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Techniques in Coloproctology

, Volume 18, Issue 9, pp 795–803 | Cite as

Complete mesocolic excision with D3 lymph node dissection in laparoscopic colectomy for stages II and III colon cancer: long-term oncologic outcomes in 168 patients

  • J. W. Shin
  • A. H. Y. Amar
  • S. H. KimEmail author
  • J. M. Kwak
  • S. J. Baek
  • J. S. Cho
  • J. Kim
Original Article

Abstract

Background

There is emerging evidence that complete mesocolic excision (CME) for colon cancer produces favorable oncologic outcomes. The applicability of CME technique in laparoscopic colectomy has not been fully explored. The aim of our retrospective study was to evaluate the feasibility of the CME technique with D3 lymphadenectomy in laparoscopic colectomy and its short- and long-term outcomes.

Methods

Between September 2006 and December 2009, 168 laparoscopic colectomies were performed for stages II and III colon cancer. Prospectively, collected data on demographics, tumor characteristics, complications, and outcomes were analyzed retrospectively.

Results

Eighty-seven patients (51.8 %) had stage II colon cancer, and 81 patients had stage III cancer. The mean operative time was 196.0 ± 61.2 min. The overall morbidity rate was 17.8 %, which included anastomotic leak in 10 patients (5.9 %). There was no operative mortality. The number of lymph nodes harvested was 27.8 ± 13.6. With a median follow-up of 57.3 months, locoregional recurrence and systemic metastasis developed in 6 (3.6 %) and 14 patients (8.3 %), respectively. Seven patients died of causes related to cancer, and all had stage III cancer. Disease-free survival at 5-years was 95.2 % for patients with stage II and 80.9 % for patients with stage III.

Conclusions

Standardization of laparoscopic CME and D3 lymphadenectomy is expedient. The technique is associated with acceptable morbidity and provides excellent oncologic outcomes for stage II and stage III colon cancer. A longer follow-up is needed to validate the enhancement of oncological outcome related to this surgical concept.

Keywords

Colon cancer Laparoscopic colectomy Complete mesocolic excision D3 lymphadenectomy 

Introduction

The global burden of colon cancer is high and continues to increase. En bloc tumor resection is widely utilized in colon cancer operations. However, the adopted surgical technique, which continues to be debated, depends on the individual surgeon and the presence of radical lymph node dissection. It is becoming increasingly evident that differences in oncologic outcomes between surgeons are due to the differences in the techniques used.

Hohenberger et al. [1] evaluated complete mesocolic excision (CME) and central vascular ligation (CVL) as standardized surgical techniques for colon cancer. They described the need to perform a sharp dissection of the visceral plane from the retroperitoneum during the procedure, which exposes the origin of the colonic arteries that are subsequently tied centrally at their origin. West et al. [2, 3] suggested that Hohenberger’s technique is a type of aggressive surgery intended to remove the entire colonic mesentery, and therefore, all potential sites of nodal and intravascular tumor spread. The principles behind this technique are to avoid any breaches of the visceral layer that might cause inadvertent exfoliation of the tumor cells into the peritoneal cavity and to maximize regional lymph node dissection, all while keeping the layers of the specimen intact. The above procedure was described exclusively for open surgery [1, 2, 3]. However, this technique still remains controversial in many Western countries. Japanese D3 dissection in colon cancer surgery [4] is based on the same concept as CME with CVL, with regard to the extent of lymph node dissection at the origin of the supplying arteries [5], and has been widely accepted in East Asian countries, including Korea.

Laparoscopic colectomy is evolving and more or less becoming a standard procedure in most colorectal departments. However, the applicability of this surgery to D3 lymphadenectomy or CME with CVL in colon cancer has not been fully explored. Recently, several studies have demonstrated the feasibility of laparoscopic CME, primarily for right colon cancer [6, 7]. We aimed to investigate the feasibility and outcomes of laparoscopic-assisted colectomy for treating stages II and III colon cancer by adopting the principle proposed by Hohenberger. We hypothesized that D3 lymphadenectomy for stage II colon cancer would reduce the potential to understage the cancer and thus increase patient survival. For stage III cancer, the procedure should remove all potential metastatic lymph nodes, resulting in at least better locoregional control than lymphadenectomy with a conventional high tie of the supplying arteries.

