Excision For Right-sided Colon Cancer Research Articles

Early recurrence after complete mesocolic excision for right-sided colon cancer with D3 lymphadenectomy: pattern, risk factors, prognostic impact, and individualized follow-up.

The definition of early recurrence (ER) for right-sided colon cancer patients after complete mesocolic excision (CME) with D3 lymphadenectomy remains unclear. This study aimed to define the optimal time for ER and clarify risk factors for ER and post-recurrence survival (PRS). A total of 578 right-sided colon cancer patients who underwent CME with D3 lymphadenectomy were included. The minimum p value method was used to evaluate theme optimal time of recurrence-free survival to discriminate between ER and late recurrence (LR). Risk factors for ER were determined by a logistics regression model. The PRS was compared between ER and LR. The optimal time to define ER was 15months (P = 1.8697E-7). 93 patients developed tumor recurrence, 46 patients had ER (≤15months) and 47 patients had LR (>15months). Preoperative serum CA19-9 > 37U/mL (OR = 3.185, P = 0.001), pathological N+ stage (OR = 3.042, P = 0.027), and lymphovascular invasion (OR = 2.182, P = 0.027) were identified as independent risk factors associated with ER. Age > 75years (HR = 1.828, P = 0.040), pathological N2 stage (HR = 1.850, P = 0.009), multiple sites of recurrence (HR = 1.680, P = 0.024), and time to recurrence ≤15months (HR = 2.018, P = 0.043) were significantly associated with worse PRS in patients with recurrence. 15months was the optimal time to distinguish ER and LR. ER was associated with a poor PRS. Elevated preoperative serum CA19-9 level, pathological N+ stage, and lymphovascular invasion were significantly predictive of ER.

Association between plane of mesocolic dissection and recurrence after complete mesocolic excision for right-sided colon cancer: a cohort study.

Dissection in the mesocolic plane is considered by some medical professionals to be crucial in complete mesocolic excision. We aimed to assess whether intramesocolic plane dissection is associated with a risk of recurrence after complete mesocolic excision for right-sided colon cancer. This is a single-centre study based on prospectively registered data on patients undergoing resection for Union for International Cancer Control Stage I-III right-sided colon adenocarcinoma during the period 2010-2017. Patients were stratified in an intramesocolic plane group or a mesocolic plane group based on a prospective assessment of fresh specimens by a pathologist. Primary outcome was the 4.2year risk of recurrence after inverse probability treatment weighting and competing risk analyses. Of 383 patients, 4 (1%) were excluded as the specimen was assessed as muscularis propria plane, 347 (91.6%) specimens were deemed as mesocolic and 32 (8.4%) as intramesocolic. The 4.2year cumulative incidence of recurrence after inverse probability treatment weighting was 9.1% (95% CI 6.0%-12.1%) in the mesocolic group compared with 14.0% (3.6%-24.5%) in the intramesocolic group with an absolute risk difference in favour of mesocolic plane dissection of 4.9% (-5.7to 15.6, p=0.37). No difference was observed in the risk of local recurrence, death before recurrence or overall survival after 4.2 years between the two groups. Mesocolic plane dissection can be achieved in more than 90% of patients. The classification seems to be a guide for good surgical practice and not to be used for research purposes.

Step by step revisiting and standardizing the robotic approach of complete mesocolic excision for right-sided colon cancer.

Step by step revisiting and standardizing the robotic approach of complete mesocolic excision for right-sided colon cancer.

Mid-term oncological outcomes after complete versus conventional mesocolic excision for right-sided colon cancer: a propensity score matching analysis.

The correct extent of mesocolic dissection for right-sided colon cancer (RCC) is still under debate. Complete mesocolic excision (CME) has not gained wide diffusion, mainly due to its technical complexity and unclear oncological superiority. This study aims to evaluate oncological outcomes of CME compared with non-complete mesocolic excision (NCME) during resection for I-III stage RCC. Prospectively collected data of patients who underwent surgery between 2010 and 2018 were retrospectively analysed. 1:1 Propensity score matching (PSM) was used to balance baseline characteristics of CME and NCME patients. The primary endpoint of the study was local recurrence-free survival (LRFS). The two groups were also compared in terms of short-term outcomes, distant recurrence-free survival, disease-free survival, and overall survival. Of the 444 patients included in the study, 292 were correctly matched after PSM, 146 in each group. The median follow-up was 45months (IQR 33-63). Conversion rate, complications, and 90-day mortality were comparable in both groups. The median number of lymph nodes harvested was higher in CME patients (23 vs 19, p = 0.034). 3-year LRFS rates for CME patients was 100% and 95.6% for NCME (log-rank p = 0.028). At 3years, there were no differences between the groups in terms of overall survival, distant recurrence-free survival, and disease-free survival. Our PSM cohort study shows that CME is safe, provides a higher number of lymph nodes harvested, and is associated with better local recurrence-free survival.

