Surgical Endoscopy

, Volume 33, Issue 1, pp 8–18 | Cite as

Comparison between conventional colectomy and complete mesocolic excision for colon cancer: a systematic review and pooled analysis

A review of CME versus conventional colectomies
  • Noura AlhassanEmail author
  • Mei Yang
  • Nathalie Wong-Chong
  • A. Sender Liberman
  • Patrick Charlebois
  • Barry Stein
  • Gerald M. Fried
  • Lawrence Lee
Review Article



Complete mesocolic excision (CME) is advocated based on oncologic superiority, but not commonly performed in North America. Many data are case series with few comparative studies. Our aim was to perform a systematic review comparing outcomes between CME and non-CME colectomy.


A systematic review was performed according to PRISMA guidelines of MEDLINE, EMBASE, HealthStar, Web of Science, and Cochrane Library. Studies were included if they compared conventional resection (non-CME) to CME for colon cancer. Quality was assessed using methodological index for non-randomized studies (MINORS). The main outcome measures were short-term morbidity and oncologic outcomes. Weighted pooled means and proportions with 95% CI were calculated using a random-effects model when appropriate.


Out of 825 unique citations, 23 studies underwent full-text reviews and 14 met inclusion criteria. Mean MINORS score was 13.3 (range 11–15). The mean sample size in CME group was 1166 (range 45–3756) and 945 (range 40–3425) in non-CME. Four papers reported plane of dissection, with CME plane achieved in 85.8% (95% CI 79.8–91.7). Mean OR time in CME group was 167 min (163–171) and 138 min (135–142) in conventional group. Perioperative morbidity was reported in six studies, with pooled overall complications of 22.5% (95% CI 18.4–26.6) for CME and 19.6 (95% CI 13.6–25.5) for non-CME. Anastomotic leak occurred in 6.0% (95% CI 2.2–9.7) of CME resections versus 6.0% (95% CI 4.1–7.9) in non-CME. CME had more lymph nodes, longer distance to high tie, and specimen length in all studies. Nine studies compared long-term oncologic outcomes and only three reported statistically significant higher disease-free or overall survival in favor of CME. Local recurrence was lower after CME in two of four studies.


The quality of evidence is limited and does not consistently support the superiority of CME. Better data are needed before CME can be recommended as the standard of care for colon cancer resections.


Colon cancer Complete mesocolic excision Central vascular ligation Lymph node dissection Systematic review Oncologic outcomes 


Compliance with ethical standards


Dr. A. Sender Liberman is on the medical advisory committee on ERAS for Merck, and on the advisory committee meeting for Novadaq. Drs. Noura Alhassan, Mei Yang, Nathalie Wong-Chong, Patrick Charlebois, Barry Stein, Gerald M. Fried, and Lawrence Lee have no conflicts of interest or financial ties to disclose.


