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Komplette mesokolische Exzision

Gibt es genügend Evidenz?

Complete mesocolic excision

Is there enough evidence?

Zusammenfassung

Nach wie vor stellt die primäre Resektion die Standardtherapie des nichtmetastasierten Kolonkarzinoms dar. Analog zum weltweit anerkannten Konzept der totalen mesorektalen Exzision („total mesorectal excision“, TME) für das Rektumkarzinom wurde für das Kolonkarzinom das Konzept der kompletten mesokolischen Exzision („complete mesocolic excision“, CME) vorgestellt, welches die Entfernung des jeweils onkologisch relevanten Mesokolons unter Respektierung der Integrität des Mesokolons sowie die zentrale vaskuläre Ligatur (CVL) mit radikaler Lymphknotendissektion beinhaltet. Die aktuelle Datenlage zur CME zeigt mit starker Evidenz, dass die Präparate nach CME-Resektionen bessere histopathologische Qualitätskriterien (inkl. einer höheren Anzahl an resezierten Lymphknoten und einer höheren Dissektionsrate in der korrekten mesokolischen Schicht) aufweisen als jene nach konventioneller, nicht den Prinzipien der CME folgenden Kolonresektion. Allerdings besteht bisher aufgrund einer teils heterogenen Studienlage und Schwächen der bisherigen Studien (fehlende Subgruppenanalysen nach Lokalisation des Karzinoms, Vergleich mit historischen Kollektiven und enorme Divergenz in der chirurgischen Ausführung der konventionellen Kolonresektionen) eine noch limitierte Evidenz für das onkologische Ergebnis und den Vergleich zwischen offener und laparoskopischer CME. Weitere Studien zum onkologischen Outcome sind notwendig, um der CME für Kolonkarzinome den gleichen Stellenwert wie der TME für Rektumkarzinome zuschreiben zu können.

Abstract

Standard therapy of nonmetastatic colon cancer is primary resection. Similar to the worldwide accepted concept of total mesorectal excision (TME) for rectal cancer, the concept of complete mesocolic excision (CME) was introduced for colon cancer and consists of resection of the mesocolon while respecting the integrity of the mesocolon as well as central vascular ligation (CVL) with radical lymph node dissection. Current data on CME shows strong evidence that specimens from CME resections have better histopathological quality criteria, including a higher number of resected lymph nodes and a higher dissection rate in the correct mesocolic plane than those after “conventional” colon resection. However, due to partly heterogeneous study results and weaknesses of previous studies (lack of subgroup analysis, comparison with historical collectives and enormous divergence in conventional colon resections), there is limited evidence for the oncological outcome and the comparison between open and laparoscopic CME. Further studies on oncological outcome after CME are needed in order that CME colon resection for colon cancer achieve the same status as TME rectal resection for rectal cancer.

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Literatur

  1. Gesellschaft der epidemiologischen Krebsregister in Deutschland e. V. (GEKID) (2017) http://www.gekid.de/. Zugegriffen: 21. Dez. 2017

  2. Parkin DM et al (2005) Global cancer statistics, 2002. Ca Cancer J Clin 55(2):74–108

    Article  PubMed  Google Scholar 

  3. Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF) S3-Leitlinie Kolorektales Karzinom, Langversion 2.0, 2017, AWMF Registrierungsnummer: 021/007OL, http://www.leitlinienprogramm-onkologie.de/leitlinien/kolorektales-karzinom/. Zugegriffen: 21. Dez. 2017