Materials and methods

Patients

Data from colon cancer patients who underwent laparoscopic resection performed by one surgeon (SHK) at Korea University Anam Hospital between September 2006 and December 2009 were collected and analyzed retrospectively. The inclusion criteria were pTNM II or pTNM III colon adenocarcinoma, located anywhere from the cecum to the rectosigmoid junction. We included the patients who underwent emergent laparoscopic colectomy for obstruction. The exclusion criteria were as follows: patients with synchronous cancers, conversion to an open surgery, and patients in whom the follow-up was less than 6 months. In total, 272 patients underwent colectomy for colon cancer during this period. After 32 patients were excluded (18 robotic surgeries, 11 open surgeries, 2 hand-assisted surgeries, and one conversion to open surgery), 240 patients remained for laparoscopic colectomy and 168 p TNM II and III patients (91 males and 77 females) were analyzed for this study.

Laparoscopic surgical techniques

Right-sided colectomy (Fig. 1)

Using a five-port technique, the omentum and transverse colon are moved toward the upper abdomen so that the ventral side of the right mesocolon is well visualized. With adequate traction of the mesocolon near the ileocecal junction toward the right upper quadrant, the ileocolic vessels are mobilized from the subperitoneal fascia leading to the duodenum. Their origins are identified from the superior mesenteric vessels at the lower border of the duodenum, skeletonized, and divided with clips. A careful dissection onto the duodenum and the caudal portion of the pancreas is performed. A dissection around the gastrocolic trunk is performed, leading to the exposure of the middle colic artery and vein. In cases of the cecal or ascending colon cancer, the right branch of the middle colic artery is skeletonized and divided. For cancers in the hepatic flexure or transverse colon, the origin of the middle colic artery is divided. The gastroepiploic arcade is not dissected for lymph node harvest. The right mesocolon is mobilized from its retroperitoneal attachment along an avascular plane with preservation of the right ureter and the gonadal vessels, while attempting to avoid breeching the mesocolon using a medial-to-lateral technique. At the right pelvic brim, the peritoneum is incised along the base of the ileal mesentery upward to the duodenum, mobilizing the ileocecal region. This plane is connected to the previous plane of dissection from the caudal side. Finally, the hepatic flexure and the right colon, including the tumor-bearing segment, are detached laterally so as to mobilize the entire right colon. The specimen is withdrawn through a vertical enlargement of the umbilical port covered with a wound protector. The resection of the ileum and the transverse colon is accomplished extracorporeally and a functional end-to-end anastomosis is performed using a stapler. The anastomotic site is returned to the peritoneal cavity.
Fig. 1

a D3 lymph node dissection at the origin of the ileocolic vessels. b D3 lymph node dissection at the origin of the middle colic vessels. c An anterior view of D3 right hemicolectomy specimen with ascending colon cancer (arrowhead). ICA ileocolic artery, ICV ileocolic vein, MCA middle colic artery, MCV middle colic vein, P pancreas, V superior mesenteric vein, A superior mesenteric artery

Left-sided colectomy (Fig. 2)

Using a five-port technique, the greater omentum and the transverse colon are placed in the upper abdomen. Subsequently, the small bowel loops are placed in the right upper quadrant. The sacral promontory and aortoiliac axis are exposed. The sigmoid mesocolon is retracted anteriorly, and the visceral peritoneum on the base of the sigmoid mesocolon is incised at the level of the sacral promontory. The incision is continued upward to the ligament of Treitz, and the origin of the inferior mesenteric artery (IMA) is exposed. The IMA is dissected free from the aorta; its origin is skeletonized, then divided. The inferior mesenteric vein is divided below the inferior border of the pancreas. The avascular plane between Toldt’s fascia and the left-sided mesocolon is identified, and the dissection continues from medial to lateral. The hypogastric nerve plexus, left ureter, and gonadal vessels are preserved. Laterally, the sigmoid loop is mobilized by incising along Toldt’s line. When the mobilization of the splenic flexure is needed, a medial approach is used. While the transverse colon is retracted anteriorly, the root of the transverse mesocolon is divided to dissect onto the body and tail of the pancreas and to enter the lesser sac. Then, the dissection moves toward the base of the distal transverse colon and the descending colon. The posterior attachments of these structures are divided while preserving Gerota’s fascia. The lateral attachment is freed up to the spleen and the phrenocolic ligament. The splenic flexure is fully mobilized after the omentum is detached from the colon. The distal division of the colon is performed intracorporeally using a linear stapler. The proximal specimen is generally extracted through an extended wound at the umbilicus. The proximal division is performed extracorporeally after dividing the mesocolon up to the chosen site. The anastomosis is performed intracorporeally using a circular stapler device, which is passed transanally.
Fig. 2