Chylous ascites after complete mesocolic excision for right-sided colon cancer with D3 lymphadenectomy: Aretrospective cohort-study.

This retrospective study was designed to evaluate risk factors of the occurrence and severity of chylous ascites after complete mesocolic excision (CME) and D3lymphadenectomy in patients with right-sided colon cancer. Consecutive patients receiving CME and D3lymphadenectomy for right-sided colon cancer were included. Risk factors of the occurrence and severity of chylous ascites by using logistic analysis were assessed. A nomogram predicting chylous ascites was constructed. Among 661 patients included in the study, postoperative chylous ascites occurred in 48 (7.3%) patients. Logistic regression analysis demonstrated that prognostic nutritional index (PNI≤47, OR=2.172, p=0.016), laparoscopic surgery (OR=2.798, p=0.034), operating time (>225min, OR=2.645, p=0.002), and apical lymph node (APN) metastasis (OR=3.698, p=0.034) were correlated with the occurrence of postoperative chylous ascites. A nomogram predicting postoperative chylous ascites was constructed (C-index 0.701). 31.2% (15/48) of patients with chylous ascites were resolved in more than 7days. The number of retrieved lymph nodes (OR=1.074, 95% CI: 1.002-1.152, p=0.044) and PNI≤47 (OR=7.890, 95% CI: 1.224-50.869, p=0.030) were independently predictive of prolonged chylous ascites resolution (≥7days). In our series, 7.3% of patients developed chylous ascites after right hemicolectomy with CME and D3 lymphadenectomy. Laparoscopic surgery, PNI, operation time, and APN metastasis were independently predictive of postoperative chylous ascites. Lower PNI and more retrieved lymph nodes were correlated with prolonged resolution of chylous ascites.

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

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. The goal of this study was to assess to what extent complete mesocolic excision contributes to the risk of local recurrence. 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. Data were collected from the 4 public colorectal cancer centers in the Capital Region of Denmark. 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. 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. 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). 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. 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 ).

Recurrence after complete mesocolic excision for right‐sided colon cancer: post hoc sensitivity analyses—early recurrence, surgery by specialist and dissection in the mesocolic plane

The aim was to investigate whether the previously reported causal treatment effect of complete mesocolic excision on the risk of recurrence was biased by inclusion of patients with potentially undiagnosed disseminated disease at the time of surgery, by non-specialist surgery, or caused by mesocolic plane dissection. A population of 1069 patients, 813 undergoing conventional resection and 256 complete mesocolic excision for colon cancer during the period 2008-2013, was stepwise reduced in the following order by excluding patients with recurrence diagnosed within 6months of the resection, having surgery performed by a non-specialist without supervision, and specimens assessed as not being mesocolic plane dissection. The primary outcome measure was risk of recurrence after 5.2years using competing risk analyses. The absolute risk reduction of complete mesocolic excision was 6.0% (95% CI 1.8-10.2; P=0.0049) after excluding patients with recurrence within 6months of resection, 6.1% (95% CI 1.9-10.4; P=0.0045) after excluding non-specialist surgery, and 7.5% (95% CI 2.9-12.0; P=0.0013) after the exclusion of patients whose specimens were assessed as dissections not being performed in the mesocolic plane. The absolute risk reduction of recurrence after complete mesocolic excision for right-sided colon cancer in our previous study was not biased by potentially undiagnosed disseminated disease at the time of surgery or non-specialist surgery, and was not solely caused by dissection in the mesocolic plane. Central vascular dissection with central lymphadenectomy seems a major factor for better oncological results.

Laparoscopic D3 dissection and complete mesocolic excision for right-sided colon cancer based on surgical anatomy

In addition to total mesenteric excision (TME) for rectal cancer, D3 dissection [central vascular ligation (CVL)] and complete mesocolic excision (CME) are two critical aspects of right hemicolectomy for right-sided colon cancer (RCC). Here we describe a safe procedure for laparoscopic right hemicolectomy using a caudal approach with D3 dissection along the superior mesenteric artery (SMA).

5-year outcome after complete mesocolic excision for right-sided colon cancer: a population-based cohort study.

