Open Complete Mesocolic Excision Research Articles

Laparoscopic Versus Open Complete Mesocolic Excision with Central Vascular Ligation for Right-sided Colon Cancer: Early Postoperative Outcomes

Laparoscopic Versus Open Complete Mesocolic Excision with Central Vascular Ligation for Right-sided Colon Cancer: Early Postoperative Outcomes

Laparoscopic Complete Mesocolic Excision Without Routine Gastro-Pancreatico-Colic Trunk Dissection: Survival Outcomes and Morbidity for 567 Cases.

Purpose: It is unclear whether the principles of open complete mesocolic excision (CME) can be safely applied to laparoscopic surgery. Furthermore, definitions vary over how radical optimal CME surgery should be. We report morbidity and oncological outcomes for laparoscopic CME without routine gastro-pancreatico-colic trunk (GPCT) dissection. Materials and Methods: An observational study with consecutive data for patients with Union for International Cancer Control (UICC) stage I-III colon adenocarcinoma who underwent elective laparoscopic resection between 2006 and 2015. Data were retrieved for demographics, tumor characteristics, treatment, and histology from prospectively maintained databases. Standardized, routinely video recorded, laparoscopic resections were performed in two United Kingdom centers from The National Training Programme for Laparoscopic Colorectal Surgery. Overall survival and disease-free survival (DFS) were reported using Kaplan-Meier curves and Cox regression. Results: Laparoscopic CME was performed in 567 patients, 52.7% (288/546) women, median (interquartile range [IQR]) age 73 (65-80) years. Median (IQR) length of stay was 4 (3-5) days with 4.0 (2.2-5.7)-year follow-up. Significant DFS predictors (hazard ratio [HR]) by multivariable Cox regression were age >80 years (1.9), American Society of Anesthesiologists (ASA) 3 and 4 (HR = 1.1), right colon cancer (1.7), UICC stage III (3.4), and intramesocolic grade (2.2). Overall 4-year DFS (95% confidence interval) was 81.3% (77-85). Four-year DFS by UICC grades I, II, and III was 94.6% (89-99), 83.4% (77-88), and 72.2% (66-78), respectively (log-rank P = .001). Morbidity by Clavien-Dindo grade was III 18 (3.2%), IV 4 (0.7%) and V 7 (1.2%). Conclusion: This large series suggests standardized laparoscopic CME without routine GPCT dissection has a low morbidity and achieves equivalent outcomes to the most radical open CME techniques.

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

BackgroundTo examine the outcome of patients treated with complete mesocolic excision (CME) with central vascular ligation (CVL) after conventional and laparoscopic surgery.MethodsWe 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.ResultsFifty‐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.ConclusionCME 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.

Updates on Robotic CME for Right Colon Cancer: A Qualitative Systematic Review.

Background. Complete mesocolic excision (CME) is a surgical technique introduced with the aim of ameliorating the oncologic results of colectomy. Various experiences have demonstrated favorable oncologic results of CME in comparison with standard colectomy, in which the principles of CME are not respected. The majority of the literature refers to open or laparoscopic CME. This review analyses current evidence regarding robotic CME for right colectomy. Methods. An extensive Medline (Pub Med) search for relevant case series, restricted to papers published in English, was performed, censoring video vignettes and case reports. Results. Fourteen studies (ten retrospective, four comparative series of robotic versus laparoscopic CME) were included, with patient numbers ranging from 20 to 202. Four different approaches to CME are described, which also depend on the robotic platform utilized. Intraoperative and early clinical results were good, with a low conversion and anastomotic leak rate and a majority of Clavien–Dindo complications being Grades I and II. Oncologic adequacy of the surgical specimens was found to be good, although a homogeneous histopathologic evaluation was not provided. Conclusions. Further large studies are warranted to define long-term oncologic results of robotic right colectomy with CME and its eventual benefits in comparison to laparoscopy.

