ABSTRACT
BACKGROUND: This study presents a laparoscopic surgical protocol for right hemicolectomy and D3 lymphadenectomy (R-D3L) in right colon cancer and reports the oncological outcomes based on a prospective series. METHODS: The study comprises two phases. In the first phase, a dynamic demonstration of the R-D3L surgical protocol is provided through textual explanation, illustrations, and edited surgical videos. The protocol emphasizes technical steps such as dissection of the embryological plane of the right mesocolon, high tie of ileocolic vessels, surgical trunk of Gillot dissection, and high tie of superior right colic vein (SRCV). In the second phase, a prospective observational study was conducted involving patients undergoing R-D3L surgery with this protocol between July 2015 and July 2021. Demographic, perioperative, and postoperative variables are analyzed, along with anatomopathological variables and oncological outcomes. RESULTS: A total of 33 patients were analyzed. Median operative time was 202 min. Perioperative bleeding occurred in 6%. Postoperative complications were mild (Clavien-Dindo III in 2%). Postoperative ileus was observed in 15%. No anastomotic dehiscence was reported. The median postoperative stay was 7 days. The median number of resected lymph nodes was 26, with 27% having positive nodes and 70% were classified as stage T3 or T4. After a median follow-up of 45 months, local recurrence, distant recurrence, and carcinomatosis rates were 0%. Mortality rate from other causes was 9%. CONCLUSION: The surgical protocol shown in the present study could help in the implementation of this technique in those units that consider it appropriate.
Subject(s)
Colectomy , Colonic Neoplasms , Laparoscopy , Lymph Node Excision , Operative Time , Postoperative Complications , Humans , Colonic Neoplasms/surgery , Colonic Neoplasms/pathology , Female , Male , Lymph Node Excision/methods , Aged , Prospective Studies , Middle Aged , Laparoscopy/methods , Laparoscopy/adverse effects , Colectomy/methods , Colectomy/adverse effects , Colectomy/standards , Postoperative Complications/etiology , Postoperative Complications/epidemiology , Treatment Outcome , Aged, 80 and over , Adult , Clinical Protocols , Neoplasm Staging , Mesocolon/surgery , Length of Stay/statistics & numerical dataABSTRACT
Complete mesocolic excision (CME) with D3 lymphadenectomy for colon cancer has been shown to improve overall as well as disease-free survival compared to conventional right hemicolectomy. Performing a laparoscopic CME/D3 right hemicolectomy with intracorporeal anastomosis (ICA) can be technically demanding even for experienced operators. Here, we present a systematic, standardized approach to the surgery.
Subject(s)
Anastomosis, Surgical , Colectomy , Colonic Neoplasms , Laparoscopy , Lymph Node Excision , Humans , Colectomy/methods , Anastomosis, Surgical/methods , Laparoscopy/methods , Colonic Neoplasms/surgery , Lymph Node Excision/methods , Mesocolon/surgeryABSTRACT
Advanced splenic flexure tumors are uncommon and have a higher risk of relapse. To ensure that the resection includes the entire area of lymphatic drainage with a complete mesocolic excision (CME), a left extended colectomy is needed. In peritoneal carcinomatosis, there is often extensive involvement of the sigma and splenic flexure of the colon. In many instances, total colectomies are chosen for these patients, even when a significant portion of the colon could be preserved. The potential impact on quality of life after splenic flexure colon resection is discussed, as well as the importance of anatomical knowledge and expertise in performing this type of surgery. Overall, this work presents a modified technique that aims to improve the outcomes and quality of life for patients with splenic flexure colon cancer. Creating a tension-free anastomosis after extended left-sided colorectal resection is challenging. There is a negative impact on quality of life when an ileorectal anastomosis is created. The colorectal anastomosis performed after modified Rosi-Cahill or Deloyers' technique allows reduced small bowel bacterial overgrowth, achieves better water and sodium absorption, and altogether permits improved stool consistency. There are potential advantages of the Rosi-Cahill technique over other popular options such as Deloyers' procedure as there is no torsion of the ileocolic vessels and no mesenteric windows. A video was recorded showing a potential pitfall during Deloyers' technique resulting in the creation of a mesenteric window. The proper rotation of the colon during the modified Rosi-Cahill procedure was also filmed. Overall, this work presents a modified technique for reconstruction after left extended colectomy that aims to improve the outcomes and quality of life for patients with splenic flexure colon cancer.
