|Year : 2019 | Volume
| Issue : 3 | Page : 58-62
Complete mesocolic excision for colon cancer
Puvvala Sriphani1, Kotagiri Sreekanth1, Gogineni Tarun Chowdary1, Vasureddy Challa1, Ajay Chanakya Vallabhaneni1, Deepak Yadlapalli2
1 Department of Surgical Oncology, GSL Medical College and General Hospital, Rajahmundry, Andhra Pradesh, India
2 Department of Medical Oncology, GSL Medical College and General Hospital, Rajahmundry, Andhra Pradesh, India
|Date of Submission||21-Jul-2020|
|Date of Decision||12-Aug-2020|
|Date of Acceptance||23-Aug-2020|
|Date of Web Publication||22-Sep-2020|
Dr. Puvvala Sriphani
Department of Surgical Oncology, GSL Medical College and General Hospital, NH 16, Lakshmi Puram, Rajahmundry, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: The aim of the present study was to define the complete mesocolic excision (CME) in conjunction with central vascular ligation (CVL) as the defined surgical treatment for colon cancer. Methods: A prospective study was conducted between August 2014 and August 2017, at GSL Medical College and General Hospital. A total of 46 patients (31 cases in open and 15 in the laparoscopic arm) demographic data, operative details, and postoperative outcomes, follow-up, the pathologic results were reviewed. Results: All patients (n = 46) underwent an elective CME + CVL for colon cancer. The mean age of patients was 57.8 ± 16.6 years. Of the 46, 28 were male, and 18 were female. The mean operation time was 61.2 ± 155.2 min. The mean blood loss was 88.6 ml. The mean number of total harvested lymph nodes was 28.6. The mean length of the hospital stay was 12.9 days. Conclusion: Based on the data presented in this study, CME with CVL is a feasible and safe procedure for treating colon cancer. Although the present study had certain limitations, like its small study, patients from a single center, CME with CVL was found to lead to better oncological outcomes for the colon surgery.
Keywords: Central vascular ligation, colon cancer, complete mesocolic excision
|How to cite this article:|
Sriphani P, Sreekanth K, Chowdary GT, Challa V, Vallabhaneni AC, Yadlapalli D. Complete mesocolic excision for colon cancer. Indian J Colo-Rectal Surg 2019;2:58-62
|How to cite this URL:|
Sriphani P, Sreekanth K, Chowdary GT, Challa V, Vallabhaneni AC, Yadlapalli D. Complete mesocolic excision for colon cancer. Indian J Colo-Rectal Surg [serial online] 2019 [cited 2022 May 20];2:58-62. Available from: https://www.ijcrsonweb.org/text.asp?2019/2/3/58/295856
| Introduction|| |
Colorectal cancer (CRC) is the third main frequent malignancy worldwide. Surgery is a key player in CRC therapy and can, therefore, affect the outcome tremendously. In 1982, Heald et al. introduced the concept of total mesorectal excision (TME) for rectal cancer. The technique of TME is focused on sharp dissection of the anatomical planes, thus obtaining an optimized specimen with intact layers.
The embryological planes, however, are not narrowed to the rectum and mesorectal layers but continue to be found in the whole gastrointestinal tract. Thus, the same surgical principles can be transferred to colon surgery cancer, too.
In 2009, Hohenberger et al. introduced the concept of complete mesocolic excision (CME) for colon cancer. This concept has two components; the anatomical layers are separated by sharp dissection; the visceral plane is separated from the parietal plane. A CME specimen features an intact tumor and its main lymphatic drainage with no tears in the fascial layers on both sides of the mesocolon. In addition, a central dissection of the relevant tumor-feeding arteries right at their origins is performed central vascular ligation (CVL), in tumors on the right side of the colon at the level of the superior mesenteric artery (SMA), in tumors on the left-hand side at the level of the inferior mesenteric artery, or the aorta for maximal retrieval of lymph nodes. Some studies reported that CME with CVL provides an increased lymph node harvest, decreased peroperative morbidity, reduced locoregional recurrence, and improved oncological outcomes., The aim of the present study was to analyze the peri- and postoperative and short-term oncological outcomes for colon cancer after CME with CVL.
| Methods|| |
A prospective study was conducted between August 2014 and August 2017 at GSL Medical College and General Hospital. A total of 46 patients (31 cases in open and 15 in the laparoscopic arm) demographic data, operative details, and postoperative outcomes, follow-up, the pathologic results were reviewed.