COMPARATIVE STUDY BETWEEN LAPAROSCOPIC VERSUS OPEN RIGHT HEMICOLECTOMY

Background: Colorectal cancer (CRC) incidence and mortality rates vary markedly around the world. The right colon has a thin wall, a large caliber, and its contents are liquid; thus, obstruction is a late event in right colon cancer. Also, right colonic tumors grow large enough to be palpable through the abdominal wall before other symptoms appear. Objective: To compare between laparoscopic and open complete mesocolic excision with central vascular ligation in right colon cancer as regards technical feasibility, advantages and disadvantages of both procedures. Patients and Methods: This study was conducted on 30 patients admitted to Al-Azhar University Hospitals, and diagnosed as operable right sided colon cancer. It was prospectively conducted during the period from October 2019 to June 2020, and all the procedures were done on elective basis. Informed consents were obtained from all patients included in the study which approved by the local ethics committee of Al-Azhar University Hospitals. Patients were 7 (46.7%) males and 8(53.3%) females. Their ages ranged from 51 to 71 years with a mean age of 58.33±5.88 in laparoscopic technique, and ranged from 50 to 70 years with a mean age of 59.93±5.20 in open technique. Results: There was no statistical significant difference between the studied groups regarding the mean age, gender distribution, DM, hypertension and the tumor location. There was a statistical significant difference between the studied groups regarding the incision length as the incision of the open technique was longer than the laparoscopic technique, regarding the operative time and intraoperative blood loss as the laparoscopic technique take more time than the open technique and the intraoperative blood loss during the laparoscopic technique was less than the open technique. Conclusion: Complete mesocolic exicion(CME), with central vascular ligation is the novel key factor in the multimodal management of right colon cancer, determining a significant improvement in loco-regional control of tumors and improving the long-term oncological outcome, especially in intermediate stages of disease. it is a safe, valid, and feasible surgical method for right colon cancers, associated with smaller incisions, less operative blood loss, earlier recovery after operation, and shorter hospital stay compared with Open technique. The open technique is still superior in shorter operative time and more number of harvested lymph nodes.

Outcomes of laparoscopic assisted versus open complete mesocolic excision for right sided colon cancer

Background: Complete mesocolic excision (CME) as a standard surgery for left sided colon cancer is proven however there is a great debate and deal of discussion if the extra effort needed for it in right sided colon cancer worth the gain that is achieved. We aimed in our study to assess the outcome of CME with central vascular ligation for treatment of right sided colon cancer performed either laparoscopic (lap.) assisted or by open technique.Methods: This was a prospective randomized study on sixty patients who were presented with right sided colonic cancer. Patients were divided into two groups. Group (A) open one and group (B) lap. assisted group.Results: Both groups were comparable regarding demographic data, although operative time was significantly shorter in open group (p>0.001). Lap. assisted group achieved a significant difference as regards to blood loss, incision length, duration of hospital stay, resume of oral feeding, tumor to high vascular tie as well as higher number of harvested lymph nodes with no difference in recurrence rate and overall survival rate over a period of 3 years follow up.Conclusions: The principles underlying CME are anatomical and logical as it entails return back to embryology, and the results published points to the improved survival and decreased local recurrence particularly when it is performed in the proper mesocolic plane, using of laparoscopy may help in that due to better visualization of planes thus the gain of CME even in right sided colon cancer may exceed the pain in hand skilled colorectal lap. surgeons.

Comparison of the effects of laparoscope and open complete mesocolic excision in the treatment of right colon cancer

Objective To compare the effects of laparoscope and open complete mesocolic excision (CME) in the treatment of right colon cancer. Methods The retrospective case-control study was adopted.The clinical data of 139 patients with right colon cancer who underwent CME at the Second People's Hospital of Lianyungang from January 2014 to November 2017 were collected.The patients were divided into laparoscopy group(55 cases) and open group(84 cases). The postoperative recovery and oncology efficacy were compared. Results The operation time in the laparoscopy group[(172.8±25.9)min]was longer than that in the open group[(142.3±20.6)min](t=7.387, P 0.05). There were no statistically significant differences in the cumulative recurrence rate, cumulative survival rate and cumulative survival rate between the two groups after 3 years (all P>0.05). Conclusion Laparoscopic CME is minimally invasive and quick recovery, and laparoscopic CME has the same oncologic clearance effects, and is worthy of clinical application. Key words: Colon neoplasm; Surgical procedures, operative; Mesocolon; Laparocopes; Postoperative complications; Comparative effectiveness research

Laparoscopic versus open complete mesocolic excision with central vascular ligation in right colon cancer