Subject(s)
Anastomosis, Surgical , Colectomy , Colon, Transverse , Colonic Neoplasms , Quality of Life , Humans , Colectomy/methods , Colon, Transverse/surgery , Anastomosis, Surgical/methods , Colonic Neoplasms/surgery , Mesocolon/surgeryABSTRACT
Complete mesocolic excision for right-sided colon cancer yields larger specimens with higher lymph node harvest. This has caused a reduction in recurrence rates and improved survival. However, the technique remains controversial and has been associated with a higher risk of intraoperative complications. More recently published studies do not indicate that CME is associated with increased postoperative morbidity rates as summarised in this review. More detailed consensus regarding the use of the technique is needed, and future studies should aim for prospective confirmation of the current positive long-term results.
Subject(s)
Colectomy , Colonic Neoplasms , Mesocolon , Humans , Colonic Neoplasms/surgery , Colonic Neoplasms/pathology , Mesocolon/surgery , Colectomy/methods , Lymph Node Excision/methods , Postoperative ComplicationsABSTRACT
PURPOSE: The adequacy of lymph node (LN) harvest is important in oncological colon cancer resections. While several studies have suggested factors influencing LN yield in colon cancer, limited data are available only regarding right hemicolectomies with complete mesocolic excision (CME) and central vessel ligation (CVL). METHODS: A retrospective analysis was conducted on 169 patients who underwent right hemicolectomies with CME and CVL for right-sided colon cancer between February 2019 and March 2023. The patients were divided into 2 groups: groups with ≤24 LN yield and >24 LN yield, and the patient, surgical, and pathologic factors, which could potentially influence the LN yield, were analyzed. RESULTS: Younger age, lower American Society of Anesthesiologists (ASA) classification, and advanced clinical TNM (cTNM) stage among patient factors, the presence of obstructions regarding the surgical factors, and the presence of desmoplastic tumor reaction in the pathologic factors were more likely to harvest >24 LNs. In a multivariate analysis, younger age, lower ASA classification, advanced cTNM stage, and an ileocolic artery (ICA) crossing pattern posterior to the superior mesenteric vein (SMV) were independently associated with a >24 LN harvest. Patients with cTNM 3,4 showed the tendency of > 24 LN yield consistently within each subgroup, irrespective of the age, ASA classification, and ileocolic artery crossing pattern. CONCLUSIONS: Our investigation revealed a significant correlation between the advanced preoperative clinical stage and an increased number of harvested lymph nodes (LNs) in patients undergoing right hemicolectomies with CME a CVL. The observed association is potentially influenced by tumor aggressiveness and the extent of surgical resection performed by the surgeon. To elucidate the intricate relationship between surgical outcomes and the quantity of LN harvest in patients subjected to standardized CME and CVL for right-sided colon cancer, further dedicated research is warranted.
Subject(s)
Colectomy , Colonic Neoplasms , Lymph Node Excision , Lymph Nodes , Neoplasm Staging , Humans , Male , Female , Colonic Neoplasms/pathology , Colonic Neoplasms/surgery , Retrospective Studies , Aged , Colectomy/methods , Middle Aged , Lymph Node Excision/methods , Lymph Nodes/pathology , Lymph Nodes/surgery , Aged, 80 and over , Lymphatic Metastasis , Mesocolon/surgery , Mesocolon/pathology , Adult , LigationSubject(s)
Colectomy , Colon, Transverse , Colonic Neoplasms , Laparoscopy , Mesocolon , Splenectomy , Humans , Colectomy/methods , Laparoscopy/methods , Colon, Transverse/surgery , Colonic Neoplasms/surgery , Mesocolon/surgery , Splenectomy/methods , Male , FemaleABSTRACT
INTRODUCTION: The complete mesocolic excision (CME) and central vascular ligation (CVL) is an advanced surgical technique used to treat colon cancer. It combines the removal of the affected portion of the colon and surrounding lymph nodes with an improved method of controlling the vascular supply to the tumour. MATERIALS AND METHODS: A retrospective study of patients with colon cancer underwent right hemicolectomy (either CME and CVL or conventional method) were operated by colorectal surgeons in a tertiary centre in Kuala Lumpur from 2018 to 2020. We review the data to compare the oncological, pathological and surgical outcomes of both techniques. Categorical variables were presented as frequencies and percentages. Continuous variables were compared using an independent t-test or Mann-Whitney Rank U test. The chi-square test was used to determine the association between categorical variables and mortality. Statistical analysis was conducted with IBM SPSS Statistics 25.0, and statistical significance was set at p<0.05. RESULTS: A total of 30 patients (CME and CVL=15 or conventional colectomies=15) were included in this study with mean age of 65 years. There was no statistical difference between the mean age of the two groups (p=0.355). Most of the patients were Malays (46.7%) followed by Chinese (43.3 %) and Indians (10.0%). The mean (SD) = 19 (9) number of lymph nodes harvested is more in CME and CVL groups which however is not statistically significant compared to the mean (SD) = 16 (9), number of lymph nodes in conventional colectomies. The duration of surgery is longer in CME and CVL groups (214 minutes) compared to conventional colectomies (188 minutes) but with no significant statistical difference. Most of the perioperative complications were similar in both groups with no significant statistical differences. CONCLUSION: CME and CVL are not inferior to conventional surgery in colon surgery in a tertiary centre. It should be considered since the advantages such as lymph node yield and median recurrence free survival are better with similar perioperative morbidity.
