Laparoscopic complete mesocolic excisions for colonic cancer in the last decade: Five-year survival in a single centre

Development of a procedure-specific tool for skill assessment in left- and right-sided laparoscopic complete mesocolic excision

AIM

To (1) develop an assessment tool for laparoscopic complete mesocolic excision (LCME) and (2) report evidence of its content validity.

METHOD

Assessment statements were revealed through (1) semi-structured expert interviews and (2) consensus by the Delphi method, both involving an expert panel of five LCME surgeons. All experts were interviewed and then asked to rate LCME describing statements from 1 (strongly disagree) to 5 (strongly agree). Responses were returned anonymously to the panel until consensus was reached. Statements were directly included as content in the assessment tool if ≥60% of the experts responded "agree" or "strongly agree" (ratings 4 and 5), with the remaining responses being "neither agree nor disagree" (rating 3). Interclass correlation coefficient (ICC) was calculated for expert agreement evaluation. All included statements were subsequently reformulated as tool items and approved by the experts.

RESULTS

Four Delphi rounds were performed to reach consensus. Disagreement was reported for statements describing instrument handling around pancreas; visualisation of landmarks before inferior mesenteric artery ligation; lymphadenectomy around the inferior mesenteric artery, and division of the terminal ileum and transverse colon. ICC in the last Delphi-round was 0.84. The final tool content included 73 statements, converted to 48 right- and 40 left-sided items for LCME assessment.

CONCLUSION

A procedure-specific, video-based tool, named complete mesocolic excision competency assessment tool (CMECAT), has been developed for LCME skill assessment. In the future, we hope it can facilitate assessment of LCME surgeons, resulting in improved patient outcome after colon cancer surgery.

Risk of Local Recurrence After Complete Mesocolic Excision for Right-Sided Colon Cancer: Post-Hoc Sensitivity Analysis of a Population-Based Study

BACKGROUND

A causal treatment effect of complete mesocolic excision for right-sided colon cancer on the risk of recurrence has been shown, but it is still unclear whether this is caused solely by a risk reduction of local recurrence.

OBJECTIVE

The goal of this study was to assess to what extent complete mesocolic excision contributes to the risk of local recurrence.

DESIGN

This study was a posthoc analyses of data from a population-based cohort. Inverse probability of treatment weighting and competing risk analyses were used to estimate the possible causal effects of complete mesocolic excision.

SETTING

Data were collected from the 4 public colorectal cancer centers in the Capital Region of Denmark.

PATIENTS

Patients undergoing elective colon resections for right-sided colon cancer without distant metastases during the period 2010-2013 were included. One center performed complete mesocolic excision and the remaining 3 centers performed conventional resections.

MAIN OUTCOME MEASURES

The primary outcome was the cumulative incidence of solely local recurrence 5.2 years after surgery. Secondary outcomes were solely distant recurrence and both local and distant recurrence diagnosed within 180 days.

RESULTS

A total of 807 patients were included with 186 undergoing complete mesocolic excision and 621 conventional resections. The 5.2-year cumulative incidence of a solely local recurrence was 3.7% (95% CI, 0.5-6.1) after complete mesocolic excision compared with 7.0% (5.0-8.9) in the control group, and the absolute risk reduction of complete mesocolic excision was 3.7% (2.5-7.1; p = 0.035). The absolute risk reduction on local and distant recurrence was 3.4% (1.3-5.6; p = 0.002) and on solely distant recurrence was 3.1% (0.0-6.2; p = 0.052).

LIMITATIONS

The recurrence risk after conventional resection might be underestimated by the use of inappropriate modalities to diagnose local recurrence for some patients and the shorter duration in this group.

