Selective central vascular ligation (D3 lymphadenectomy) in patients undergoing minimally invasive complete mesocolic excision for colon cancer: optimizing the risk–benefit equation

Abstract

AimComplete mesocolic excision (CME) with central vascular ligation (CVL) has been advocated for right colon adenocarcinoma (RC), but the radicality of vascular dissection remains controversial. Our aim is to report outcomes of selective CVL (D3 lymphadenectomy) during minimally invasive CME for RC.MethodA prospective database identified patients who were treated for RC between 2009 and 2016. Minimally invasive CME was standard. The radicality of lymphadenectomy was defined as high ligation (HL) versus CVL based on operative reports and videos. Two blinded radiologists independently evaluated the pre‐ and postoperative CT scans for radiographically abnormal nodes.ResultsOf 197 patients who underwent CME, HL was performed in 56 (28%) and CVL in 141 (72%). There were no baseline differences in age, sex, body mass index, American Society of Anesthesiologists score or pathological staging, and there were no major intra‐operative complications in either group (including no major vascular injuries). The median total number of nodes retrieved was 27 and 31 (P = 0.011) in HL and CVL groups, resepctively, with pathologically positive nodes identified in 33.9% and 39.8% (P = 0.704), respectively. Preoperative imaging identified abnormal cN3 nodes in 1.5% of patients; all of whom underwent CVL. No abnormal cN2 or cN3 nodes remained on postoperative imaging. The 60‐day mortality was 0.5%, and major morbidity was 4%. One patient (0.5%) had an anastomotic recurrence after a median follow‐up of 22 months.ConclusionWith imperfect preoperative clinical nodal staging, and in the absence of randomized data, the low morbidity and oncological outcomes observed support the approach of CME with HL as a minimum standard, with CVL (D3 lymphadenectomy) in selected cases.

Oncological reasons for performing a complete mesocolic excision: a systematic review and meta‐analysis

“…A total of 19 publications met the inclusion criteria, and these were included in the final analysis ( Table 1). [2][3][4][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] There was a total of 25 688 patients who underwent surgery for colorectal cancer, who were dichotomised into two groups; patients who underwent CME, and those who underwent traditional colectomy. A total of 14 431 patients (56.2%) underwent CME.…”

“…In one study with 45 patients, there were no instances of local recurrence, and another study had just one patient with local recurrence among a pool of 56 patients. 4,16 There was a significant difference between lymph node yield between the two groups with an SMD of 1.31 favouring CME (95% CI 0.66-1.95, P < 0.001) (Appendix S1). There were no significant differences between the two groups in terms of pooled 3-year DFS (RR 0.92, 95% CI 0.82-1.04, P = 0.174), 5-year DFS (RR 0.99, 95% CI 0.90-1.09, P = 0.827), and overall mortality (OR 1.19, 95% CI 0.86-1.66, P = 0.335), but pooled 5-year OS was significantly higher in the CME group (RR 0.82, 95% CI 0.77-0.87, P < 0.001).…”

“…In terms of oncological outcomes, rates of local and distant recurrence favoured the CME group, with a pooled OR of 0.66 (95% CI 0.52–0.83, P < 0.001) and 0.73 (95% CI 0.61–0.87, P < 0.001), respectively, as compared to the non‐CME group (Table 2, Figs 3,4). In one study with 45 patients, there were no instances of local recurrence, and another study had just one patient with local recurrence among a pool of 56 patients 4,16 . There was a significant difference between lymph node yield between the two groups with an SMD of 1.31 favouring CME (95% CI 0.66–1.95, P < 0.001) (Appendix S1).…”

The feasibility and safety of complete laparoscopic extended right hemicolectomy with preserving the ileocecal junction in right-transverse colon cancer

“…The principle of CME has been adopted for many years with solid evidence and strong support by more and more surgeons as the optimal approach for colon cancer surgery [11][12] . It is reported that central nodal metastases occurs in up to 11% of cases (usually range from 0 to 5.8%) [13][14] . Therefore, CME with central vascular ligation (CVL) was thought to be potentially successful in removing lymph node metastases and avoiding vascular and neural invasion in the entire regional draining area.…”

Superior Mesenteric Vein-First Approach for Robotic Salvage Surgery with Indocyanine Green Fluorescence Angiography

“…Following the SMV-first approach principles provides a safe plane for dissection, and, in conjunction with ICG, facilitates the delineation of the vascular anatomy, to enable robotic salvage surgery to be performed. [1][2][3] FUNDING No sources of support.…”