Subject(s)
Colectomy , Colonic Neoplasms , Mesocolon , Tertiary Care Centers , Humans , Colonic Neoplasms/surgery , Colonic Neoplasms/mortality , Retrospective Studies , Male , Female , Ligation , Aged , Colectomy/methods , Mesocolon/surgery , Mesocolon/blood supply , Middle Aged , Malaysia , Treatment OutcomeSubject(s)
Lymphangioma, Cystic , Mesocolon , Humans , Lymphangioma, Cystic/surgery , Lymphangioma, Cystic/diagnostic imaging , Lymphangioma, Cystic/pathology , Lymphangioma, Cystic/diagnosis , Mesocolon/surgery , Mesocolon/pathology , Colonic Neoplasms/surgery , Colonic Neoplasms/pathology , Colonic Neoplasms/diagnosis , Male , Female , AdultABSTRACT
BACKGROUND: The modified complete mesocolic excision (mCME) procedure for right-sided colon cancer is a tailored approach based on the original complete mesocolic excision (CME) methodology. Limited studies evaluated the safety and feasibility of laparoscopic mCME using objective surgical quality assessments in patients with right colon cancer. The objectives of the PIONEER study were to evaluate oncologic outcomes after laparoscopic mCME and to identify optimal clinically relevant endpoints and values for standardizing laparoscopic right colon cancer surgery based on short-term outcomes of procedures performed by expert laparoscopic surgeons. MATERIALS AND METHODS: This is an ongoing prospective, multi-institutional, single-arm study conducted at five tertiary colorectal cancer centers in South Korea. Study registrants included 250 patients scheduled for laparoscopic mCME with right-sided colon adenocarcinoma (from the appendix to the proximal half of the transverse colon). The primary endpoint was 3-year disease-free survival. Secondary outcomes included 3-year overall survival, incidence of morbidity in the first 4 weeks postoperatively, completeness of mCME, central radicality, and distribution of metastatic lymph nodes. Survival data will be available after the final follow-up date (June 2024). RESULTS: The postoperative complication rate was 12.9%, with a major complication rate of 2.7%. In 87% of patients, central radicality was achieved with dissection at or beyond the level of complete exposure of the superior mesenteric vein. Mesocolic plane resection with an intact mesocolon was achieved in 75.9% of patients, as assessed through photographs. Metastatic lymph node distribution varied by tumor location and extent. Seven optimal clinically relevant endpoints and values were identified based on the analysis of complications in low-risk patients. CONCLUSIONS: Laparoscopic mCME for right-sided colon cancer produced favorable short-term postoperative outcomes. The identified optimal clinically relevant endpoints and values can serve as a reference for evaluating surgical performance of this procedure.
Subject(s)
Adenocarcinoma , Colonic Neoplasms , Laparoscopy , Mesocolon , Humans , Adenocarcinoma/surgery , Colectomy/methods , Laparoscopy/methods , Lymph Node Excision/methods , Mesocolon/surgery , Prospective Studies , Treatment OutcomeABSTRACT
While neoadjuvant chemotherapy has become the standard of care for rectal cancers in most centres, there is much interest in neoadjuvant chemotherapy in colon cancer after the recent publication of the FOxTROT trial. The management of colon cancers seems to be heading down the same path as rectal cancer, where the radicality of surgery is replaced by chemotherapy intensification. The role of demanding procedures such as complete mesocolic excision with central venous ligation in this new paradigm of upfront chemotherapy remains uncertain and uninvestigated.