Good performance status histologically verified carcinoma of the colon, clinically and radiologically Staged I-III colon cancers.
Stage IV tumors, synchronous tumors, hereditary colon cancers, who underwent multivisceral resections, and recurrent or perforated tumors were excluded from this study.
All patients and their families were correctly informed and gave their full consent before the surgery. The data of all the clinical and pathological features were reviewed retrospectively. All patients underwent routine colonoscopy and biopsy, staging workup (contrast-enhanced computed tomography [CECT] the abdomen and pelvis, CECT chest), and occasional positron emission tomography scan.
Clinicopathological, postoperative outcomes, hospital stay, postoperative morbidity and mortality, and short-term oncological outcomes, including the number of lymph nodes, the distal margin, radial margin, and pathological staging were compared. After the surgery, all patients with Stage II or Stage III cancer were given adjuvant chemotherapy, as recommended by the National Comprehensive Cancer Network Guidelines. The patients received closed follow-ups every 3–6 months upto 3 years after surgery, and the results of the follow-ups were recorded until May 2019 or death. Disease-free survival (DFS) was defined as the state between the date of surgery and the date of the detection of recurrence, the last follow-up, or death.
In this study, for all the colon cancers, a Lateral to Medial approach for open surgery and medial to lateral approach for laparoscopic surgery was deployed. For right-sided colon cancers, the dissection commences laterally by identifying the lateral peritoneal fold and separating the overlying mesocolon from the underlying retroperitoneum (Toldt's fascia). The mesenteric root up to the origin of the superior mesenteric pedicle is mobilized, and the dissection continues over the duodenum and pancreatic uncinate process to allow complete access to the superior mesenteric vein, as well as to the medially and inferiorly located SMA [Figure 1].
|Figure 1: Complete mesocolic excision.(a) Superior mesenteric vein, (b) _24uncinate process, (c) duodenum second part, (d) kidney|
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After the complete mobilization, the ligation of the supplying vessels follows. Initially, the ileocolic and the right colic vessels (if present) are divided at their origin from the superior mesenteric vessels. Sharp dissection is then carried out centrally along the SMA, ensuring clearance of all associated lymph nodes. For cecal and ascending colon cancers, only the right branch of the middle colic vessels is divided. The transverse mesocolon dissection is continued vertically to meet the dissection along the superior mesenteric vascular pedicle, producing a rectangular specimen with an intact mesocolic envelope containing all central lymph nodes. At that point, the colon is divided at the level of the middle colic vessels [Figure 2].
|Figure 2: Left colon growth with mesocolon and lymph nodes, intact specimen|
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For left colon cancers, the “lateral-to-medial” dissection begins at the lateral peritoneal fold and continues in the mesofascial interface. After the whole mesocolon of the descending and sigmoid colon is dissected, the ureter and the vesicular or ovarian vessels are recognized and left behind. The splenic flexure is mobilized when needed. For cancers of the descending colon, ligation of the ascending branch of the left colic artery and dissection of the lymph nodes at the origin of the SMA, without damaging the superior hypogastric plexus, is advocated.
| Results|| |
All patients (n = 46) underwent an elective CME for colon cancer. The mean age of the patients was 57.8 ± 16.6 years. Of the 46 patients, 28 (60.8%) were male and 18 (39.2%) were female. The mean body mass index scores of the patients was 23.5 ± 4.8 kg/m2. In terms of the tumor location, caecal cancer occurred in 12 (26.8%) patients, ascending and hepatic flexure of colon occurred in 20 (43.4%) patients, transverse colon in 3 (6.5%) patients and splenic flexure and descending colon occurred in 11 (23.91%) patients. Open hemicolectomy was performed in 31 (67.3%) patients and Laparoscopic-assisted hemicolectomy was performed in 15 (32.6%) patients. The mean initial CEA levels of the patients were 22.7 ± 69.8 ng/ml [Table 1].
