Complete mesocolic excision for colon cancer is technically challenging but the most oncological appealing

Feasibility and Safety of Laparoscopic Complete Mesocolic Excision (CME) for Right-sided Colon Cancer: Short-term Outcomes. A Randomized Clinical Study

OBJECTIVE

The aim of this prospective clinical study is to compare short-term outcome of laparoscopic right hemicolectomy using the Complete Mesocolic Excision (CME group) with patients who underwent conventional right-sided colonic resection (NCME group).

SUMMARY BACKGROUND DATA

Although CME with central vascular ligation in laparoscopic right hemicolectomy is associated with a significant decrease in local recurrence rates and improvements in cancer-related 5-year survival, there may be additional risks associated with this technique because of increased surgical complications. As a result, there is controversy surrounding its use.

METHODS

In this randomized controlled trial, several primary endpoints (operative time, intraoperative blood loss, other complications, conversion rate, and anastomotic leak) and secondary endpoints (overall postoperative complications) were evaluated. In addition, we evaluated histopathologic data, including specimen length and the number of lymph nodes harvested, as objective signs of the quality of CME, related to oncological outcomes.

RESULTS

The CME group had a significantly longer mean operative time than the NCME group (216.3 minutes vs 191.5 minutes, P = 0.005). However, the CME group had a higher number of lymph nodes (23.8 vs 16.6; P < 0.001) and larger surgical specimens (34.3 cm vs 29.3 cm; P = 0.002). No differences were reported with respect to intraoperative blood loss, conversion rate, leakage, or other postoperative complications.

CONCLUSIONS

In this study laparoscopic CME were a safe and feasible technique with improvement in lymph nodes harvesting and length of surgical specimens with no increase of surgical intraoperative and postoperative complications.

Histotype influences emergency presentation and prognosis in colon cancer surgery

AIM

To investigate whether differences in histotype in colon cancer correlate with clinical presentation and if they might influence oncological outcomes and survival.

METHODS

Data regarding colon cancer patients operated both electively or in emergency between 2009 and 2014 were retrospectively collected from a prospectively maintained database and analyzed for the purpose of this study. Rectal cancer was excluded from this analysis. Statistical univariate and multivariate analyses were performed to investigate possible significant variables influencing clinical presentation, as well as oncological outcomes and survival.

RESULTS

Data from 219 patients undergoing colorectal resection for cancer of the colon only were retrieved. One hundred seventy-four patients had an elective procedure and forty-five had an emergency colectomy. Emergency presentation was more likely to occur in mucinous (p < 0.05) and signet ring cell (p < 0.01) tumors. No definitive differences in 5-year overall (44.7% vs. 60.6%, p = 0.078) and disease-free (51.2% vs. 64.4%, p = 0.09) survival were found between the two groups as a whole, but the T3 emergency patients showed worse prognosis than the elective (p < 0.03). Lymph node invasion, laparoscopy, histology, and blood transfusions were independent variables found to influence survival. Distribution assessed for pTNM stage showed T3 cancers were more common in emergency (p < 0.01).

CONCLUSIONS AND DISCUSSION

Mucinous and signet ring cell tumors are related to emergency presentation, pT3 stage, poorest outcomes, and survival. Disease-free survival in patients who had emergency surgery for T3 colon cancer seems related to the histotype.

The fusion fascia of Fredet: an important embryological landmark for complete mesocolic excision and D3-lymphadenectomy in right colon cancer

BACKGROUND

The fusion fascia of Toldt is a well-known landmark used by colorectal surgeons. On the contrary, the fusion fascia of Fredet (the plane between the ascending mesocolon and the visceral duodenal-pancreatic peritoneum) still remains a neglected embryological structure. Aim of this study was to provide an anatomic description of this fascia and its application to minimally invasive D3-lymphadenectomy (D3-L) and complete mesocolic excision (CME) for right colon cancer.

METHODS

First phase: Cadaveric dissection and anatomic description of the fascia of Fredet. Second phase: prospective evaluation of its surgical application in a consecutive series of laparoscopic right hemicolectomies with CME and D3-L at a tertiary hospital.

RESULTS

The fascia of Fredet was identified and dissected in one fresh and two formalin-fixed cadavers. The trunk of Henle and the medial border of the superior mesenteric vein defined the medial limit of this embryologic plane. Seventeen patients were operated on. Laparoscopic dissection of the fascia of Fredet was possible in every patient. Median operative time was 210 (120-380) min. There were no major postoperative complications. All cases were adenocarcinomas, except one adenomatous polyp. T stage was Tis in three, T2 in two, T3 in seven, and T4 in five patients. Median number of harvested lymph nodes was 24 (9-39). Lymphatic invasion was found in six patients. All resections were classified as satisfactory mesocolic excision and R0. Median postoperative length of stay was 6 (4-20) days. Median follow-up time was 28 (16-41) months. Local and distal recurrence rate was 0.

CONCLUSION

The fusion fascia of Fredet is useful to achieve CME and D3-L in right colon cancers with reduced risk of intraoperative complications. This structure is particularly suitable for minimally invasive surgery; therefore, we encourage awareness of the fascia of Fredet by colorectal surgeons.