BACKGROUNDQuality control in colon cancer surgery is an ongoing debate ever since standardization proved to be highly efficient in improving survival in rectal cancer. Complete mesocolic excision (CME) is widely acclaimed as the new gold-standard in colon cancer resections, thus it is imperative to establish quality criteria of CME in order to make it easily understood and verified by surgeons worldwide. One simple and reproducible tool could be the measurement of arterial stumps postoperatively and a straightforward way to test its reliability is to test it in a comparative study between CME and non-CME surgery.AIMTo validate arterial stump measurement as a surgical quality tool by comparing CME with conventional radical colectomies.METHODSThis was a retrospective study, carried out on a prospective database. We collected data from two groups of patients, divided according to standard CME with D2 central vascular ligation (group A) and non-standardized surgery (group B). The two groups were compared with regard to the arterial stump length after right- and left-sided colectomies for colon cancer. The actual stump lengths of the ileocolic artery (ICA) and inferior mesenteric artery (IMA) were compared with their theoretical best D2 position of predicted ligation levels (D2PLLs) for calculating the potential for improvement. Measurements on follow-up computed tomography scans were carried out by three observers. Pathological data were recorded (specimen length, lymph node yield) and correlated with stump length.RESULTSWe analysed 58 colectomies. The stump lengths (mean ± SD) in group A were 16.97 ± 4.77 mm for ICA and 31.70 ± 15.71 mm for IMA, whereas group B had 49.93 ± 20.29 mm for ICA and 67.24 ± 28.71 mm for IMA. Shorter lengths were obtained in group A, by a mean difference of 35.66 mm (χ2 = 27.38, P < 0.001), which was significant for all types of colectomies. Except for a 5.85 ± 4.71 mm difference for right colectomies, all the ligations from group A significantly reached their potential height (0.26 ± 12.18 mm from D2PLL; χ2 = 0.005, P = 0.944). Apart from three left colectomies, group B failed to reach D2PLL, by a mean difference of 32.14 ± 26.15 mm (χ2 = 21.77, P < 0.001). The calculated improvement potentials were significantly shorter in group A than in group B, by a mean of 31.88 mm (χ2 = 22.13, P < 0.001). The large spread of results in group B showed that there is significant variability (P = 0.004) when compared to standard surgery. Significant correlations were found between stump length, specimen length and number of lymph nodes (P = 0.018 and P = 0.008 respectively). No statistical difference was found between observers’ measurements (P = 0.866).CONCLUSIONArterial stump monitoring is a significant step in defining surgical quality, as longer stumps contain residual mesocolic tissue and correlate with major prognostic factors.

Background: Monitoring surgical quality has been shown to reduce locoregional recurrence (LRR). We previously showed that the arterial stump length (ASL) after complete mesocolic excision (CME) is a reproducible quality instrument and correlates with the lymph-node (LN) yield. We hypothesized that generating an LRR prediction score by integrating the ASL would predict the risk of LRR after suboptimal surgery. Methods: 502 patients with curative resections for stage I–III colon cancer were divided in two groups (CME vs. non-CME) and compared in terms of surgical data, ASL-derived parameters, pathological parameters, LRR and LRR-free survival. A prediction score was generated to stratify patients at high risk for LRR. Results: The ASL showed significantly higher values (50.77 mm ± 28.5 mm) with LRR vs. (45.59 mm ± 28.1 mm) without LRR (p < 0.001). Kaplan–Meier survival analysis showed a significant increase in LRR-free survival at 5.58 years when CME was performed (Group A: 81%), in contrast to non-CME surgery (Group B: 67.2%). Conclusions: The prediction score placed 76.6% of patients with LRR in the high-risk category, with a strong predictive value. Patients with long vascular stumps and positive nodes could benefit from second surgery to complete the mesocolic excision.