The benefits of extensive lymph node dissection as performed in complete mesocolic excision are still debated, although recent studies have shown an association with improved long-term outcomes. However, none of these studies had an intention-to-treat design or aimed to show a causal effect; therefore in this study, we aimed to estimate the causal oncological treatment effects of complete mesocolic excision on right-sided colon cancer. We did a population-based cohort study involving prospective data collected from four hospitals in Denmark. We compared the oncological outcome data of patients at one centre performing central lymph node dissection and vascular division after almost complete exposure of the proximal part of the superior mesenteric vein (ie, the complete mesocolic excision group) with three other centres performing conventional resections with unstandardised and limited lymph node dissection (ie, non-complete mesocolic excision; control group). We included data for all patients in the Capital Region of Denmark undergoing elective curative-intent right-sided colon resections for stages I-III colon cancer, as categorised by the Union for International Cancer Control (UICC; 5th edition), from June 1, 2008, to Dec 31, 2013. Patients were followed-up for 5·2 years after surgery. The primary outcome was the cumulative incidence of recurrence after 5·2 years of surgery. Inverse probability of treatment weighting and competing risk analyses were used to estimate the possible causal effects of complete mesocolic excision. This study is registered with ClinicalTrials.gov, number NCT03754075. 1069 patients (813 in the control group and 256 in the complete mesocolic excision group) underwent curative-intent elective surgery for right-sided colon cancer during the study period. None of the patients were lost to follow-up regarding survival or recurrence status, and consequently no patient was censored in the analyses. The 5·2-year cumulative incidence of recurrence was 9·7% (95% CI 6·3-13·1) in the complete mesocolic excision group compared with 17·9% (15·3-20·5) in the control group, and the absolute risk reduction of complete mesocolic excision after 5·2 years was 8·2% (95% CI 4·0-12·4; p=0·00015). In the control group, 145 (18%) of 813 patients were diagnosed with a recurrence and 281 (35%) died during follow-up, whereas in the complete mesocolic excision group 25 (10%) of 256 patients were diagnosed with a recurrence and 75 (29%) died during follow-up. This study shows a causal treatment effect of central mesocolic lymph node excision on risk of recurrence after resection for right-sided colon adenocarcinoma. Complete mesocolic excision has the potential to reduce the risk of recurrence and improve long-term outcome after resection for all UICC stages I-III of right-sided colon adenocarcinomas. The Tvergaard Fund, Helen Rude Fund, Krista and Viggo Petersen Fund, Olga Bryde Nielsen Fund, and Else and Mogens Wedell-Wedellsborg Fund.

Laparoscopic Complete Mesocolic Excision for Right-Sided Colon Cancer: Analysis of Feasibility and Safety from a Single Western Center

BackgroundColectomies performed according to complete mesocolic excision (CME) principles have demonstrated an improvement in the quality of surgical specimen and a potential improvement of long-term results. Laparoscopic CME right hemicolectomy is considered a demanding procedure and adopted in few centers from the West. The main purpose of this paper is to present a video showing our technique for laparoscopic CME right hemicolectomy and to analyze our short-term results to prove its safety. MethodsData from 38 patients operated on at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust, between September 2014 and February 2017, were included in the study. ResultsIn the present series, 37% of patients were ≥75 years old, 32% of patients were ASA class 3, 46% of patients had ≥2 comorbidities, 30% of patients had BMI >28 and 17% of patients had ≥2 previous abdominal surgeries. Despite these unfavorable clinic characteristics, no mortality was observed, Clavien-Dindo ≥3 complications occurred in 13.1% and redo surgery in 5.3%. Good quality specimens were obtained with a mean (SD) length of 34.5±7.5 cm, a proximal margin of 16.8±9.2 cm and a distal margin of 14.3±6.4 cm. The mean (SD) number of harvested lymph nodes was 24.3 (8.3). ConclusionsWhen implemented in a Western center, laparoscopic CME right hemicolectomy is feasible and safe and allows obtaining good quality specimens.

Totally robotic complete mesocolic excision for right-sided colon cancer.

Complexity and operative risks of complete mesocolic excision (CME) seem to be important drawbacks to generalize this procedure in the surgical treatment of right colon cancer. Robotic systems have been developed to improve quality and outcomes of minimal invasive surgery. The aim of this study was to evaluate the feasibility of robotic right-sided CME and present our initial experience. A retrospective review of 37 patients undergoing totally robotic right-sided CME between February 2015 and November 2017 was performed. All the operations were carried out using the key principles of both CME with intracorporeal anastomosis and no-touch technique. Data on perioperative clinical findings and short-term outcomes were analyzed. There were 20 men and 17 women with a mean age of 64.4 ± 13.5years and a body mass index of 26.8 ± 5.7kg/m2. The mean operative time and estimated blood loss were 289.8 ± 85.3min and 77.4 ± 70.5ml, respectively. Conversion to laparoscopy occurred in one patient (2.7%). All the surgical margins were clear and the mesocolic plane surgery was achieved in 27 (72.9%) of the cases. The mean number of harvested lymph nodes was 41.8 ± 11.9 (median, 40; range 22-65). The mean length of hospital stay was 6.6 ± 3.7days. The intraoperative and postoperative complication rates were 5.4 and 21.6%, respectively. We believe that use of robot for right-sided CME is feasible and appears to provide remarkably a high number of harvested lymph nodes with good specimen quality.

Laparoscopic complete mesocolic excision for right-sided colon cancer using a cranial approach: anatomical and embryological consideration.