Of the 46 patients, PT stages, none were in T1; 19 (41.3%) patients were in T2; 16 (34.7%) patients were in T3; 8 (17.3%) patients were in T4a; 3 (6.52%) patients were in T4b. Of the N stages; 21 (45.6%) patients were in N0, 16 (34.7%) patients were in N1 and 10 (21.73%) patients were in N2. Of the patients, 29 (63.04%) had well-differentiated cancer cells, 12 (26.08%) had moderately differentiated cancer cells and 5 (10.8%) had poorly differentiated cancer cells. Lymphovascular invasion was seen in 14 (23.1%) patients and peri-neural invasion was seen in 9 (8.6%) patients. The mean proximal resected margin was 12.2 ± 4.2 cm and the mean distal resected margin was 10.8 ± 5.6 cm. The mean tumor size was 7.2 ± 4.5 cm. The mean number of lymph nodes harvested was 28.4 ± 12.6 [Table 2].
Intra-and postoperative results
The mean operation time of the patients was 61.2 ± 155.2 min. The mean blood loss was 75.6 ± 90.2 ml; the mean hospital stay was 5.1 ± 12.8 days. The mean time to start a liquid diet was 7.2 ± 3.6 days. The total number of postoperative complications was in 9 (21.7%). Pulmonary complications occurred in 2 (4.34%) patients. Postoperative ileus was seen in 2 (4.34%) patients and wound dehiscence in 5 (10.86%) patients. Anastomosis leakage was in 2 (4.34%) patients. Postoperative mortality within 30 days occurred in 1 (2.17%) patient due to respiratory infections [Table 3].
The mean follow-up period was 43.6 months. The 3-year DFS rate was 71.7% and the 3-year cancer-specific survival (CSS) rate was 83.10%. In Stage I, the DFS and CSS rates were both 96%. In Stage II, the DFS rate was 91.0% and the CSS rate was 92.3%. In Stage III, the DFS rate was 53.5% and the CSS rate was 59.5%.
The total number of patients who experienced recurrence was 8 (17.3%). During the follow-up period, systemic recurrence occurred in 7 (15.2%) patients and local recurrence occurred in 1 (2.17%).
| Discussion|| |
In CME, the mesorectal plane is dissected to produce an intact fascial-lined specimen, which contains blood vessels, lymphatic vessels, and lymph nodes. The colon is surrounded by the visceral fascia and its mesocolon, including its vessels and lymphatics; therefore, there is no lymphatic flow into the tissues of the mesocolon. The surgical techniques of CME with CVL used in the present study were somewhat different from CME as initially described by Hohenberger et al. First, the kocherization of the duodenum was not performed routinely. Second, if the tumor was not located in the hepatic flexure or the proximal transverse colon, only vessel ligation of the right side of the middle colic vessel was performed without the whole ligation of the middle colic vessel totally. However, most of the surgical techniques and concepts used in the present study were the same as those originally described by Hohenberger et al.
In the present study, the tumor location was more in ascending and hepatic flexure of the colon (20 patients, 43.4%), with well-differentiated adenocarcinoma as the most common histology. The mean blood loss in the study was 88.6 ml, the means of the length of hospital stay was (12.2 days) and time to start a liquid diet (6.2 days) in the present study were similar to those reported in previous studies. The mean operation time of CME in previous studies ranged from 136 to 269 min, and no significant difference was reported between open and laparoscopic surgeries. The mean operation time in the present study was found to be 156.2 min. In the present study, the total postoperative complication rate was found to be 21.7%. The most commonly occurring complications were found to be wound dehiscence and ileus. Specimens of colon cancer patients who underwent CME in the present study (n = 46, 99%) and had a higher number of harvested lymph nodes (28.6), than non-CME specimens. The mean number of harvested lymph nodes in the present study was 28.4 ± 12.6.