a D3 lymph node dissection at the origin of the inferior mesenteric artery. b During a left hemicolectomy, the dissection onto the superior aspect of the pancreas is achieved by dividing the root of the transverse mesocolon to enter the lesser sac, while the transverse colon is retracted anteriorly. c A specimen of the D3 left hemicolectomy for splenic flexure cancer (arrowhead) shows the lymph nodes harvested at the origin of the middle and the left colic arteries. There is always a slit along the distal transverse colonic mesentery (arrow), secondary to the detachment from the pancreas. IMA inferior mesenteric artery, A aorta, TM transverse mesocolon, LS lesser sac, P pancreas, M lymph nodes around the middle colic artery, L lymph nodes around the left colic artery

Outcome assessment

This study was approved by the Institutional Review Board (IRB No. ED12136). Local recurrence was defined as a tumor that had recurred at the anastomotic site or at the tumor bed. Regional recurrence was defined as a tumor recurring in the regional nodes according to the American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 7th edition. Distant metastasis was defined as a tumor recurring at a site distant from the site of resection (for instance liver or lung) including peritoneal seeding(s). Operative mortality was defined as a death within 30 days after the operation, or a death during the same hospitalization without discharge. Follow-up studies included physical examination and serum carcinoembryonic antigen (CEA) assay every 3 months for the first 2 years and thereafter every 6 months. A chest X-ray and abdominopelvic computed tomography (CT) scan were taken every 6 months, for the first 2 years then annually for the following years. Colonoscopy was performed annually. Additional tests including chest CT or positron emission tomography (PET) scan were performed on an as-needed basis.

Statistics

All analyses were performed using the SPSS for Windows version 17.0 (SPSS Inc., Chicago, IL, USA). Locoregional recurrence, distant metastasis, and overall survival were calculated using the Kaplan–Meier method and the log-rank (Mantel–Cox) test. A p value of <0.05 was considered to be significant.

Results

There were 87 stage II tumors (51.8 %) and 81 stage III (48.2 %) tumors. Seventy-five patients with stage III tumors (92.6 %) received FOLFOX 4 regimen for adjuvant chemotherapy. Among the 87 patients with stage II cancer, 16 patients (18.3 %) that had the following risk factor(s): lymphatic invasion, vascular invasion, obstruction or obstruction received the same chemotherapy. None of the patients received radiotherapy. The mean age was 61.9 ± 12.4 years, and the mean body mass index (BMI) was 23.9 ± 2.9 kg/m2. The majority of cases were American Society of Anesthesiologists (ASA) class I and II (n = 70, 41.7 % and n = 88, 52.3 %, respectively). The most common location of the tumor was the sigmoid colon (n = 74, 44 %) followed by the right-sided colon (cecum, ascending colon and hepatic flexure; n = 65, 38.7 %), transverse colon (n = 15, 8.9 %), and the left-sided colon (descending colon and splenic flexure; n = 14, 8.3 %). Patient demographics are summarized in Table 1. The mean number of lymph nodes harvested was 27.8 ± 13.6 (range, 3–76) nodes. The majority of patients (n = 158, 94 %) had more than 12 lymph nodes harvested. The mean proximal and distal resection margins for ascending colon cancers were 12.8 ± 6.5 and 16.4 ± 10.1 cm, respectively and for descending and sigmoid colon cancers, the margins were 15.0 ± 9.3 and 6.8 ± 5.4 cm, respectively. Perioperative complications occurred in 30 patients (17.8 %) but there was no operative mortality. There were 10 (5.9 %) anastomotic leaks, and five of them required surgical treatment. The mean operating time was 196.0 ± 61.2 min, the estimated blood loss was 81.6 ± 205.2 mL, and the mean hospital stay was 8.8 ± 4.6 days (Table 2).
Table 1