Subject(s)
Colonic Neoplasms , Neoadjuvant Therapy , Humans , Colonic Neoplasms/surgery , Neoadjuvant Therapy/methods , Chemotherapy, Adjuvant , Colectomy/methods , Mesocolon/surgerySubject(s)
Colectomy , Colon, Transverse , Colonic Neoplasms , DNA Mismatch Repair , Laparoscopy , Mesocolon , Microsatellite Instability , Neoadjuvant Therapy , Humans , Middle Aged , Colectomy/methods , Colon, Transverse/surgery , Colonic Neoplasms/surgery , DNA Mismatch Repair/genetics , Immunotherapy/methods , Laparoscopy/methods , Mesocolon/surgery , Neoadjuvant Therapy/methodsABSTRACT
BACKGROUND: Robotic-assisted complete mesocolic excision is an advanced procedure mainly because of the great variability in anatomy. Phantoms can be used for simulation-based training and assessment of competency when learning new surgical procedures. However, no phantoms for robotic complete mesocolic excision have previously been described. This study aimed to develop an anatomically true-to-life phantom, which can be used for training with a robotic system situated in the clinical setting and can be used for the assessment of surgical competency. METHODS: Established pathology and surgical assessment tools for complete mesocolic excision and specimens were used for the phantom development. Each assessment item was translated into an engineering development task and evaluated for relevance. Anatomical realism was obtained by extracting relevant organs from preoperative patient scans and 3D printing casting moulds for each organ. Each element of the phantom was evaluated by two experienced complete mesocolic excision surgeons without influencing each other's answers and their feedback was used in an iterative process of prototype development and testing. RESULTS: It was possible to integrate 35 out of 48 procedure-specific items from the surgical assessment tool and all elements from the pathological evaluation tool. By adding fluorophores to the mesocolic tissue, we developed an easy way to assess the integrity of the mesocolon using ultraviolet light. The phantom was built using silicone, is easy to store, and can be used in robotic systems designated for patient procedures as it does not contain animal-derived parts. CONCLUSIONS: The newly developed phantom could be used for training and competency assessment for robotic-assisted complete mesocolic excision surgery in a simulated setting.
Subject(s)
Colonic Neoplasms , Laparoscopy , Mesocolon , Robotic Surgical Procedures , Humans , Mesocolon/diagnostic imaging , Mesocolon/surgery , Robotic Surgical Procedures/methods , Colonic Neoplasms/surgery , Colectomy/methods , Lymph Node Excision/methods , Diagnostic Imaging , Printing, Three-Dimensional , Laparoscopy/methodsSubject(s)
Colectomy , Colon, Transverse , Colonic Neoplasms , Laparoscopy , Mesocolon , Aged , Humans , Colectomy/methods , Colon, Transverse/surgery , Colonic Neoplasms/surgery , Laparoscopy/methods , Mesocolon/surgerySubject(s)
Colectomy , Colonic Neoplasms , Laparoscopy , Mesocolon , Humans , Colectomy/methods , Colonic Neoplasms/surgery , Laparoscopy/methods , Mesocolon/surgeryABSTRACT
Background: Surgical correction is the main line of treatment for the congenital disorder Hirschsprung's disease (HD). Laparoscopic techniques proved their safety and efficacy in previous studies. LigaSure™ is the gold standard for colorectal dissection. However, other sealing methods could be used during the unavailability of LigaSure. Purpose: This study aimed to assess the safety profile of the hook diathermy technique compared to LigaSure in colorectal dissection during laparoscopic-assisted pull-through for HD. Materials and Methods: This case-control study was held in the pediatric surgery department at Assiut University Hospitals between September 2017 and January 2023. The study included 57 HD patients who were surgically operated on during a laparoscopic-assisted pull-through. They were divided into 2 groups according to the sealing methods: the ligasure group included 25 patients, and the hook diathermy group included 32 patients. Results: Both groups had no statistically significant differences regarding age, sex, or weight. The transition zone was present in all patients, and most transition zones were rectosigmoid. No cases reported intraoperative blood transfusion or conversion to an open or transanal approach. Minimum intraoperative blood loss was reported in both groups, with no significant differences. As regards postoperative complications, including bleeding, leakage, perianal excoriation, and enterocolitis, no significant differences between both groups were found. Conclusion: The LigaSure and hook diathermy techniques are safe and effective sealing methods for colorectal dissection during laparoscopic-assisted pull-through for HD.