  4. Hermanek P Jr et al (1994) Langzeitergebnisse der chirurgischen Therapie des Coloncarcinoms. Chirurg 65(4):287–297

    PubMed  Google Scholar 

  5. Kessler H et al (1998) Does the surgeon affect outcome in colon carcinoma? Semin Colon Rectal Surg 9:233–240

    Google Scholar 

  6. Heald RJ et al (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1(8496):1479–1482

    CAS  Article  PubMed  Google Scholar 

  7. Quirke P et al (2009) Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet 373(9666):821–828

    Article  PubMed  PubMed Central  Google Scholar 

  8. Heald RJ (1988) The „Holy Plane“ of rectal surgery. J R Soc Med 81(9):503–508

    CAS  PubMed  PubMed Central  Google Scholar 

  9. Hohenberger W et al (2009) Standardized surgery for colonic cancer: complete mesocolic excision and central ligation – technical notes and outcome. Colorectal Dis 11(4):354–364 (discussion 364–365)

    CAS  Article  PubMed  Google Scholar 

  10. Killeen S et al (2014) Complete mesocolic resection and extended lymphadenectomy for colon cancer: a systematic review. Colorectal Dis 16:577–594

    CAS  Article  PubMed  Google Scholar 

  11. Willaert W et al (2015) Extent of surgery in cancer of the colon: is more better? World J Gastroenterol 21:132–138

    Article  PubMed  PubMed Central  Google Scholar 

  12. Killeen S et al (2014) Complete mesocolic resection and extended lymphadenectomy for colon cancer: a systematic review. Colorectal Dis 16(8):577–594

    CAS  Article  PubMed  Google Scholar 

  13. Kontovounisios C et al (2015) Complete mesocolic excision in colorectal cancer: a systematic review. Colorectal Dis 17(1):7–16

    CAS  Article  PubMed  Google Scholar 

  14. Dimitriou N et al (2015) Complete mesocolic excision: techniques and outcomes. World J Gastrointest Oncol 7(12):383–388

    Article  PubMed  PubMed Central  Google Scholar 

  15. Gouvas N et al (2016) Surgery along the embryological planes for colon cancer: a systematic review of complete mesocolic excision. Int J Colorectal Dis 31(9):1577–1594

    Article  PubMed  Google Scholar 

  16. West NP et al (2008) Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study. Lancet Oncol 9(9):857–865

    Article  PubMed  Google Scholar 

  17. West NP et al (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(2):272–278

    Article  PubMed  Google Scholar 

  18. West NP et al (2010) Improving the quality of colon cancer surgery through a surgical education program. Dis Colon Rectum 53(12):1594–1603

    Article  PubMed  Google Scholar 

  19. West NP et al (2012) Understanding optimal colonic cancer surgery: comparison of Japanese D3 resection and European complete mesocolic excision with central vascular ligation. J Clin Oncol 30(15):1763–1769

    Article  PubMed  Google Scholar 

  20. Bertelsen CA et al (2011) Can the quality of colonic surgery be improved by standardization of surgical technique with complete mesocolic excision? Colorectal Dis 13(10):1123–1129

    CAS  Article  PubMed  Google Scholar 

  21. Galizia G et al (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(1):89–97

    Article  PubMed  Google Scholar 

  22. Bertelsen CA et al (2015) Disease-free survival after complete mesocolic excision compared with conventional colon cancer surgery: a retrospective, population-based study. Lancet Oncol 16(2):161–168

    Article  PubMed  Google Scholar 

  23. Merkel S et al (2016) Prognosis of patients with colonic carcinoma before, during and after implementation of complete mesocolic excision. Br J Surg 103(9):1220–1229

    CAS  Article  PubMed  Google Scholar 

  24. Storli KE et al (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(6):557–564

    CAS  Article  PubMed  Google Scholar 

  25. Bokey EL et al (2003) Surgical technique and survival in patients having a curative resection for colon cancer. Dis Colon Rectum 46(7):860–866

    CAS  Article  PubMed  Google Scholar 

  26. Siani LM et al (2015) Laparoscopic complete mesocolic excision with central vascular ligation in right colon cancer: long-term oncologic outcome between mesocolic and non-mesocolic planes of surgery. Scand J Surg 104(4):219–226