Demographics of the 168 patients undergoing laparoscopic colectomy with CME and D3 dissection for stages II and III colon cancer

Age (years)

 Mean ± SD

61.9 ± 12.4

 Median, range

63 (23–91)

Gender [n (%)]

 Male

91 (54.2)

 Female

77 (45.8)

BMI (kg/m2)

 Mean ± SD

23.9 ± 2.9

 Median, range

23.7 (17.2–32.4)

ASA score [n (%)]

 I

70 (41.7)

 II

88 (52.3)

 III

10 (6.0)

Tumor locations

 Right colon

65 (38.7)

 Transverse colon

15 (8.9)

 Left colon

14 (8.3)

 Sigmoid colon

74 (44.1)

SD standard deviation, BMI body mass index, ASA American Society of Anesthesiologists; CME complete mesocolic excision

Table 2

Clinicopathological variables, operative outcomes, and oncologic outcomes after CME with D3 lymph node dissection

 

Stage II (n = 87)

Stage III (n = 81)

Total (n = 168)

pT stage [n (%)]

 T1

 

2 (2.5)

2 (1.2)

 T2

 

3 (3.7)

3 (1.8)

 T3

78 (89.7)

69 (85.2)

147 (87.5)

 T4

9 (10.3)

7 (8.6)

16 (9.5)

pN stage [n (%)]

 N0

   

 N1

 

61 (75.3)

61 (36.3)

 N2

 

20 (24.7)

20 (11.9)

Tumor differentiation [n (%)]

 Well

37 (42.5)

20 (25.0)

57 (34.1)

 Moderate

44 (50.6)

54 (67.4)

98 (58.7)

 Poor

1 (1.2)

3 (3.8)

4 (2.4)

 Other

5 (5.7)

3 (3.8)

8 (4.8)

LVN infiltration [n (%)]

 0

79 (90.8)

61 (75.3)

140 (83.3)

 1

8 (9.2)

20 (24.7)

28 (16.7)

Number of the harvested LN

 Mean ± SD

  

27.8 ± 13.6

 Median, range

  

25.5 (3–76)

LN harvested [n (%)]

 <12 LNs

3 (3.4)

7 (8.6)

10 (6.0)

 >12 LNs

84 (96.6)

74 (91.4)

158 (94.0)

Proximal margin (cm)

 Ascending colon

  

12.8 ± 6.5

 Transverse colon

  

22.2 ± 17.8

 Descending/sigmoid colon

  

15.0 ± 9.3

Distal margin (cm)

 Ascending colon

  

16.4 ± 10.1

 Transverse colon

  

13.8 ± 10.3

 Descending/sigmoid colon

  

6.8 ± 5.4

Operative time (min)

 Mean ± SD

  

196.0 ± 61.2

 Median

  

187.5

Estimated blood loss (mL, mean ± SD)

  

81.6 ± 205.2

Time to oral intake (days, mean ± SD)

  

2.4 ± 1.6 (range 1–15)

Postoperative hospital stay (days, mean ± SD)

  

8.8 ± 4.6 (range 4–30)

Complications [n (%)]

  

30 (17.8)

 Anastomotic leak

6 (6.9)

4 (5)

10 (5.9)

  Perianastomotic inflammation only

1 (1.2)

2 (2.5)

3 (1.8)

  Requiring percutaneous drainage

2 (2.3)

0

2 (1.2)

  Requiring surgical intervention

3 (3.4)

2 (2.5)

5 (3)

 Wound infection

1 (1.2)

3 (3.7)

4 (2.4)

 Bleeding

2 (2.3)

0

2 (1.2)

 Urinary retention

2 (2.3)

1 (1.2)

3 (1.8)

 Chyle leakage

0

2 (2.5)

2 (1.2)

 Ileus

3 (3.4)

6 (7.4)

9 (5.4)

Operative mortality

0

0

None

Follow-up (months)

 Mean ± SD

  

56.4 ± 14.6

 Median, range

  

57.3 (6–81.3)

Recurrence [n (%)]

5 (5.7)

15 (18.5)

20 (11.9)

 Locoregional

1 (1.1)

5 (6.2)

6 (3.6)

 Distant metastasis

4 (4.6)

10 (12.3)

14 (8.3)