Subject(s)
Hirschsprung Disease , Laparoscopy , Humans , Hirschsprung Disease/surgery , Female , Male , Laparoscopy/methods , Case-Control Studies , Infant , Diathermy/methods , Diathermy/instrumentation , Child, Preschool , Mesocolon/surgery , Blood Loss, Surgical/statistics & numerical data , Dissection/methods , Treatment Outcome , ChildABSTRACT
BACKGROUND: Colon cancer is a disease with a worldwide spread. Surgery is the best option for the treatment of advanced colon cancer, but some aspects are still debated, such as the extent of lymphadenectomy. In Japanese guidelines, the gold standard was D3 dissection to remove the central lymph nodes (203, 213, and 223), but in 2009, Hoenberger et al. introduced the concept of complete mesocolic excision, in which surgical dissection follows the embryological planes to remove the mesentery entirely to prevent leakage of cancer cells and collect more lymph nodes. Our study describes how lymphadenectomy is currently performed in major Italian centers with an unclear indication on the type of lymphadenectomy that should be performed during right hemicolectomy (RH). METHODS: CoDIG 2 is an observational multicenter national study that involves 76 Italian general surgery wards highly specialized in colorectal surgery. Each center was asked not to modify their usual surgical and clinical practices. The aim of the study was to assess the preference of Italian surgeons on the type of lymphadenectomy to perform during RH and the rise of any new trends or modifications in habits compared to the findings of the CoDIG 1 study conducted 4 years ago. RESULTS: A total of 788 patients were enrolled. The most commonly used surgical technique was laparoscopic (82.1%) with intracorporeal (73.4%), side-to-side (98.7%), or isoperistaltic (96.0%) anastomosis. The lymph nodes at the origin of the vessels were harvested in an inferior number of cases (203, 213, and 223: 42.4%, 31.1%, and 20.3%, respectively). A comparison between CoDIG 1 and CoDIG 2 showed a stable trend in surgical techniques and complications, with an increase in the robotic approach (7.7% vs. 12.3%). CONCLUSIONS: This analysis shows how lymphadenectomy is performed in Italy to achieve oncological outcomes in RH, although the technique to achieve a higher lymph node count has not yet been standardized. Trial registration (ClinicalTrials.gov) ID: NCT05943951.
Subject(s)
Colonic Neoplasms , Laparoscopy , Mesocolon , Humans , Colectomy/methods , Colonic Neoplasms/surgery , Colonic Neoplasms/pathology , Laparoscopy/methods , Lymph Node Excision/methods , Mesocolon/surgery , Prospective StudiesABSTRACT
PURPOSE: Persistent descending mesocolon (PDM) increases the difficulty and colonic ischemia in the surgery of colorectal cancer, but the preoperative diagnostic criteria have not yet been clearly demonstrated. This study explored the MR imaging features and diagnostic criteria of PDM to improve the preoperative diagnostic rate. METHODS: The clinical data of 54 patients with PDM and 270 patients without PDM who underwent rectal surgery at the Department of Colorectal Surgery, Fujian Medical University Union Hospital, from March 2018 to December 2022 were analyzed, retrospectively. The radiological parameters of PDM from MRI were analyzed. RESULTS: On MRI T2WI axial image, the left edge of the abdominal aorta was defined as the reference line. The shortest vertical distance between the right edge of the descending colon and this line (dN) and the maximum transverse diameter of the peritoneal cavity (dA) at the same level and the maximum vertical distance between the right edge of the descending colon and this line (dW) were measured. There were significant statistical differences in dN, dW, dN/dW, and dN/dA between the PDM group and the non-PDM group. dN, dN/dW, and dN/dA have high diagnostic performance for the PDM. dN < 4.16 cm, dN/dW < 0.52, and dN/dA < 0.15 can all be used as clues to diagnose PDM. CONCLUSIONS: We propose a feasible set of diagnostic criteria for PDM based on abdominal MRI, which can quickly and accurately diagnose PDM, and provide some reference for preoperative planning and surgical decision-making.