Complete mesocolic excision and extended lymphadenectomy: Where should we stand?

Debate regarding the risks and merits of complete mesocolic excision and extended lymphadenectomy is ongoing, particularly for right-sided colon cancers. In this article, we hope to provide a succinct yet encompassing review of the relevant literature. We posit that complete mesocolic excision with D3 dissection is indicated in select patients with colon cancers, particularly those distal to the cecum.

Hasfalat infiltráló coecum tumor eltávolítása komplett mesocolicus excisióval, hasfali resectióval és musculus tensor fasciae latae musculocutan lebenyes rekonstrukcióval

A korai és lokálisan előrehaladott colontumorok esetében a megfelelő onkológiai minőségű sebészi resectio a kezelés központi eleme. Jobb oldali vastagbél tumorok sebészi ellátásában - a kedvezőbb hosszú távú onkológiai eredmények elérése céljából - egyre szélesebb körben elfogadott a Hohenberger által 2009-ben elsőként publikált "complett mesocolicus-excisio" (CME) és centrális érlekötés (CVL).Esetünkben egy 78 éves nőbeteg jobb alhasi faeculens váladékozása miatt indult kivizsgálása során a hasfalat szélesen infiltráló coecum tumor igazolódott. Az Onkoterápiás Bizottság - tekintettel az egyértelmű távoli áttét hiányára, a beteg jó általános állapotára, a fennálló colo-cutan sipolyra és egyértelmű irresecabilitási jelek hiányára - műtétet javasolt. A kuratív intenció és kellő radikalitás érdekében, komplett mesocolicus excisio és kiterjesztett hasfali resectio mellett döntöttünk. A műtét során a kialakult hasfali defektus rekonstrukciójához a jobb comb lateralis felszínéről tensor fasciae lateae musculocutan (TFL) lebenyt preparáltunk. A hasfali defektust, mind a fascia, mind a subcutis-cutis rétegében helyreállítottuk, a donor területet primeren zártuk. A posztoperatívumban a lebeny distalis végén vénás pangás jelei majd felületes necrosis mutatkozott. Sorozatos necrectomia és negatívnyomás-terápia (NPWT) mellett a hasfal végig intakt maradt és per secundam gyógyult.Megfelelő betegszelekció esetén, centrumokban elvégezve - onkosebész és helyreállító plasztikai sebész szoros együttműködésével - a radikális műtét kiterjesztett hasfali resectiót igénylő jobb colonfél tumoroknál is biztonsággal elvégezhető.

Selective approach to arterial ligation in radical sigmoid colon cancer surgery with D3 lymph node dissection: A multicenter comparative study

Objectives

Radical surgery for sigmoid colon cancer is commonly performed with complete mesocolic excision (CME) and apical lymph node dissection, reached by central vascular ligation (CVL) of the inferior mesenteric artery (IMA) and associated extended left colon resection. However, IMA branches can be ligated selectively according to tumor location with D3 lymph node dissection (LND), economic segmental colon resection and tumorspecific mesocolon excision (TSME) if IMA is skeletonized. This study aimed to compare left hemicolectomy with CME and CVL and segmental colon resection with selective vascular ligation (SVL) and D3 LND.

Material and Methods

Patients (n= 217) treated with D3 LND for adenocarcinoma of the sigmoid colon between January 2013 and January 2020 were included in the study. The approach to vessel ligation, colon resection and mesocolon excision was based on tumor location in the study group, while in the comparison group, left hemicolectomy with routine CVL was performed. Survival rates were estimated as the primary endpoints of the study. Long- and short-term surgery-related outcomes were evaluated as the secondary endpoints of the study.

Results

The studied approach to the IMA branch ligation was associated with a statistically significant decrease in intraoperative complication rates (2 vs 4, p= 0.024), operative procedure length (225.56 ± 80.356 vs 330.69 ± 175.488, p <0.001), and severe postoperative morbidity (6.2% vs 19.1%, p= 0.017). Meanwhile, the number of examined lymph nodes significantly increased (35.67 vs 26.69 per specimen, p <0.001). There were no statistically significant differences in survival rates.

Conclusion

Selective IMA branch ligation and TSME resulted in better intraoperative and postoperative outcomes with no difference in survival rates.

Complete mesocolic excision in comparison with conventional surgery for right colon cancer: a nationwide multicenter study of the Italian Society of Surgical Oncology colorectal cancer network (CoME-in trial). Study protocol for a randomized controlled trial

Complete mesocolic excision with central vascular ligation, or simply CME, includes the sharp dissection along the mesocolic visceral and parietal layers, with the ligation of the main vessels at their origins. To date, there is low evidence on its safety and efficacy. This is a study-protocol of a multicenter, randomized, superiority trial in patients with right-sided colon cancer. It aims to investigate whether the complete mesocolic excision improves the oncological outcomes as compared with conventional right hemicolectomy, without worsening early outcomes. Data on efficacy and safety of complete mesocolic excision are available only from a large trial recruiting eastern patients and from a low-volume single-center western study. No results on survival are still available. For this reason, complete mesocolic excision continues to be a controversial topic in daily practice, particularly in western world. This new nationwide multicenter large-volume trial aims to provide further data on western patients, concerning both postoperative and survival outcomes.