Background: The purpose of this study was to compare between laparoscopic and open complete mesocolic excision (CME) with central vascular ligation (CVL) in right colon cancer.Methods: From January 2016 to December 2018, a prospective cohort study of 60 patients who diagnosed as operable right sided colon cancer was performed. The patients were classified into laparoscopic CME with CVL and open CME with CVL groups. Demographic variables, comorbidities, tumor location, intraoperative parameters, duration of hospital study, histopathological findings, postoperative complications and follow up data were compared between the two groups. Demographic variables included age and sex distribution. Intraoperative parameters included incision length, operative time and operative blood loss.Results: 60 patients were selected in this study. Both groups were the same in the age and sex distribution, potential comorbidities and tumor location. Patients in the Laparoscopic CME with CVL group had shorter incision lengths, longer operative times, less operative blood loss, shorter hospital stay, less number of retrieved lymph nodes , the same TNM (tumor nodes metastasis) classifications, similar histopathological findings and comparable incidence of postoperative complications.Conclusions: Laparoscopic CME with CVL procedure is a safe, valid and feasible surgical method for right colon cancers.

Safety and Short-term Efcacy of a Laparoscopic Complete Mesocolic Excision for the Surgical Treatment of Right Hemicolon Cancer

Objective: This study was designed to evaluate the safety and short-term efficacy of a laparoscopic complete mesocolic excision (CME) in patients with right hemicolon cancer. Methods: A total of 88 patients with right hemicolon cancer were retrospectively reviewed. Forty patients underwent laparoscopic CMEs, and 48 patients underwent open CMEs. The clinical data were analyzed and the outcomes were compared between the two groups. Results: There was no significant difference between the laparoscopic CME group and open CME group with regard to the harvested lymph node number (16.60±3.20 vs. 15.33±3.10, respectively, P=0.060), hospital stay length (18.15±5.17 days vs. 17.21±4.47 days, respectively, P=0.360), and postoperative complications (10.0% vs. 10.4%, respectively, P=0.950). The operation time in the laparoscopic CME group (3.02±0.55 hours) was significantly longer than that in the open CME group (2.58±0.50 hours, P=0.004). The time to first flatus (3.28±0.75 days vs 3.92±0.71 days, respectively, P=0.001) and getting out of bed time (1.95±0.75 days vs 3.54±0.71 days, respectively, P=0.001) were both earlier in the laparoscopic CME group than in the open CME group. Conclusion: A laparoscopic CME is a safe and effective minimally invasive surgery for the treatment of right hemicolon cancer.

Effect of laparoscopic complete mesocolic excision (CME) for right colon cancer

Objective To evaluate the experience of laparoscopic complete mesocolic excision (CME) for right colon cancer. Methods 45 patients with right colon cancer underwent laparoscopic CME were selected as research subjects(laparoscopy group), and 40 patients with right colon cancer underwent open CME were selected as control group(open group). The clinical effects of the two groups were observed. Results All the 45 cases were successfully performed with laparoscopic CME and 40 specimens were evaluated pathologically as mesocolic plane surgery.The average time for passage of flatus in the laparoscopy group [(3.43±0.72)d] was less than that in the open group [(4.10±0.99)d, P=0.039, P 0.05). The overall postoperative complication rate of the laparoscopy group was 13.33%, which was lower than 22.50% of the open group, but the difference was not statistically significant between the two groups(P=0.268, P>0.05). Conclusion Laparoscope complete mesocolic excision for right colon cancer is safe and feasible. Key words: Right colon cancer; Laparoscopy; Complete mesocolic excision

Implementing complete mesocolic excision for colon cancer - mission completed?

