Complete mesocolic excision with central venous ligation/D3 lymphadenectomy for colon cancer – A comprehensive review of the evidence

Abstract

Complete mesocolic excision (CME), central vascular ligation (CVL) and D3 lymphadenectomy refers to mesocolic excision within an intact mesenteric fascia, ligation of the vascular origin, and removal of all lymph nodes along the arterial root. While denoting different techniques, the terms CME, CVL and D3 are often used interchangeably. This review aims to provide the most up-to-date summary on CME.A total of nine meta-analyses were published from 2020 to 2021, as well as preliminary results from three randomised trials. CME invariably resulted in a greater lymph node yield compared to non-CME surgery. Other quality indicators were poorly reported, including completeness of the mesocolic plane. CME improved short to long term survival outcomes. Three meta-analyses showed a reduction in local recurrence rates with CME, and one demonstrated improved incidence of distant recurrence. Analysis of the evidence suggests a benefit for routine CME surgery in all but the earliest colon cancers.CME was associated with a longer surgical duration but reduced operative blood loss. All but two meta-analyses showed no difference in overall complication rates with CME. While vascular, lymphatic and autonomic injury are potential concerns during CME, there was consistently no significant difference between the rates of anastomotic leakage and postoperative mortality as well as the duration of post-operative hospital stay between CME and conventional colectomy. Long-term bowel function and quality of life was similar between both techniques.A substantial learning curve exists for CME. Standardised training regimes are necessary for mastery of the technique to achieve the best outcomes.