Initial Retrocolic Endoscopic Tunnel Approach As an Ergonomic and Oncologically Apt Laparoscopic Technique for Resection of Malignant Right Colonic Lesions: An Experience from a University Hospital

Introduction: Radical minimal access cancer surgery has demonstrated similar outcomes as open surgery of late, but with less morbidity, improving the quality of life especially in patients with colorectal cancer. Initial retrocolic endoscopic tunnel approach (IRETA) has been described in the literature by Palanivelu et al. as a laparoscopic technique for radical resection of malignant right colonic lesions (MRCL) following the modified concept of medial to lateral dissection. In this work, the authors present their experience of this ergonomic surgical technique. Materials and Methods: To begin with, retrocolic dissection was carried out to free and dissect the ascending colon up to hepatic flexure with the reflection of the peritoneum over the right colon along the white line of Toldt with abdominal wall kept intact initially to sustain intracorporeal specimen steadiness. Subsequently, the specimen is lifted medially in a distinct lymphovascular sheath, leading to high ligation of ileocolic, right colic, and the right branch of the middle colic vein with a consequent definite en bloc thorough removal of the lesion. The specimen was delivered through a transumbilical incision. Results: Ten patients (age 45.4 ± 5.6 years) underwent resection by the IRETA technique with a mean operating time of 185 ± 30 minutes and blood loss of 90 ± 20 mL. Mean hospital stay was 6 days. R0 surgical resection was achieved in all patients with proper marginal clearance. Ninety percent had adequate lymph nodal resection. One patient had an intraoperative complication and n = 3 patients developed postoperative ileus. Adjuvant chemotherapy was given and there is no recurrence on 28 months of average follow-up. Conclusion: With the increasing use of laparoscopic surgery for the management of colorectal cancers, the IRETA technique appears to be an ergonomic and oncologically robust procedure for the removal of MRCL. The presented data set needs to be increased with at least 5 years of follow-up to establish long-term surgical outcomes.

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.

Laparoscopic Versus Open Right Colectomy for Cancer in the Era of Complete Mesocolic Excision with Central Vascular Ligation: Pathology and Short-Term Outcomes

Background: Colectomies performed according to complete mesocolic excision with central vascular ligation (CME-CVL) principles have been associated with enhanced oncologic outcomes. Nonetheless, laparoscopic CME-CVL right hemicolectomy has not been widely adopted. We aimed to compare the perioperative and pathology outcomes of laparoscopic and open CME-CVL right hemicolectomy. Materials and Methods: We compared data from a prospectively collected database regarding patients who underwent either laparoscopic or open CME-CVL right hemicolectomy for nonmetastatic right colon cancer in a University Hospital, between January 2012 and December 2018. Results: A total of 130 consecutive patients were included in the study. Of them, 73 patients underwent laparoscopic and 57 patients open right colectomy, following the CME-CVL principles. The laparoscopic approach was associated with less hospital stay (6.6 versus 9.1 days; P < .001) and septic complications (P = .046), at a cost of an increased operative time (180 versus 125.1 minutes; P < .001). Patients treated with either open or laparoscopic approach presented similar outcomes regarding pathology endpoints. In fact, both groups demonstrated similar R0 resection rate (P = .202), number of harvested and positive lymph nodes (P = .751 and P = .734, respectively), number of harvested lymph nodes at the level of D1 and D2 lymph node dissection (P > .05), rate of vascular (P = .501), and perineural infiltration (P = .956). Furthermore, no difference was found regarding the rate of intact mesocolic plane (P = .799), along with the tumor diameter (P = .154) and the length of specimen (P = .163). Conclusion: Laparoscopic CME-CVL right hemicolectomy appears to offer certain advantages in short-term outcomes compared to open procedure. Pathology outcomes did not differ between the two approaches. Future studies should further evaluate their long-term outcomes.

Selective central vascular ligation (D3 lymphadenectomy) in patients undergoing minimally invasive complete mesocolic excision for colon cancer: optimizing the risk-benefit equation

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.

Results of a pilot study and bi-institutional cooperation

INTRODUCTION

Complete mesocolic excision (CME) is generally accepted as state of the art in colon cancer surgery. However, the long-term impact of CME has not been systematically examined. Therefore cohort studies might be a possible way to clarify any differences between conventional resections and CME. Following bilateral cooperation between the Department of Surgery/University Hospital of Erlangen and the 1^st Surgical Department of the General Hospital of Nikaia/Piraeus, including teaching activities for introduction of CME, a cohort study was performed, considering surgical quality criteria and clinical outcome.

