlik öncesi ve sorası fazlardaki hastaların karşılaştırılmasında demografik, onkolojik ve operasyonel veriler açısından fark bulunamamıştır. Sonuç: Cerrahlar sağ kolon kanseri için laparoskopik komplet mezokolik eksizyon prosedürünü yaklaşık 21 ile 25 vaka sonrasında rahatlıkla yapabilirler.

Comparison of Short- and Long-term Outcomes of Laparoscopic and Open Right Hemicolectomy for Colon Cancer

<br><b>Introduction:</b> Colorectal cancer is still among the most common malignancies in the world.</br> <br><b>Aim:</b> The aim of this study is to compare the outcomes of open and laparoscopic right hemicolectomy for colon cancer.</br> <br><b>Materials and methods:</b> This retrospective study included 87 patients who underwent laparoscopic and open right hemicolectomy for colon cancer between January 2014 and January 2020. Patients were categorized into two groups according to the surgical technique: laparoscopic (46 cases) and open (41 cases). Patient characteristics and clinicopathological findings, surgical findings, short- and long-term results were included in the evaluation parameters. Patients with pathological diagnosis other than adenocarcinoma, distant metastases, and incomplete file datas were excluded from the study.</br> <br><b>Results:</b> Forty-six (52.9%) patients underwent laparoscopic and 41 (47.1%) patients underwent open right hemicolectomy. The operation time of the laparoscopic group was found to be significantly higher (P<0.001). The amount of blood loss was significantly higher in the open group (P < 0.001). The incidence of post-operative complications in the open group (26.8%) was higher than in the laparoscopic group (6.5%) (P = 0.010). The rate of anastomotic leakage (9.8%) was higher in patients who underwent open surgery compared to laparoscopic group (0%) (P = 0.045). It was found that the laparoscopic group had a shorter hospital stay (P = 0.009). No statistically significant differences were found between the groups in terms of overall overall survival (OS) rate (P = 0.400) and disease-free survival (DFS) rate (P = 0.781).</br> <br><b>Conclusion:</b> Laparoscopic right hemicolectomy for colon cancer is a feasible and reliable method with lower postoperative morbidity and similar long-term results to the open method.</br>

Is Laparoscopic Complete Mesocolic Excision and Central Vascular Ligation Really Necessary for All Patients With Right-Sided Colon Cancer?

Colon cancer treatment is on the way to evolution over several decades. The minimally invasive surgery has improved postoperative short-term outcomes. Adjuvant chemotherapy has prolonged the survival of advanced colon cancer patients. Hohenberger proposed the noble concept of complete mesocolic excision (CME) which consists of 3 components: plane surgery, sufficient longitudinal bowel resection, and central vascular ligation (CVL). Mesocolic plane surgery shares the same surgical principle of total mesorectal excision, which is maintaining the intact mesothelial envelope. However, there remain debates about the extent of bowel resection and the level of CVL for maximizing lymph node dissection. There is no solid clinical evidence for the oncological necessity and benefit of extended radical dissection in right hemicolectomy. CME with CVL based on open surgery has been adopted in laparoscopic surgery. So, it is also necessary to look at how the CME could be transformed and successfully implanted in the laparoscopic era. Recent rapid advances in surgical technology and cancer biology are preparing for fundamental changes in cancer surgery. In this study, we reviewed the history, oncological necessity, and compatibility of CME for the right hemicolectomy in the laparoscopic era and outline the new perspectives on the evolution of cancer surgery.