    CAS  Article  PubMed  Google Scholar 

  27. Leite J et al (2011) Clinical significance of macroscopic completeness of mesorectal resection in rectal cancer. Colorectal Dis 13:381–386

    CAS  Article  PubMed  Google Scholar 

  28. Nagtegaal I et al (2008) What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 26:303–312

    Article  PubMed  Google Scholar 

  29. Quirke P et al (2009) Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet 373:821–828

    Article  PubMed  PubMed Central  Google Scholar 

  30. Lux P et al (2014) Laparoscopic surgery for colon cancer: quality requirements for (extended) right hemicolectomy. Chirurg 85(7):593–598

    CAS  Article  PubMed  Google Scholar 

  31. Toyota S et al (1995) Rationale for extent of lymph node dissection for right colon cancer. Dis Colon Rectum 38(7):705–711

    CAS  Article  PubMed  Google Scholar 

  32. Kanemitsu Y et al (2013) D3 lymph node dissection in right hemicolectomy with a no-touch isolation technique in patients with colon cancer. Dis Colon Rectum 56(7):815–824

    Article  PubMed  Google Scholar 

  33. Benz SR et al (2015) Complete mesocolic excision for right-sided colon cancer – the role of central lymph nodes. Zentralbl Chir 140(4):449–452

    CAS  PubMed  Google Scholar 

  34. Weber K et al (2013) Is there a disadvantage to radical lymph node dissection in colon cancer? Int J Colorectal Dis 28(2):217–226

    CAS  Article  PubMed  Google Scholar 

  35. Bertelsen CA et al (2016) Short-term outcomes after complete mesocolic excision compared with „conventional“ colonic cancer surgery. Br J Surg 103(5):581–589

    CAS  Article  PubMed  Google Scholar 

  36. Bertelsen CA et al (2017) Long-term bowel function after right sided complete mesocoloc excision compared with conventional surgery: a questionnaire survey. Colorectal Dis 19(suppl.2):18

    Google Scholar 

  37. Storli KE et al (2013) Outcome after introduction of complete mesocolic excision for colon cancer is similar for open and laparoscopic surgical treatments. Dig Surg 30(4–6):317–327

    Article  PubMed  Google Scholar 

  38. Bae SU et al (2014) Laparoscopic-assisted versus open complete mesocolic excision and central vascular ligation for right-sided colon cancer. Ann Surg Oncol 21(7):2288–2294

    Article  PubMed  Google Scholar 

  39. Cho MS et al (2015) Modified complete mesocolic excision with central vascular ligation for the treatment of right-sided colon cancer: long-term outcomes and prognostic factors. Ann Surg 261(4):708–715

    Article  PubMed  Google Scholar 

  40. Perrakis A et al (2014) Lymph node metastasis of carcinomas of transverse colon including flexures. Consideration of the extramesocolic lymph node stations. Int J Colorectal Dis 29(10):1223–1229

    Article  PubMed  Google Scholar 

  41. Bertelsen CA et al (2014) Lymph node metastases in the gastrocolic ligament in patients with colon cancer. Dis Colon Rectum 57(7):839–845

    Article  PubMed  Google Scholar 

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Correspondence to R. Grützmann MBA.

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Interessenkonflikt

M. Brunner, M. Maak, K.E. Matzel, A. Denz, K. Weber und R. Grützmann geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Brunner, M., Maak, M., Matzel, K.E. et al. Komplette mesokolische Exzision. coloproctology 40, 8–14 (2018). https://doi.org/10.1007/s00053-017-0219-3

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  • DOI: https://doi.org/10.1007/s00053-017-0219-3

Schlüsselwörter

  • Kolonresektion
  • Kolonkarzinom
  • Zentrale Gefäßligatur
  • Lymphknotendissektion
  • Integrität des Mesokolons

Keywords

  • Colon resection
  • Colon cancer
  • Central vascular ligation
  • Lymph node dissection
  • Mesocolic plane