5-year cancer-specific survival (95 % CI)

100.0 %

90.5 % (83.8–97.2)

95.5 % (92.2–98.8)

5-year disease-free survival (95 % CI)

95.2 % (90.7–99.7)

80.9 % (72.3–89.5)

88.3 % (83.4–93.2)

5-year overall survival (95 % CI)

93.9 % (87.9–99.9)

84.9 % (77.06–92.74)

89.6 % (84.9–94.3)

SD standard deviation, LVN lymphovascular and perineural, LN lymph node, CI confidence interval, CME complete mesocolic excision

With a mean follow-up of 56.4 ± 14.6 months (range, 6–81.3 months), locoregional recurrence developed in six patients (3.6 %), and distant metastasis occurred in 14 patients (8.3 %). Among the patients with stage II cancer, one patient had local recurrence at the anastomotic site and 4 had distant metastases. Among the patients with stage III cancer, fie had regional recurrences at the main mesenteric artery nodes and 10 had distant metastases. Seven patients, all with stage III cancer, died of causes related to cancer. The disease-free survival rates at 5-years for stages II and III were 95.2 % [95 % confidence interval (CI), 90.7–99.7 %] and 80.9 % (95 % CI, 72.3–89.5 %), respectively. The cancer-specific survival at 5-years for stages II and III were 100 and 90.5 % (95 % CI, 83.8–97.2 %), respectively. The overall survival rates at 5-years for stages II and III were 93.9 % (95 % CI, 87.9–99.9 %) and 84.9 % (95 % CI, 77.06–92.74 %), respectively. The oncologic outcomes are summarized in Table 2. Kaplan–Meier curves of disease-free survival, cancer-specific survival, and overall survival are depicted in Fig. 3.
Fig. 3

Kaplan–Meier curves of disease-free survival, cancer-specific survival, and overall survival (blue line = stage II, green line = stage III). Five patients who died of non-cancerous disease within 1 year were excluded from analysis of cancer-specific survival

Discussion

Rectal cancer surgery has continued to progress since the concept of total mesorectal excision (TME) was introduced [8]. TME emphasized the importance of maintaining the integrity of the mesorectal envelope, as this decreases local recurrence that is the end point for a locoregional treatment. Quirke et al. [9] demonstrated that local recurrence was related to the state of the circumferential resection margin when examined in resected specimens. Hohenberger et al. [1] applied this concept in operative strategies for colon cancer based on the hypothesis that the degree of intactness of the visceral fascia of the resected specimen has prognostic relevance. They showed that after the implementation of this technique, the 5-year cancer-related survival rate increased by 7 % (from 82.1 to 89.1 %) and the locoregional recurrence rate decreased by 2.9 % (from 6.5 to 3.6 %). This was subsequently supported by West et al. [2, 3]. In fact, the importance of mobilization of the colon along the anatomical planes with regard to oncologic outcome was not a new concept. Bokey et al. [10] demonstrated that the overall 5-year survival rose from 48.1 to 63.7 % and cancer-specific survival increased from 66.4 to 77.6 % after the introduction of a standardized surgical technique based on this concept. Another key point of Hohenberger’s technique is radical lymph node dissection around the origin of the supplying arteries, which is the same concept used in Japanese D3 lymphadenectomy [5]. Most of these surgical techniques have been well described for CME and CVL, particularly in relation to open surgery [11, 12].

The general surgical field has changed with a shift toward the laparoscopic technique. Even in colorectal fields, laparoscopic colectomy is gaining popularity and has become more or less a “standard” operation in major colorectal centers worldwide. Most of the controversial issues regarding safety, the advantages of laparoscopic colectomy, and oncological outcomes have been resolved after multiple studies in large-scale randomized trials [13, 14, 15, 16, 17, 18, 19]. Hohenberger’s concept may be adopted in minimally invasive surgery to achieve similar outcomes. However, we believe that laparoscopic colectomy with the application of CME with CVL or D3 lymph node dissection is not widely practiced. This is partly due to the lack of good evidence that this technique has a positive effect on oncologic outcomes, and perhaps more practically due to the technical difficulty associated with performing this type of radical operation laparoscopically. Currently, several single institutions, in small studies, have reported that laparoscopic CME or D3 resection is feasible and does not compromise patient safety [6, 7, 20, 21, 22, 23]. Even so, the technique has not been well described and standardized in laparoscopy, particularly for cancers located in the transverse colon [7]. Recently, we published the long-term oncologic outcomes of 58 patients with transverse colon cancer treated by laparoscopic resection and adapted CME with D3 lymph node dissection [24]. The results demonstrate 5-year disease-free survival rates of 93.3 % in stage II cancers and 76.9 % in stage III cancers.