The definition of complete mesocolic excision (CME) for colon carcinomas revolutionized the way of colon surgery. This technique conquered the world starting from Erlangen. Nevertheless, currently new developments especially in minimally invasive surgery challenge CME to become settled as a standard of care. To understand the evolution of CME, anatomical details occurring during embryogenesis and their variations have to be considered. This knowledge is indispensable to transfer CME from an open to a minimally invasive setting. Conventional surgery for colon cancer (non-CME) has a morbidity of 12.1–28.5% and a 3.7% mortality risk vs. 12–36.4% morbidity and 2.1–3% mortality for open CME. The morbidity of laparoscopic CME is between 4 and 31% with a mortality of 0.5–0.9%. In robotic assisted surgery, morbidity between 10 and 25% with a mortality of 1% was published. The cancer-related survival after 3 and 5 years for open CME is respectively 91.3–95% and 90% vs. 87% and 74% for non-CME. For laparoscopic CME the 3- and 5-year cancer-related survival is 87.8–97% and 79.5–80.2%. In stage UICC III the 3- and 5-year cancer-related survival is 83.9% and 80.8% in the Erlangen data of open technique vs. 75.4% and 65.5–71.7% for laparoscopic surgery. For stage UICC III the 3- and 5-year local tumor recurrence is 3.8%. The published data and the results from Erlangen demonstrate that CME is safe in experienced hands with no increased morbidity. It offers an obvious survival benefit for the patients which can be achieved solely by surgery. Teaching programs are needed for minimally invasive CME to facilitate this technique in the same quality compared to open surgery. Passing these challenges CME will become the standard of care for patients with colon carcinomas offering all benefits of minimally invasive surgery and oncological outcome.

Laparoscopic vs open complete mesocolic excision with central vascular ligation for colon cancer: A systematic review and meta-analysis.

AIMTo compare the effectiveness of laparoscopic complete mesocolic excision (CME) with central vascular ligation (L-CME) with its open (O-CME) counterpart.METHODSWe conducted an electronic search of the PubMed/MEDLINE, Excerpta Medica Database, Web of Science Core Collection, Cochrane Center Register of Controlled Trails, Cochrane Database of Systematic Reviews, SciELO, and Korean Journal databases from their inception until May 2017. We considered randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that included patients with colonic cancer comparing L-CME and O-CME. Primary outcomes included the quality of the resected specimen (lymph nodes retrieved, complete mesocolic plane excision, tumor to arterial high tie, resected mesocolon surface). Secondary outcomes included the three-year and five-year overall and disease-free survival rates, recurrence of the disease, surgical data, and postoperative morbidity and mortality. Two authors of the review screened the methodological quality of the eligible trials and independently extracted data from individual studies.RESULTSA total of one RCT and eleven CCTs (four from Europe and seven from Asia) met the inclusion criteria for the current meta-analysis. These studies involved 1619 patients in L-CME and 1477 patients in O-CME. The L-CME was associated with the same quality of the resected specimen, with no differences regarding the retrieved lymphnodes (MD = -1.06, 95%CI: -3.65 to 1.53, P = 0.42), and tumor to high tie distance (MD = 14.26 cm, 95%CI: -4.30 to 32.82, P = 0.13); the surface of the resected mesocolon was higher in the L-CME group (MD = 11.75 cm2, 95%CI: 9.50 to 13.99, P < 0.001). The L-CME was associated with a lower rate of blood transfusions (OR = 0.45, 95%CI: 0.27 to 0.75, P = 0.002), faster recovery of gastrointestinal function, and less postoperative overall complication rate. The L-CME approach was associated with a statistical significant better three-year overall (OR = 2.02, 95%CI: 1.31 to 3.12, P = 0.001, I2 = 28%) and disease-free (OR = 1.45, 95% CI: 1.00 to 2.10, P = 0.05, I2 = 0%) survival.CONCLUSIONThe laparoscopic approach offers the same quality of the resected specimen as the open approach in complete mesocolic excision with central vascular ligation for colon cancer. The laparoscopic complete mesocolic excision with central vascular ligation is superior in all perioperative results and at least non-inferior in long-term oncological outcomes.

Efficacy of complete mesocolic excision in radical operation for right colon cancer