MATERIAL AND METHODS

All patients with colon carcinomas (CME group, n = 31) referred to the 1^st Surgical Department of General Hospital, Nikaia/Piraeus, Greece for surgery from January 2012 to December 2013 were prospectively analyzed and compared with patients who underwent conventional surgery for colon cancer between January 2008 and December 2011 (non-CME group, n = 35). Patients' follow-up was at least 48 months.

RESULTS

There were significantly better results in terms of lymph node yield (CME group: 29.6 vs. non-CME group: 17.85; p < 0.001) and lymph node ratio (LNR) (CME group: 0.12 vs. non-CME group: 0.24; p < 0.001) and recurrence-free survival in favor of the CME group (CME group: n = 0 vs. non-CME group: n = 5) without any increase in surgical morbidity (CME group: n = 6 vs. non-CME group: n = 11; p = 0.10).

CONCLUSIONS

Complete mesocolic excision appears to offer a superior oncological result without any increase of postoperative morbidity and mortality. Furthermore, CME represents a surgical technique which can be established in a surgical department after previous teaching without increasing the postoperative complication rate.

Initial experience of laparoscopic right hemicolectomy with complete mesocolic excision in Singapore: a case series

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.

Vascular Structures of the Right Colon: Incidence and Variations with Their Clinical Implications

BACKGROUND AND AIMS

There is a demand for a better understanding of the vascular structures around the right colonic area. Although right hemicolectomy with the recent concept of meticulous lymph node dissection is a standardized procedure for malignant diseases among most surgeons, variations in the actual anatomical vascular are not well understood. The aim of the present review was to present a detailed overview of the vascular variation pertinent to the surgery for right colon cancer.

MATERIALS AND METHODS

Medical literature was searched for the articles highlighting the vascular variation relevant to the right colon cancer surgery.

RESULTS

Recently, there have been many detailed studies on applied surgical vascular anatomy based on cadaveric dissections, as well as radiological and intraoperative examinations to overcome misconceptions concerning the arterial supply and venous drainage to the right colon. Ileocolic artery and middle colic artery are consistently present in all patients arising from the superior mesenteric artery. Even though the ileocolic artery passes posterior to the superior mesenteric vein in most of the cases, in some cases courses anterior to the superior mesenteric artery. The right colic artery is inconsistently present ranging from 63% to 10% across different studies. Ileocolic vein and middle colic vein is always present, while the right colic vein is absent in 50% of patients. The gastrocolic trunk of Henle is present in 46%-100% patients across many studies with variation in the tributaries ranging from bipodal to tetrapodal. Commonly, it is found that the right colonic veins, including the right colic vein, middle colic vein, and superior right colic vein, share the confluence forming the gastrocolic trunk of Henle in a highly variable frequency and different forms.

CONCLUSION

Understanding the incidence and variations of the vascular anatomy of right side colon is of crucial importance. Failure to recognize the variation during surgery can result in troublesome bleeding especially during minimal invasive surgery.

Laparoscopic complete mesocolic excision with central vascular ligation in right colon cancer: Long-term oncologic outcome between mesocolic and non-mesocolic planes of surgery

AIM

To analyze our experience in translating the concept of total mesorectal excision to "no-touch" complete removal of an intact mesocolonic envelope (complete mesocolic excision), along with central vascular ligation and apical node dissection, in the surgical treatment of right-sided colonic cancers, comparing "mesocolic" to less radical "non-mesocolic" planes of surgery in respect to quality of the surgical specimen and long-term oncologic outcome.

METHOD

A total of 115 patients with right-sided colonic cancers were retrospectively enrolled from 2008 to 2013 and operated on following the intent of minimally invasive complete mesocolic excision with central vascular ligation.

RESULTS

Morbidity and mortality were 22.6% and 1.7%, respectively. Mesocolic, intramesocolic, and muscularis propria planes of resection were achieved in 65.2%, 21.7%, and 13% of cases, respectively, with significant impact for mesenteric plane of surgery on R0 resection rate (97.3%), circumferential resection margin <1 mm (2.6%), and consequent survival advantage (82.6% at 5 years) when compared to muscularis propria plane of surgery, with R0 resection rate and overall survival falling to 72% and 60%, respectively, and with circumferential resection margin <1 mm raising to 33.3%, all being statistically significant. Stratifying patients for stage of disease, laparoscopic complete mesocolic excision with central vascular ligation significantly impacted survival in patients with stage II, IIIA/B, and in a subgroup of IIIC patients with negative apical nodes.

CONCLUSION

In our experience, minimally invasive complete mesocolic excision with central vascular ligation allows for both safety and higher quality of surgical specimens when compared to less radical intramesocolic or muscularis propria planes of "standard" surgery, significantly impacting loco-regional control and thus overall survival.