  1. 1.
    Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616CrossRefGoogle Scholar
  2. 2.
    Wibe A, Moller B, Norstein J, Carlsen E, Wiig JN, Heald RJ, Langmark F, Myrvold HE, Soreide O, Norwegian Rectal Cancer G (2002) A national strategic change in treatment policy for rectal cancer—implementation of total mesorectal excision as routine treatment in Norway. A national audit. Dis Colon Rectum 45:857–866CrossRefGoogle Scholar
  3. 3.
    Khani MH, Smedh K (2010) Centralization of rectal cancer surgery improves long-term survival. Colorectal Dis 12:874–879CrossRefGoogle Scholar
  4. 4.
    Martling AL, Holm T, Rutqvist LE, Moran BJ, Heald RJ, Cedemark B (2000) Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project. Lancet 356:93–96CrossRefGoogle Scholar
  5. 5.
    West NP, Morris EJ, Rotimi O, Cairns A, Finan PJ, Quirke P (2008) Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study. Lancet Oncol 9:857–865CrossRefGoogle Scholar
  6. 6.
    Chang GJ, Rodriguez-Bigas MA, Skibber JM, Moyer VA (2007) Lymph node evaluation and survival after curative resection of colon cancer: systematic review. J Natl Cancer Inst 99:433–441CrossRefGoogle Scholar
  7. 7.
    Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S (2009) Standardized surgery for colonic cancer: complete mesocolic excision and central ligation—technical notes and outcome. Colorectal Dis 11:354–364CrossRefGoogle Scholar
  8. 8.
    Chow CF, Kim SH (2014) Laparoscopic complete mesocolic excision: West meets East. World J Gastroenterol 20:14301–14307CrossRefGoogle Scholar
  9. 9.
    Bertelsen CA, Neuenschwander AU, Jansen JE, Kirkegaard-Klitbo A, Tenma JR, Wilhelmsen M, Rasmussen LA, Jepsen LV, Kristensen B, Gogenur I, Copenhagen Complete Mesocolic Excision Study, Danish Colorectal Cancer Group (2016) Short-term outcomes after complete mesocolic excision compared with ‘conventional’ colonic cancer surgery. Br J Surg 103:581–589CrossRefGoogle Scholar
  10. 10.
    Hogan AM, Winter DC (2009) Complete mesocolic excision (CME): a “novel” concept? J Surg Oncol 100:182–183CrossRefGoogle Scholar
  11. 11.
    Gouvas N, Agalianos C, Papaparaskeva K, Perrakis A, Hohenberger W, Xynos E (2016) Surgery along the embryological planes for colon cancer: a systematic review of complete mesocolic excision. Int J Colorectal Dis 31:1577–1594CrossRefGoogle Scholar
  12. 12.
    Sondenaa K, Quirke P, Hohenberger W, Sugihara K, Kobayashi H, Kessler H, Brown G, Tudyka V, D’Hoore A, Kennedy RH, West NP, Kim SH, Heald R, Storli KE, Nesbakken A, Moran B (2014) The rationale behind complete mesocolic excision (CME) and a central vascular ligation for colon cancer in open and laparoscopic surgery. Int J Colorectal Dis 29:419–428CrossRefGoogle Scholar
  13. 13.
    West NP, Kobayashi H, Takahashi K, Perrakis A, Weber K, Hohenberger W, Sugihara K, Quirke P (2012) Understanding optimal colonic cancer surgery: comparison of Japanese D3 resection and European complete mesocolic excision with central vascular ligation. J Clin Oncol 30:1763–1769CrossRefGoogle Scholar
  14. 14.
    Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J (2003) Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 73:712–716CrossRefGoogle Scholar
  15. 15.
    Bertelsen CA, Bols B, Ingeholm P, Jansen JE, Neuenschwander AU, Vilandt J (2011) Can the quality of colonic surgery be improved by standardization of surgical technique with complete mesocolic excision? Colorectal Dis 13:1123–1129CrossRefGoogle Scholar
  16. 16.
    Bertelsen CA, Neuenschwander AU, Jansen JE, Wilhelmsen M, Kirkegaard-Klitbo A, Tenma JR, Bols B, Ingeholm P, Rasmussen LA, Jepsen LV, Iversen ER, Kristensen B, Gogenur I, Danish Colorectal Cancer Group (2015) Disease-free survival after complete mesocolic excision compared with conventional colon cancer surgery: a retrospective, population-based study. Lancet Oncol 16:161–168CrossRefGoogle Scholar
  17. 17.
    West NP, Hohenberger W, Weber K, Perrakis A, Finan PJ, Quirke P (2010) Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol 28:272–278CrossRefGoogle Scholar
  18. 18.
    West NP, Sutton KM, Ingeholm P, Hagemann-Madsen RH, Hohenberger W, Quirke P (2010) Improving the quality of colon cancer surgery through a surgical education program. Dis Colon Rectum 53:1594–1603CrossRefGoogle Scholar
  19. 19.
    Tagliacozzo S, Tocchi A (1997) Extended mesenteric excision in right hemicolectomy for carcinoma of the colon. Int J Colorectal Dis 12:272–275CrossRefGoogle Scholar
  20. 20.
    Kotake K, Mizuguchi T, Moritani K, Wada O, Ozawa H, Oki I, Sugihara K (2014) Impact of D3 lymph node dissection on survival for patients with T3 and T4 colon cancer. Int J Colorectal Dis 29:847–852CrossRefGoogle Scholar
  21. 21.
