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CT and operative images for evaluation of right colectomy with extended D3 mesenterectomy anterior and posterior to the mesenteric vessels

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Summary

Background

Surgical techniques like complete mesocolic excision (CME) and D3 mesenterectomy, D3 refering to the N3 lymph node groups central in the mesentery removed at surgery, were introduced without proper evaluation of the lymphadenectomy. The aim of this study was to measure the vascular stumps and evaluate the extent and quality of lymphadenectomy after right colectomy with extended D3 mesenterectomy anterior/posterior to the mesenteric vessels. We also compared the investigation methods.

Methods

Residual vascular stumps were measured using three-dimensional (3D) reconstructed anatomy from follow-up computed tomography (CT) datasets and images taken during surgery. The quality of central lymphadenectomy was evaluated on the images.

Results

In total, 31 patients (15 females), median age 67 years (50–78), with stage I (n = 7), stage II (n = 13), and stage III (n = 11) disease, were operated. Tumor locations were: 14 (45%) in the cecum, ten (32%) in the ascending colon, three (10%) in the hepatic flexure, and four (13%) in the transverse colon. The middle colic artery (MCA) was divided at its origin (13 patients) or its right branch (18 patients). Median lengths (range) of residual vascular stumps measured on 3D reconstructed CT and photographic images taken during surgery were: right colic artery: 0.0 mm (0.0–1.8)/0.0 mm (0.0–1.1), ileocolic artery: 0.0 mm (0.0–7.2)/0.0 mm (0.0–3.0), ileocolic vein: 0.0 mm (0.0–7.5)/0.0 mm (0.0–0.0), MCA: 0.0 mm (0.0–18.1)/1.0 mm (0.0–8.0), and right branch of the MCA: 0.0 mm (0.0–1.8)/0.0 mm (0.0–2.0). There was no significant difference between average lengths measured with the two techniques. The extent of lymphadenectomy was deemed acceptable in all patients. No differences in stump lengths were found in patients with different vascular crossing patterns in the central mesentery and presumably different degree of difficulty at surgery.

Conclusion

The results demonstrate very short residual vascular stumps and together with operative photographs provide objective evidence for superior lymphadenectomy in right colectomy with extended D3 mesenterectomy.

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The Right Colectomy for Cancer (RCC) Study Group

Prof. Tom Oresland MD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway; Arne Engebreth Færden MD, PhD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway; Yngve Thorsen, MD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway; Prof. Solveig Andersen MD, Akershus University Hospital, Department of Pathology, University in Oslo, Norway; Anne Negaard, MD, PhD, Akershus University Hospital, Department of Radiology, University in Oslo, Norway; Russel Jacobsen MD, Department of Vascular Surgery, Vestfold Hospital Trust, Tonsberg, Norway; Kari Mette Langerød von Brandis MD, Department of Radiology, Vestfold Hospital Trust, Tonsberg, Norway; Tania Hansen, Department of Radiology, Vestfold Hospital Trust, Tonsberg, Norway; Pål Suhrke MD, Department of Pathology, Vestfold Hospital Trust, Tonsberg, Norway; Christer-Daniel Willard, medical student, University in Oslo, Norway; Javier Luzon MD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway; Bjarte Tidemann Andersen MD, Department of Digestive Surgery, Vestfold Hospital Trust, Tonsberg, Norway; Robin Gaupset MD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway; Prof. Roberto Bergamaschi MD, Division of Colorectal Surgery, Westchester Medical Center, New York Medical College, NY, USA; Frieder Pulling MD, Vizeralchirurgie Klinicum, Karlsruhe, Germany; Joerg Baral MD, Vizeralchirurgie Klinicum, Karlsruhe, Germany; Marcos Gomez Ruiz MD, Coloproctologia Cirugia Colorectal—Cirurgia General y Ap. Digestivo Hospital Universario Marques de Valdecilla, Spain; Baris Sevinc MD, Dep. Of General Surgery, Medical Park Usak Hospital, Usac, Turkey; Jonas Lindstrøm, Health Services Research Unit, Akershus University Hospital, Norway; Ariba Ehsan Sheikh MD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway; Tine Strømmen MD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway.

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Authors and Affiliations

  1. Department of Gastrointestinal Surgery, Vestfold Hospital Trust, Postbox 2168, 3103, Tonsberg, Norway

    J. M. Nesgaard MD

  2. Anatomy Sector, Teaching Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland

    B. V. Stimec MD, PhD

  3. Interventional Centre, Gastrointestinal and Pediatric Surgery, Oslo University Hospital—Rikshospitalet, Oslo, Norway

    B. Edwin MD, PhD

  4. Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lorenskog, Norway

    A. O. Bakka MD, PhD &  D. Ignjatovic MD, PhD

  5. Institute of Clinical Medicine, University of Oslo, Oslo, Norway

    B. Edwin MD, PhD,  A. O. Bakka MD, PhD &  D. Ignjatovic MD, PhD

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  1. J. M. Nesgaard MD
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  2. B. V. Stimec MD, PhD
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  3. B. Edwin MD, PhD
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  4. A. O. Bakka MD, PhD
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Consortia

The Right Colectomy for Cancer (RCC) Study Group

  • Tom Oresland
  • , Arne Engebreth Færden
  • , Yngve Thorsen
  • , Solveig Andersen
  • , Anne Negaard
  • , Russel Jacobsen
  • , Kari Mette Langerød von Brandis
  • , Tania Hansen
  • , Pål Suhrke
  • , Christer-Daniel Willard
  • , Javier Luzon
  • , Bjarte Tidemann Andersen
  • , Robin Gaupset
  • , Roberto Bergamaschi
  • , Frieder Pulling
  • , Joerg Baral
  • , Marcos Gomez Ruiz
  • , Baris Sevinc
  • , Jonas Lindstrøm
  • , Ariba Ehsan Sheikh
  •  & Tine Strømmen

Corresponding author

Correspondence to J. M. Nesgaard MD.

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Conflict of interest

J.M. Nesgaard, B.V. Stimec, B. Edwin, A.O. Bakka, and D. Ignjatovic declare that they have no competing interests.

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Nesgaard, J.M., Stimec, B.V., Edwin, B. et al. CT and operative images for evaluation of right colectomy with extended D3 mesenterectomy anterior and posterior to the mesenteric vessels. Eur Surg 52, 29–36 (2020). https://doi.org/10.1007/s10353-019-0604-y

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