CONCLUSION

This study shows a causal treatment effect of complete mesocolic excision on the risk of a solely local recurrence and of distant recurrence with or without local recurrence. See Video Abstract at http://links.lww.com/DCR/B832 .RIESGO DE RECURRENCIA LOCAL DESPUÉS DE LA ESCISIÓN MESOCÓLICA COMPLETA PARA EL CÁNCER DE COLON DEL LADO DERECHO: ANÁLISIS DE SENSIBILIDAD POST-HOC DE UN ESTUDIO POBLACIONALANTECEDENTES:Se ha demostrado un efecto del tratamiento causal de la escisión mesocólica completa para el cáncer de colon del lado derecho sobre el riesgo de recurrencia, pero aún no está claro si esto se debe únicamente a una reducción del riesgo de recurrencia local.OBJETIVO:Evaluar en qué medida la escisión mesocólica completa se atribuye al riesgo de recurrencia local.DISEÑO:Análisis posthoc de datos de una cohorte poblacional. Se utilizaron análisis de probabilidad inversa de ponderación del tratamiento y de riesgo competitivo para estimar los posibles efectos causales de la escisión mesocólica completa.AJUSTE:Datos de los cuatro centros públicos de cáncer colorrectal en la Región Capital de Dinamarca.PACIENTES:Pacientes sometidos a resecciones de colon electivas por cáncer de colon derecho sin metástasis a distancia durante el período 2010-2013. Un centro realizó escisión mesocólica completa, el resto resecciones convencionales.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la incidencia acumulada de la recidiva local únicamente, 5,2 años después de la cirugía. Los resultados secundarios fueron únicamente la recidiva a distancia y ambas,la recidiva local y a distancia diagnosticada dentro de los 180 días.RESULTADOS:Se incluyeron un total de 807 pacientes, 186 sometidos a escisión mesocólica completa y 621 resecciones convencionales. La incidencia acumulada de 5,2 años de una recidiva únicamente local fue del 3,7% (IC del 95%: 0,5 a 6,1) después de la escisión mesocólica completa en comparación con el 7,0% (5,0 a 8,9) en el grupo de control, y la reducción del riesgo absoluto de la escisión mesocólica completa fue del 3,7% (2,5-7,1; p = 0,035). La reducción del riesgo absoluto de recidiva local y distante fue del 3,4% (1,3-5,6; p = 0,0019) y de recidiva únicamente a distancia 3,1% (0,0-6,2; p = 0,052).LIMITANTES:El riesgo de recurrencia después de la resección convencional podría subestimarse por el uso de modalidades inapropiadas para el diagnostico de la recurrencia local en algunos pacientes y la duración más corta en este grupo.CONCLUSIÓN:Este estudio muestra un efecto del tratamiento causal de la escisión mesocólica completa sobre el riesgo de una recidiva únicamente local y de recidiva a distancia con o sin recidiva local. Consulte Video Resumen en http://links.lww.com/DCR/B832 . (Traducción-Dr. Mauricio Santamaria ).

Laparoscopic and open complete mesocolic excision with central vascular ligation for right colonic adenocarcinoma: a retrospective comparative study

BACKGROUND

To examine the outcome of patients treated with complete mesocolic excision (CME) with central vascular ligation (CVL) after conventional and laparoscopic surgery.

METHODS

We retrospectively evaluated stage I-IV colon adenocarcinoma patients treated by the same surgeon (L.M.) from 2013 to 2018. Postoperative complications, recurrences and survival are assessed.

RESULTS

Fifty-one patients (M/F: 24/27) underwent laparoscopic right hemicolectomy with CME (L-CME) or open CME (O-CME) plus CVL. Tumour location was the caecum in 39.2% of cases, the transverse in 23.5%, the hepatic colonic flexure in 21.5%, and the ascending colon in 15.6%. Twenty-four patients underwent L-CME while 27 underwent O-CME. More than 15 harvested lymphnodes are reported in 74.1% of O-CME patients and in 66.7% of L-CME patients (p = 0.562). Postoperative complications occurred in 7 O-CME and 5 L-CME patients, respectively (p = 0.669). Three-year overall survival, including stage IV, was of 75% versus 77.8% for L-CME and O-CME patients, respectively, while for stage I-III, was of 88.9% vs. 80% in L-CME and O-CME, respectively (p = 0.440). The median follow-up was of 2.43 years.

CONCLUSION

CME with CVL is a meticulous, complex but feasible technique. In our experience, oncological results in terms of recurrences and overall survival, after conventional and laparoscopic CME plus CVL, are comparable. Patients with stage I-III colon adenocarcinoma have a better prognostic trend especially when more than 15 lymphnodes are removed. The respect of oncological radicality and the correct indication to minimally invasive surgery are the undiscussed key outcome variables.