In our division, most of the colorectal cases are operated on laparoscopically. A principle similar to the concept of CME and CVL has been applied to colon cancers to achieve optimum oncological resection in cases in which the preoperative clinical stage is T2-4 or N positive, as described in the Japanese guidelines [4]. The present study analyzed a relatively large number of pathologically proven stage II and III cancers (n = 168). Our data showed that the median number of lymph nodes harvested was 25.5. Only 6 % (n = 10) of cases had less than 12 lymph nodes harvested. However, the number of lymph nodes retrieved can vary with age, gender, tumor grade, and tumor site [25, 26, 27]. Lymph node yields also depend on the skill of both the surgeon and the pathologist [28]. Moreover, merely counting the number of nodes in the resected specimen does not guarantee that an adequate oncologic resection has been achieved, since simple removal of a long segment of the colon with epiploic and paracolic lymph nodes can theoretically show the same number of nodes as the removal of a smaller colonic segment with central nodal harvest. Therefore, we believe that the extent of lymph node dissection in combination with an adequate number of lymph nodes harvested is much more important. Additionally, considering that there are some patients in whom lymph node metastasis has been skipped, the above statement seems especially true. According to Liang et al. [20], mapping of dissected lymph nodes showed that 18.2 % (16 of 88) patients had skipped metastasis. Other studies also report that skipped lymph node metastasis may occur in about 20 % of the patients [29, 30]. Although we did not obtain our own data on the rate of skipped metastasis because of the retrospective nature of this study, we can deduce that there was little to no possibility of understaging in stage II cancers because all the regional lymph nodes were dissected off at the vascular origin. This may be one explanation as to why there was only one anastomotic recurrence and no regional recurrences in our stage II cases (n = 87). The anastomotic recurrence developed in a T4N0M0 rectosigmoid cancer patient. The 5-year disease-free survival rate was 95.4 %. This may also be a reflection of the improved accuracy of staging especially after harvesting more lymph nodes around the vascular pedicles when minimally invasive surgery is performed as an aggressive procedure. Furthermore, our data strongly supported the hypothesis on the survival superiority of radical D3 dissection in stage II colon cancer compared with conventional high ligation, perhaps because of stage migration. An additional hypothesis of our study was that D3 lymph node resection provides excellent locoregional control in stage III cancers since all potentially positive regional lymph nodes are removed. In this analysis, 5 patients had regional recurrence (6.2 %). Overall and disease-free survival at 5 years for stage III cancers were 84.9 and 80.9 %, respectively, which we believe to be an outstanding outcome. The Japanese Society for Cancer of the Colon and Rectum also recommends a colectomy with D3 lymphadenectomy as a standard procedure. They affirmed that this is of critical importance for both accurate staging and local control of the disease and reported an overall 5-year survival rate of up to 76 % in stage III disease [31]. We agree that the follow-up time in this study was insufficient to evaluate all patterns of recurrence. Actually, five patients were followed-up for less than 12 months because they died of non-cancerous diseases. However, a median follow-up of 57.3 months seems acceptable for assessing at least locoregional recurrence. The oncologic outcomes of our study, compared with data from other CME or conventional colon cancer surgery, are summarized in Table 3 and suggest that CME with CVL is superior to conventional techniques.
Table 3

Comparison of long-term oncologic outcomes between CME with CVL (= D3 lymph node dissection) and conventional colon cancer surgery

Author

Operation type

TNM stage

Locoregional recurrence

Distant metastasis

5-year OS

Median follow-up

Hohenberger [1]

CME, open

I, II, III (n = 1,438)

4.6 %

NA

85 %

103 months

Pramateftakis [12]

CME, open RHC

0, I, II, III, IV (n = 115)

0.9 %

17.4 %

72.4 %

NA

COST trial [14]

CONV, open/lap

I, II, III (n = 863)