In the present study, the 3 years DFS rate was 77.1% and the 3 years CSS rate was 83.1% with a mean follow up of 43.6 days. The local recurrence rate was 2.17%, less than the systemic recurrence. It is possible that the improved outcomes of CME patients are related to the resection plane and the vessel site of ligation. The T stage was not found to be a factor effecting survival rate; however, the N stage was found to be a prognostic factor effecting survival.
| Conclusion|| |
Standardized oncologic survey shows particular importance of CME for colon surgery by reducing the rate of local recurrence and achieving increased survival rate. CME for colon cancer is a specimen oriented technique of the surgery. By central dissection of the supplying arteries, one can remove as many as lymph nodes. Based on the data presented in this study, CME with CVL is a feasible and safe procedure for treating colon cancer. Although the present study had certain limitations, like its small study, patients from a single center, CME with CVL was found to lead to better oncological outcomes for colon surgery.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Torre La, Bra F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2017. CA cancer J Clinic 2017;65:87-108.
National Comprehensive Cancer Network. National comprehensive Cancer Network Guidelines, Colon Cancer. Ver. 2. J Natl Compr Canc Netw; 2017. doi: 10.6004/jnccn.2018.0021
Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery-the clue to pelvic recurrence? Br J Surg 1982;69:613-6.
Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. Standardized surgery for colonic cancer: Complete mesocolic excision and central ligation-technical notes and outcome. Colorectal Dis 2009;11:354-64.
Le Voyer TE, Sigurdson ER, Hanlon AL, Mayer RJ, Macdonald JS, Catalano PJ, et al
. Colon cancer survival is associated with increasing number of lymph nodes analyzed: A secondary survey of intergroup trial INT-0089. J Clin Oncol 2003;21:2912-9.
Kontovounisios C, Kinross J, Tan E, Brown G, Rasheed S, Tekiss P, et al.
Complete mesocolic excision in colorectal cancer: A systemic review. Colorectal Dis2015;17:7-16.
West NP, Kobayashi H, Takahashi K, Perrakis A, Weber K, Hohenberger W, Sugihara K, Quirke P, et a
l. Understanding optimal colonic cancer surgery: Comparison of Japanese D3 resection and European complete mes colic excision with central vascular ligation safe and effective in the surgical treatment of right-sided colon cancers? A prospective study. Int J Colorectal Dis. 2014;29:89-97.
Killeen S, Kessler H. Complete mesocolic excision and central vessel ligation for right colon cancers. Tech Coloproctol 2014;18:1129-31.
Galizia G, Lieto E, de Vita F, Ferraraccio F, Zamboli A, Mabilia A, et al.
Is complete mesocolic excision with central vascular ligation. Int J Colorectal Dis 2014;29:89-97.
Culligan K, Coffey JC, Kiran RP, Kalady M, Lavery IC, Remzi FH. The mesocolon: A prospective observational study. Colorectal Dis 2012;14:421-8.
Gao Z, Ye Y, Zhang W, Shen D, Zhong Y, Jiang K, et al
. An anatomical, histopathological, and molecular biological function study of the fascias posterior to the interperitoneal colon and its associated mesocolon: Their relevance to colonic surgery. J Anat 2013;223:123-32.
Kim IY, Kim BR, Choi EH, Kim YW. Short-term and oncologic outcomes of laparoscopic and open complete mesocolic excision and central ligation. Int J Surg 2016;27:151-7.
Adamina M, Manwaring ML, Park KJ, Delaney CP. Laparoscopic complete mesocolic excision for right colon cancer. Surg Endosc 2012;26:2976-80.
Gouvas N, Pechlivanides G, Zervakis N, Kafousi M, Xynos E. Complete mesocolic excision in colon cancer surgery: A comparison between open and laparoscopic approach. Colorectal Dis 2012;14:1357-64.
Hogan AM, Winter DC. Complete mesocolic excision-a marker of surgical quality? J Gastrointest Surg 2009;13:1889-91.
Jayne DG, Thorpe HC, Copeland J, Quirke P, Brown JM, Guillou PJ. Five-year follow-up of the medical research council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br J Surg 2010;97:1638-45.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]