To investigate the efficacy of complete mesocolic excision (CME) in the radical operation for right hemicolon cancer. Clinical data of 336 cases of right hemicolon cancer undergoing radical resection, including 218 cases of CME surgery group and 118 cases of traditional surgery group, from January 2005 to December 2014 in Department of Gastrointestinal Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University were retrospectively analyzed. Intraoperational events, perioperative status and postoperative survival were compared between the two groups. The baseline information was not significantly different between the two groups (all P>0.05). The number of harvested lymph nodes in CME and traditional group was 11.4±0.3 and 9.3±0.5 respectively(P=0.000) and the proportion of greater than or equal to 12 lymph nodes per case was 47.3%(103/218) and 28.8%(34/118)(P=0.002), which both were significantly different. The operation time in CME and traditional group was (147.2±2.9) and (148.8±3.9) minutes, which was not significantly different (P>0.05), whereas operative blood loss was (125.7±7.5) and (305.1±20.5) milliliters in CME and traditional group with significant difference (P=0.000). Postoperative hospital stay was (12.9±0.9) and (16.3±1.0) days in CME and traditional group with significant difference (P=0.018), while the time to postoperative liquid intake and normal diet was not significantly different between two groups (both P>0.05). The morbidity of postoperative complication of CME group was lower compared to traditional group (14.2%, 31/218 vs. 24.6%, 29/118), which was significantly different (P=0.018). Among them, infection occurred in 19 (8.7%) cases and 21 (17.8%) cases with significant difference between the two groups (P=0.014). The average time of follow-up was (34.5±1.2) months and (27.9±1.5) months in CME and traditional group, and the five-year survival rate was 85.6% and 78.0% with significant difference(P=0.043). Moreover, 102 cases underwent laparoscopic-assisted CME and 116 cases underwent open CME in CME group. The 5-year survival rate was 89.8% and 82.2% in laparoscopic and open group with significant difference (P=0.048). Compared with traditional radical resection, CME radical resection for right hemicolon cancer can harvest more lymph nodes, decrease operative blood loss, lower the riskof postoperative complication, shorten the postoperative hospital stay, and increase the 5-year survival rate. Furthermore, laparoscopic-assisted CME has more advantages.

Short-term results of laparoscopic and open complete mesocolic excision with D3 lymph node dissection for left-sided colon cancer

Aim of investigation. To estimate possible advantages and shortcomings of laparoscopic complete mesocolic excision with D3 lymph node dissection in the treatment of left-sided colon cancer in comparison to open approach according to analysis of short-term outcomes. Material and methods. Investigation was designed as retrospective-prospective case-control study (with analog group comparison). Patients with left-sided colon cancer of stages II-III were selected from prospectively collected database. Groups have been generated according to case-control principle: the I group included patients who underwent open complete mesocolic excision with D3 lymph node dissection, the II group comprised patients who underwent laparoscopic intervention in the same volume. Results. Each group included 54 patients. Duration of operation and volume of intraoperative blood loss in the II group patients was less, than in the I group. Postoperative morbidity rate had no statistically significant differences in both groups. Rehabilitation in early postoperative period was faster in the II group vs I group. Conclusion. Laparoscopic complete mesocolic excision with D3 lymph node dissection is safe type of surgery, which allows to improve short-term results of surgical treatment of patients with stage II-III left-sided colon cancer. Morphological scores indicate identical efficacy in achievement of radical treatment for laparoscopic and open techniques from the standpoint of modern oncology principles. However, correct estimation of long-term outcomes require further studies.

Short-term and oncologic outcomes of laparoscopic and open complete mesocolic excision and central ligation

PurposeTo evaluate the pathologic, short-term and oncologic outcomes of laparoscopic and open complete mesocolic excision (CME) and central ligation for right-sided colon cancer. MethodsAll patients (n = 215) underwent elective CME either by open surgery (n = 99) or laparoscopy (n = 116). ResultsMean number of retrieved lymph nodes (31 vs. 27, p = 0.012) was greater in the open CME group. Between the open and laparoscopic CME groups, there were no differences of length of the specimen (44.3 cm and 43.2 cm), ileum (14 cm and 13.3 cm), or colon (30.3 cm and 29.8 cm), respectively. Proximal and distal margins were similar. Mean operative time was similar between the open and laparoscopic CME groups (175 min vs. 178 min). The rate of 30-day postoperative complications (36.4% vs. 23.3%, p = 0.036) was higher in the open CME group. There were no differences in 3-year overall survival rates (86.9% vs. 95.5% in stage II disease and 70.2% vs. 90.7% in stage III disease) or recurrence-free survival rates (84.5% vs. 84.8% in stage II disease and 64.2% vs. 68.9% in stage III disease) between the open and laparoscopic CME groups. ConclusionsPathologic (specimen lengths, resection margin lengths, number of lymph nodes, and R0 resection) and oncologic outcomes of the laparoscopic CME group were comparable. Moreover, laparoscopic CME conferred short-term benefits in terms of lower rates of postoperative complications, reduced time to soft diet, and reduced length of hospital stay. Based on these results, laparoscopic CME can be considered as a routine elective approach for right-sided colon cancer.