Complete mesocolic excision (CME) with central vascular ligation (CVL) should be employed for the treatment of colon cancer patients because of its superior oncological outcomes. However, this technique is technically challenging in laparoscopic right hemicolectomy because of the anatomical complexity of the transverse mesocolon. We focused on the embryology and anatomy of the transverse mesocolon to overcome the difficulty of this surgery. The validity and efficacy of a cranial approach in achieving CME with CVL in laparoscopic right hemicolectomy was elucidated from the embryological point of view. In total, 28 consecutive patients with right-sided colon cancer were treated by laparoscopic right hemicolectomy using a cranial approach. There were no conversion to open surgery or switching to another approach. Using this approach, torsion and fusion of the transverse mesocolon, which occurred during embryological development, could be reversed and the complex anatomy of the transverse mesocolon could be simplified before performing CVL of colonic vessels. A cranial approach is considered valid and useful for CME with CVL in laparoscopic right hemicolectomy from the embryological point of view.

Long-term oncologic results of laparoscopic D3 lymphadenectomy with complete mesocolic excision for right-sided colon cancer with clinically positive lymph nodes.

To assess surgical outcomes of patients undergoing D3 lymph node dissection and complete mesocolic excision for the treatment of right-sided colon cancer in the context that both procedures were performed laparoscopically. 244 consecutive patients with clinically staged III right-sided colon cancer were recruited to undergo the laparoscopic D3 lymph node dissection with complete mesocolic excision. Postoperatively, the patients were stratified as N0, N1, N2, and N3 groups according to the level of lymph node metastasis, prospectively followed up for more than 5 years, and compared. The 5-year cumulative recurrence rate and the estimated time-to-recurrence [mean (95 % confidence interval)] was 16.6 % (n = 7/42), 113.8 (101.4-126.2) months in N0 group; 21.3 % (n = 17/80), 108.9 (99.1-118.7) months in N1 group; 43.2 % (n = 32/74), 85.4 (73.0-97.8) months in N2 group; and 52.0 % (n = 25/48), 65.2 (49.0-81.4) months in N3 group. When N1 and N0 groups of patients were lumped together, and compared with patients with N2 or N3 metastasis, we found that the latter were with a significantly higher recurrence rate (p < 0.0001). D3 lymph node dissection with complete mesocolic excision could assure the harvest of sufficient number (n = 34.4 ± 8.4) of lymph nodes for precise pathologic cancer staging. Skip lymph node metastasis was detected in 19.8 % (n = 40/202) of patients, and such surgical procedures facilitated up-staging in 4.5 % (n = 11/244) of patients. The present study encourages the dissemination of such concepts to surgical oncologists dealing with colorectal cancer through didactic education, and international consensus meeting is therefore mandatory to optimize the surgery of colon cancer.

Right hemicolectomy with central vascular ligation in colon cancer

We read with interest the report by Spasojevic et al. [1] describing the origin of the right colic artery and the implications for oncologic resection of the ascending colon. Using computed tomographic (CT) angiography, the authors demonstrated a right colic artery arising from the superior mesenteric artery in 54% of patients, with this vessel passing posterior to the superior mesenteric vein in only 7.4% of cases. Contrary to the authors’ suggestion, we did not fail to report the described variations in our series of extended lymphadenectomy for right colon cancer [2]. Rather, it is our surgical experience that a true right colic artery is rarely seen. Our finding of a true right colic artery in approximately 15% of patients is consistent with that of previous reports [3, 4]. Perhaps the discrepancy between our experience and that of Spasojevic et al. [1] is partly a matter of definition. We and others have observed, for example, that the middle colic artery has many variations. VanDamme and Bonte [5] described two or more middle colic arteries with separate origins in 25% of their patients. When performing a complete mesocolic excision for right-sided colon cancer, we do not routinely divide such middle colic vessels centrally because lymph node metastases are not seen in this distribution. When, however, a true right colic artery originating from the superior mesenteric artery and passing posterior to the superior mesenteric vein is identified, then a central ligation should be performed. By rotating the fully mobilized colon in a clockwise direction, the origin of both the right colic artery (when present) and the ileocolic artery may be fully exposed to allow true central ligation [2]. Thus, an arterial stump with potentially involved lymph nodes is never missed. In the procedure, the autonomic nerve plexus enveloping the superior mesenteric artery must be preserved to avoid postoperative diarrhea. As correctly observed by Spasojevic et al. [1], the right mesocolon is not clearly defined at its medial aspect. When a complete mesocolic excision for right-sided colon cancer is performed, the fascia on both sides of the mesocolon, including the contained ileocolic artery (and the right colic artery when present) must be actively divided in a plane parallel to the mesenteric root. In this way the excision of the mesocolon and its mesocolic lymph nodes is maximized.