Robotic Complete Mesocolic Excision (CME) is a safe and feasible option for right colonic cancers: short and midterm results from a single-centre experience

BACKGROUND

Complete mesocolic excision (CME) for right colon cancers has traditionally been an open procedure. Surgical adoption of minimal access CME remains limited due to the technical challenges, training gaps and lack of level-1 data for proven benefits. Currently there is limited published data regarding the clinical results with the use of robotic CME surgery. Aim To report our experience, results and techniques, highlighting a clinical and oncological results and midterm oncological outcomes for robotic CME.

AIM

To report our experience, results and techniques, highlighting a clinical and oncological results and midterm oncological outcomes for robotic CME.

METHODS

All patients undergoing standardised robotic CME technique with SMV first approach between January 2015 and September 2019 were included in this retrospective review of a prospectively collected database. Patient demographics, operative data and clinical and oncological outcomes were recorded.

RESULTS

Seventy-seven robotic CME resections for right colonic cancers were performed over a 4-year period. Median operative time was 180 (128-454) min and perioperative blood loss was 10 (10-50) ml. There were 25 patients who had previous abdominal surgery. Median postoperative hospital stay was 5 (3-18) days. There was no conversion to open surgery in this series. Median lymph node count was 30 (10-60). Three (4%) patients had R1 resection. There was one (1%) local recurrence in stage III disease and 4(5%) distal recurrence in stage II and stage III. There was no 30- or 90-day mortality. Three-year disease-free survival was 100%, 91.7% and 92% for stages I, II and III, respectively. Overall survival was 94%.

CONCLUSIONS

Robotic CME is feasible, effective and safe. Good oncological results and improved survival are seen in this cohort of patients with a standardised approach to robotic CME.

Minimally invasive complete mesocolic excision and central vascular ligation (CME/CVL) for right colon cancer

Total mesorectal excision (TME) is the standard of care in rectal cancer surgery. Complete mesocolic excision and central vascular ligation (CME and CVL) are surgical concepts that are extrapolated from the principles of TME. Increasingly adopted by surgical units worldwide, laparoscopic CME/CVL for right sided colon cancer is a challenging procedure that requires meticulous dissection by the surgeon and detailed knowledge of the colonic vascular anatomy. This review article addresses the main issues pertaining to this surgical technique and also discusses steps on how to perform this operation safely.

The impact of anastomotic leakage on recurrence and long-term survival in patients with colonic cancer: A systematic review and meta-analysis

BACKGROUND/OBJECTIVE

Anastomotic leakage (AL) is one of the most severe complications following colorectal cancer surgery and is associated with increased short and long term mortality. The literature is conflicting regarding increased risk of recurrence after AL. The aim of this study was to systematically review the impact of anastomotic leakage on the risk of local or distant recurrence and overall survival, cancer specific survival, and disease-free survival.

METHODS

A systematic review and meta-analysis was conducted in accordance with the PRISMA guidelines. A systematic search in PubMed, EMBASE, CINHAL, and The Cochrane Library was performed and meta-analyses were performed on all outcomes including analysis based on time-to-event data.

RESULTS

A total of eighteen cohort studies, including 69,047 patients whereof 2,555 patients had anastomotic leakage, were included. Meta-analysis demonstrated no significant effects of anastomotic leakage on local recurrence (RR 1.16, 95% CI 0.84-1.59) or distant recurrence (RR 1.44, 95% CI 0.52-3.96). Anastomotic leakage decreased overall survival (RR 0.85, 95% CI 0.77-0.94), disease free survival (RR 0.80, 95% CI 0.72-0.89), and cancer specific survival (RR 0.90, 95% CI 0.83-0.97). A time-to-event analysis was conducted on available data and the results were congruent with the frequency analyses.

CONCLUSION

Anastomotic leakage following colonic resections is significantly associated with impaired overall survival, disease free survival and cancer specific survival. The study did not show any statistically significant association between anastomotic leakage and recurrence.