Laparoscopic Complete Mesocolic Excision versus Open Complete Mesocolic Excision for Transverse Colon Cancer: Long-Term Survival Results of a Prospective Single Centre Non-Randomized Study

Background/Aim: Laparoscopic complete mesocolic excision (CME) used in the treatment of transverse colon cancer has been questioned on the basis of the technical challenges. The aim of this study was to evaluate the medium- and long-term clinical and survival outcomes after laparoscopic and open CME for transverse colon cancer and to compare the 2 approaches. Methods: This study was a retrospective non-randomized study of patients with prospectively registered data on open and laparoscopic CME for transverse colon cancer tumour-node-metastasis stages I-III operated on between 2007 and 2014. This was a single-centre study in a community teaching hospital. A total of 56 patients with transverse colon cancer were included, excluding those with tumours in the colonic flexures. The outcome aims were 4-year time to recurrence (TTR) and cancer-specific survival (CSS). Morbidity was also measured. Results: The 4-year TTR was 93.9% in the laparoscopic group and 91.3% in the open group (p = 0.71). The 4-year CSS was 97.0% in the laparoscopic group and 91.3% in the open group (p = 0.42). Limitations: This was a prospective single-institution study with a small sample size. Conclusion: Results of the study suggest that the laparoscopic CME approach might be the preferred approach for transverse colon cancer, especially regarding its benefits in terms of short-term morbidity, length of stay and oncological outcome.

Comparison of laparoscopic versus open complete mesocolic excision for right colon cancer

AimTo explore the feasibility, safety, efficacy, and short-term oncologic outcomes of laparoscopic-assisted complete mesocolic excision (CME) for right colon cancer. MethodsThe clinical data from 102 patients with right colon cancer who underwent laparoscopic CME (n = 53; LS group) and open CME (n = 49; OS group) from June 2012 to December 2013 were retrospectively reviewed. Outcomes of the two groups were compared. ResultsThere were no conversions to open surgery in the LS group. The operative time in the LS group was similar to that in the OS group (194 ± 57 vs. 177 ± 51 min, respectively, p = 0.118). Intraoperative blood loss was significantly less in the LS group compared with the OS group (94 ± 56 vs. 118 ± 60 ml, respectively, p = 0.039). There was no difference in the total number of harvested lymph nodes (14 ± 6 vs. 13 ± 5, respectively, p = 0.313). The time to resume liquid diet (3 ± 2 vs. 5 ± 2 d, p < 0.001) and length of hospital stay (11 ± 4 vs. 14 ± 6 d, p = 0.002) were significantly shorter in the LS group. The rate of complications was similar between the groups (4% vs. 12%, respectively, p = 0.222). No recurrences were noted in either group during follow-up (range, 6–24 months). ConclusionLaparoscopic CME is a safe, feasible, and effective minimally invasive procedure for right colon cancer.

The uncinate process first approach: a novel technique for laparoscopic right hemicolectomy with complete mesocolic excision.

Current evidence suggests that complete mesocolic excision (CME) for right-sided colon cancer could be beneficial in terms of long-term survival. However, CME is a considerably more complex operation than standard right hemicolectomy; this is especially true for the laparoscopic approach. Consequently, we have explored a new laparoscopic approach that provides surgical radicality at the mesenteric root on the one hand and maximum safety on the other hand. The key feature of the uncinate process first approach (UFA) is the commencement of the dissection at the fourth part of the duodenum using a medial to lateral approach, thus mobilizing the whole mesenteric root posteriorly before the central parts of the mesenteric vessels are accessed. Twenty-eight selected patients with right-sided colon cancer underwent surgery using the UFA and were compared with 51 patients who underwent an open CME procedure (CON). In 11/28 and 51/51 patients in the UFA and CON groups, respectively, a planimetric assessment of the specimen was performed. Surgical time was longer (144.8 vs. 202.5min; p<0.000) and postoperative stay shorter (8.0 vs. 10.5days; p<0.01) for the laparoscopic approach. The area of the resected mesentery (UFA, 15,097mm(2); CON, 15,788mm(2); p=0.47) and the lymph node count (UFA, 59.0; CON, 51.0; p=0.09) was not significantly different; additionally, no difference was observed regarding anastomotic leakage (both n=0) and postoperative mortality (UFA, 0/28; CON, 1/51; p=1.0). Laparoscopic right hemicolectomy with CME using the UFA provides adequate radicality according to the CME principles and seems feasible and as safe as an open technique. However, future trails will have to demonstrate whether the theoretical advantages of the UFA, with a higher degree of mobility and accessibility of the mesenteric root, translate into a significant clinical benefit, especially relative to the other laparoscopic techniques.

