Comprehensive standardization of complete mesocolic surgery is now possible

Abstract

Dear Sir,We read with great interest the article of Storli et al. [1].The article compares two distinct surgical techniques forthe treatment of stage I–II colon cancer and very elegantlydemonstrates significant improvements in 3-year overallsurvival, and disease-free survival in patients who under-went a complete mesocolic excision (CME) with a high(apical) vascular tie (D3) when compared with conven-tional (standard, i.e., D2 resection) approach (n = 105).Although CME appears promising, the authors unfortu-nately did not describe the technique in any detail, nor didthey acknowledge the importance of adhering to funda-mental mesocolic surgical tissue planes while performingan oncologic colonic mobilization. Furthermore, the studyonly utilized lymph node yield as a surrogate measure ofradical resection and failed to provide any histologicaldescriptions of the surgical specimens.Despite the strong evidence supporting CME such asthat provided by Storli et al. [1], CME is still surrounded bycontroversy and has not as yet become the gold standard(unlike total mesorectal excision for rectal cancer). This islargely due to misconceptions related to mesocolic anat-omy, indoctrinated in mainstream literature, and whichhave hampered a clear understanding of planes utilized incolonic mobilization. Clinical papers such as that publishedby Storli et al. [1] justify a formal appraisal of the meso-colic anatomy which in turn can provide a level playingfield for surgeons to accurately conceptualize the meso-colon and associated surgical tissue planes and thereforerationalize the importance of performing a safe andeffective CME.Our group has recently provided novel insights into themesocolic anatomy. Interestingly, our gross anatomicfindings of the mesocolon are contrary to those described bySir Frederick Treves in 1889 (which are part of mainstreamliterature), and in fact mostly echo the mesocolic descrip-tions provided by Carl Toldt 10 years prior to Treves, in1879 [2]. We have noted that the mesocolon is continuousfrom the ileocaecal to rectosigmoid level; a mesentericconfluence occurs at the ileocaecal and rectosigmoid junc-tion as well as at the hepatic and splenic flexures; eachflexure (and ileocaecal junction) is a complex of peritonealand omental attachments to the colon centered on a mes-enteric confluence; the proximal rectum originates at theconfluence of the mesorectum and mesosigmoid; and themesocolic plane of Toldt’s fascia separates the entireapposed mesocolon from the true retroperitoneal compart-ment [3]. Histologically, the mesocolon is separated bydistinct mesothelial and connective tissue layers that sepa-rate it from the underlying retroperitoneum [4]. Further-more, we have systematically determined and quantified thedistribution of lymphatic vessels within the mesentericorgan and underlying Toldt’s fascia and shown a richlymphatic network within all levels of the mesenteric con-nective tissue lattice [2].The exciting clinical findings provided by Storli et al.[1] reinforce the argument for performing a safe andeffective CME that adheres to a crystallized comprehen-sion of mesocolic anatomy. The findings of Storli, when