    Kotake K, Kobayashi H, Asano M, Ozawa H, Sugihara K (2015) Influence of extent of lymph node dissection on survival for patients with pT2 colon cancer. Int J Colorectal Dis 30:813–820CrossRefGoogle Scholar
  22. 22.
    Galizia G, Lieto E, De Vita F, Ferraraccio F, Zamboli A, Mabilia A, Auricchio A, Castellano P, Napolitano V, Orditura M (2014) Is complete mesocolic excision with central vascular ligation safe and effective in the surgical treatment of right-sided colon cancers? A prospective study. Int J Colorectal Dis 29:89–97CrossRefGoogle Scholar
  23. 23.
    Ishihara S, Otani K, Yasuda K, Nishikawa T, Tanaka T, Tanaka J, Kiyomatsu T, Kawai K, Hata K, Nozawa H, Kazama S, Yamaguchi H, Sunami E, Kitayama J, Sugihara K, Watanabe T (2016) Prognostic impact of lymph node dissection is different for male and female colon cancer patients: a propensity score analysis in a multicenter retrospective study. Int J Colorectal Dis 31:1149–1155CrossRefGoogle Scholar
  24. 24.
    Merkel S, Weber K, Matzel KE, Agaimy A, Gohl J, Hohenberger W (2016) Prognosis of patients with colonic carcinoma before, during and after implementation of complete mesocolic excision. Br J Surg 103:1220–1229CrossRefGoogle Scholar
  25. 25.
    Olofsson F, Buchwald P, Elmstahl S, Syk I (2016) No benefit of extended mesenteric resection with central vascular ligation in right-sided colon cancer. Colorectal Dis 18:773–778CrossRefGoogle Scholar
  26. 26.
    Storli KE, Sondenaa K, Furnes B, Nesvik I, Gudlaugsson E, Bukholm I, Eide GE (2014) Short term results of complete (D3) vs. standard (D2) mesenteric excision in colon cancer shows improved outcome of complete mesenteric excision in patients with TNM stages I-II. Tech Coloproctol 18:557–564CrossRefGoogle Scholar
  27. 27.
    Thorsen Y, Stimec B, Andersen SN, Lindstrom JC, Pfeffer F, Oresland T, Ignjatovic D (2016) Bowel function and quality of life after superior mesenteric nerve plexus transection in right colectomy with D3 extended mesenterectomy. Tech Coloproctol 20:445–453CrossRefGoogle Scholar
  28. 28.
    Killeen S, Mannion M, Devaney A, Winter DC (2014) Complete mesocolic resection and extended lymphadenectomy for colon cancer: a systematic review. Colorectal Dis 16:577–594CrossRefGoogle Scholar
  29. 29.
    Kontovounisios C, Kinross J, Tan E, Brown G, Rasheed S, Tekkis P (2015) Complete mesocolic excision in colorectal cancer: a systematic review. Colorectal Dis 17:7–16CrossRefGoogle Scholar
  30. 30.
    Kobayashi H, West NP, Takahashi K, Perrakis A, Weber K, Hohenberger W, Quirke P, Sugihara K (2014) Quality of surgery for stage III colon cancer: comparison between England, Germany, and Japan. Ann Surg Oncol 21(Suppl 3):S398–S404CrossRefGoogle Scholar
  31. 31.
    Ishiguro M, Higashi T, Watanabe T, Sugihara K, Japanese Society for Cancer of the Colon and Rectum (2014) Changes in colorectal cancer care in Japan before and after guideline publication: a nationwide survey about D3 lymph node dissection and adjuvant chemotherapy. J Am Coll Surg 218:969–977CrossRefGoogle Scholar
  32. 32.
    Colon Cancer Laparoscopic or Open Resection Study Group, Buunen M, Veldkamp R, Hop WC, Kuhry E, Jeekel J, Haglind E, Pahlman L, Cuesta MA, Msika S, Morino M, Lacy A, Bonjer HJ (2009) Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol 10:44–52CrossRefGoogle Scholar
  33. 33.
    Fleshman J, Sargent DJ, Green E, Anvari M, Stryker SJ, Beart RW Jr, Hellinger M, Flanagan R Jr, Peters W, Nelson H, Clinical Outcomes of Surgical Therapy Study Group (2007) Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg 246:655–662 (discussion 662–654)CrossRefGoogle Scholar
  34. 34.
    Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Smith AM, Heath RM, Brown JM, Group UMCT (2007) Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol 25:3061–3068CrossRefGoogle Scholar
  35. 35.
    Lacy AM, Delgado S, Castells A, Prins HA, Arroyo V, Ibarzabal A, Pique JM (2008) The long-term results of a randomized clinical trial of laparoscopy-assisted versus open surgery for colon cancer. Ann Surg 248:1–7CrossRefGoogle Scholar
  36. 36.
    Coffey JC, Dockery P (2016) Colorectal cancer: surgery for colorectal cancer—standardization required. Nat Rev Gastroenterol Hepatol 13:256–257CrossRefGoogle Scholar
  37. 37.
    McSorley ST, Horgan PG, McMillan DC (2016) The impact of the type and severity of postoperative complications on long-term outcomes following surgery for colorectal cancer: a systematic review and meta-analysis. Crit Rev Oncol Hematol 97:168–177CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Centre for Colon and Rectal SurgeryMcGill University Health CentreMontrealCanada
  2. 2.Steinberg-Bernstein Centre for Minimally Invasive Surgery and InnovationMcGill University Health CentreMontrealCanada
  3. 3.Department of Surgery, College of MedicineKing Saud UniversityRiyadhSaudi Arabia

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