COMPLEATE MESOCOLIC EXCISION AND RIGHT HEMICOLECTOMY

In order to understand the term complete mesocolic excision, the knowledge of anatomy is crucial. In the classical literature, mesenteric organ is described as fragmented and discontinuous. Total mesorectal excision (TME) has become the “gold standard” for the surgical management of rectal cancer. In describing it, Heald provided an anatomical basis for surgery. Similar description was needed for colon cancer surgery. According to the modern anatomical studies, fibers of Toldt’s fascia form a plane between the apposed portions of the mesocolon and the underlying retroperitoneum. The demonstration of mesocolic continuity, combined with the presence of Toldt’s fascia, interposed between the apposed portions of the mesocolon and the retroperitoneum, rationalize planar dissection in colonic resection. By addressing these anatomical features, the mobilization of the entire colon and mesocolon (which remain intact) can be performed. Hohenberger et al. used the concept of TME for colon cancer surgery and in 2009 introduced the term complete mesocolic excision (CME). The concept for CME is the consequent surgical separation by sharp dissection of the visceral fascia layer from the parietal one resulting in complete mobilization of the entire mesocolon covered by an intact visceral fascial layer, ensuring safe exposure and tie of the supplying arteries at their origin. With this technique, survival rate increased. In comparison to open CME, laparoscopic CME has comparable results. Complete mesocolic excision seems to offer a survival benefit and better local control, but none of this is proved by randomized controlled trials. Acta Medica Medianae 2015;54(1):107-114.

A randomized controlled trial to evaluate laparoscopic versus open complete mesocolic excision (CME) for stage II, III colorectal cancer (CRC): First efficacy results from Japan Clinical Oncology Group Study JCOG0404.

656 Background: The benefits of laparoscopic surgery (LAP) compared with open surgery (OP) have been suggested; however, the long-term survival of LAP for advanced CRC requiring CME is still unclear. We conducted a trial to confirm the non-inferiority of LAP to OP in terms of overall survival (OS). Favorable short-term complications and clinical benefits of LAP have already been demonstrated. Overall survival, the primary endpoint, and late post-operative complications are presented here. Methods: Only accredited surgeons from 30 Japanese institutions participated. Eligibility criteria included histologically proven CRC; tumor located in the cecum, ascending, sigmoid or rectosigmoid colon; T3 or deeper lesion without involvement of other organs; N0-2 and M0; tumor size =&lt;8 cm; age 20-75 years. Patients with pathological stage III received adjuvant chemotherapy with fluorouracil plus leucovorin. The planned sample size was 1,050 patients with a power of 80%, a one-sided alpha of 5% and the non-inferiority margin of the hazard ratio (HR) as 1.366. Results: A total of 1,057 patients were randomized (OP 528, LAP 529) between October 2004 and March 2009. Conversion to OP was needed for 29 patients in LAP arm. 5-year OS was 90.4% (95% CI: 87.5-92.6%) in OP, and 91.8% (89.1-93.8%) in LAP. The non-inferiority of laparoscopic CME in OS was not demonstrated (HR: 1.06 [90% CI: 0.79-1.41(&gt;1.366)], p=0.073). 5-year RFS was 79.7% (76.0-82.9) in OP and 79.3% (75.6-82.6) in LAP (HR: 1.07 [95%CI: 0.82-1.38]). Proportion of grade (G) 2-4 late complications was 22.6% (OP 12.5%, LAP 10.1%). Late complications (G2-G4) included constipations (OP 6.0%, LAP 4.4%), diarrhea (OP 2.9%, LAP 2.7%), paralytic ileus (OP 1.2%, LAP 1.7%), and bowel obstruction of small intestine (OP 3.1%, LAP 2.1%). Conclusions: The non-inferiority of laparoscopic CME in OS was not demonstrated for stage II, III CRC. However, since OS of both arms are almost identical and better than expected, laparoscopic CME is acceptable as a treatment option for stage II, III CRC. Clinical trial information: C000000105.