Open: 2.6 %

Open: 19.2 %

Open: 74.6 %

7 years

Lap: 2.3 %

Lap: 17.1 %

Lap: 76.4 %

CLASICC trial [16]

CONV, open/lap

I, II, III (n = 140/273)

NA

NA

Open: 62.7 %

56.3 months

Lap: 55.7 %

COLOR trial [18]

CONV, open/lap

I, II, III (n = 534/542)

Open: 7.0 %

Open: 12.2 %

Open: 74.2 %

53 months

Lap: 9.1 %

Lap: 14.8 %

Lap: 73.8 %

Storli [32]

CME, Open/lap

I, II, III (n = 123/128)

Open: 4.9 %

Open: 7.3 %

Open: 80.4 % (3-year)

48 months

Lap: 3.9 %

Lap: 9.4 %

Lap: 88.2 % (3-year)

Current study

CME, lap

II, III (n = 168)

3.6 %

8.3 %

89.6 %

57.3 months

CME complete mesocolic excision, CVL central vascular ligation, OS overall survival, Lap laparoscopic, CONV conventional, RHC right hemicolectomy, NA not applicable

The morbidity associated with a more radical dissection is a concern. In our study, postoperative recovery without any complications was observed in 82.2 % of patients, and there was no operative mortality. Two patients (1.2 %) experienced postoperative bleeding, which ceased with conservative management. Anastomotic leakage developed in 10 patients (5.9 %), but surgical intervention was needed in only five of them. The other five were treated conservatively (antibiotics with or without radiological intervention for percutaneous drainage). Three patients (1.8 %) had urinary retention, which was self-limiting. This may be due to the temporary disturbance of the autonomic nerve around the mesenteric root during the surgical procedure. The morbidity rates were all acceptable in other CME papers, ranging from 13.9 to 22.6 % [1, 11, 12].

One limitation of this study is that we could not provide the tissue morphometry data from the resected specimens, as described by West et al. [3]. However, the distance from the colon to the feeding artery origin may vary between individuals as may the volume of the mesentery, depending on vascular anatomy or body habitus [5]. Thus, we believe that this limitation did not negatively influence the outcome analysis. In addition, the grading of the dissection plane as described by West et al. [2] was not evaluated in our prospective database, which is definitely another limitation of this study. However, we can tell that the mesocolic plane dissection was intended in each case in this study. Another critical weakness of this study is that there was no control group (either open surgery or less extensive lymph node dissection) to more scientifically test our hypotheses. This inherent bias may influence our perspective on the efficacy and safety of this technique.

Additionally, we think that the population in this study might be different from that in Western countries. It is still unclear whether laparoscopic CME with D3 lymph node dissection is equally applicable to the typical Western patients. In 2013, Storli et al. [32] reported their prospective study of radical colon cancer surgery performed in a community teaching hospital in Norway, which is very similar to our technique. They concluded that there was no survival difference between patients who underwent open (n = 123) and laparoscopic (n = 128) CME colon cancer resection, and this type of radical oncologic surgery improved overall survival compared with their previous data from a conventional operation. This suggests that the implementation of this technique is highly feasible (either in open and laparoscopic operations) and should be applied even in Western countries to improve survival.

Conclusions

Laparoscopic colectomy with CME and D3 lymphadenectomy is highly feasible for stage II and stage III colonic carcinomas and has shown excellent oncologic results in a relatively large number of patients. However, a long follow-up is necessary. This may become a subject of interest in future studies on minimally invasive surgery. Well-designed randomized, prospective studies are needed to affirm this concept and to assess whether it is equivalent to or better than the open CME plus CVL surgery technique.

Notes

Conflict of interest

None.

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Copyright information

© Springer-Verlag Italia 2014

Authors and Affiliations

  • J. W. Shin
    • 1
  • A. H. Y. Amar
    • 2
  • S. H. Kim
    • 1
    Email author
  • J. M. Kwak
    • 1
  • S. J. Baek
    • 1
  • J. S. Cho
    • 1
  • J. Kim
    • 1
  1. 1.Colorectal Division, Department of SurgeryKorea University Anam Hospital, Korea University College of MedicineSeoulSouth Korea
  2. 2.Department of SurgeryHospital MelakaMelakaMalaysia

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