Extent of surgery in cancer of the colon:Is more better?

Since the introduction of total mesorectal excision as the standard approach in mid and low rectal cancer,the incidence of local recurrence has sharply declined.Similar attention to surgical technique in colon cancer(CC) has resulted in the concept of complete mesocolic excision(CME),which consists of complete removal of the intact mesentery and high ligation of the vascular supply at its origin.Although renewed attention to meticulous surgical technique certainly has its merits,routine implementation of CME is currently unfounded.Firstly,in contrast to rectal cancer,local recurrence originating from an incompletely removed mesenteryis rare in CC and usually a manifestation of systemic disease.Secondly,although CME may increase nodal counts and therefore staging accuracy,this is unlikely to affect survival since the observed relationship between nodal counts and outcome in CC is most probably not causal but confounded by a range of clinical variables.Thirdly,several lines of evidence suggest that metastasis to locoregional nodes occurs early and is a stochastic rather than a stepwise phenomenon in CC,in essence reflecting the tumor-host-metastasis relationship.Unsurprisingly,therefore,comparative studies in CC as well as in other digestive cancers have failed to demonstrate any survival benefit associated with extensive,additional or extra-mesenteric lymphadenectomy.Finally,routine implementation of CME may cause patient harm by longer operating times,major vascular damage and autonomic nerve injury.Therefore,data from randomized trials reporting relevant endpoints are required before CME can be recommended as a standard approach in CC surgery.

Near-infrared fluorescence guided esophageal reconstructive surgery: A systematic review

BACKGROUND After an esophagectomy, the stomach is most commonly used to restore continuity of the upper gastrointestinal tract. These esophago-gastric anastomoses are prone to serious complications such as leakage associated with high morbidity and mortality. Graft perfusion is considered to be an important predictor for anastomotic integrity. Based on the current literature we believe Indocyanine green fluorescence angiography(ICGA) is an easy assessment tool for gastric tube(GT) perfusion, and it might predict anastomotic leakage(AL).AIM To evaluate feasibility and effectiveness of ICGA in GT perfusion assessment and as a predictor of AL.METHODS This study was designed according to the PRISMA guidelines and registered in the PROSPERO database. PubMed and EMBASE were independently searched by 2 reviewers for studies presenting data on intraoperative ICGA GT perfusion assessment during esophago-gastric reconstruction after esophagectomy.Relevant outcomes such as feasibility, complications, intraoperative surgical changes based on ICGA findings, quantification attempts, anatomical data and the impact of ICGA on postoperative anastomotic complications, were collected by 2 independent researchers. The quality of the included articles was assessed based on the Methodological Index for Non-Randomized Studies. The 19 included studies presented data on 1192 esophagectomy patients, in 758 patients ICGA was used perioperative to guide esophageal reconstruction.RESULTS The 19 included studies for qualitative analyses all described ICGA as a safe and easy method to evaluate gastric graft perfusion. AL occurred in 13.8% of the entire cohort, 10% in the ICG guided group and 20.6% in the control group(P <0.001). When poorly perfused cases are excluded from the analyses, the difference in AL was even larger(AL well-perfused group 6.3% vs control group 20.5%, P <0.001). The AL rate in the group with an altered surgical plan based on the ICG image was 6.5%, similar to the well perfused group(6.3%) and significantly less than the poorly perfused group(47.8%)(P < 0.001), suggesting that the technique is able to identify and alter a potential bad outcome.CONCLUSION ICGA is a safe, feasible and promising method for perfusion assessment. The lower AL rate in the well perfused group suggest that a good fluorescent signal predicts a good outcome.