Laparoscopic right radical hemicolectomy: Central vascular ligation and complete mesocolon excision vs D3 lymphadenectomy - How I do it?

In colon cancer surgery,ensuring the complete removal of the primary tumor and draining lymph nodes is crucial.Lymphatic drainage in the colon follows the vascular supply,typically progressing from pericolic to paraaortic lymph nodes.While NCCN guidelines recommend the removal of 10-12 lymph nodes for ade-quate oncological resection,achieving complete oncological resection involves more than just meeting these numerical targets.Various techniques have been developed and studied over time to attain optimal oncological outcomes.A key technique central to this goal is identifying the ileocolic vessels at their origin from the superior mesenteric vessels.Complete excision of the visceral and parietal mesocolon ensures the intact removal of the specimen,while D3 lymphade-nectomy targets all draining regional lymph nodes.Although these principles emphasize different aspects,they ultimately converge to achieve the same goal of complete oncological resection.This article aims to simplify the surgical steps that align with the principle of central vascular ligation and mesocolon mobilization while ensuring adequate D3 dissection.

Techniques and feasibility of laparoscopic extended right hemicolectomy with D3 lymphadenectomy

AIM: To illustrate the critical techniques and feasibility of laparoscopic extended right hemicolectomy (LERH), according to our previous experience.

Bowel function and quality of life after minimally invasive colectomy with D3 lymphadenectomy for right-sided colon adenocarcinoma

BACKGROUND Changes in bowel function after right-sided colectomy are not well understood compared to those associated with left-sided colectomy or rectal resection.In particular,there are concerns about bowel function after right-sided colectomy with complete mesocolic excision,which has become popular in the West.AIM To evaluate the functional outcomes of patients who underwent right-sided colectomy with D3 lymphadenectomy for colon cancer.METHODS Functional data from patients who underwent minimally invasive right-sided colectomy for colon cancer from October 2017 to September 2018 were prospectively collected.Functional outcomes were evaluated preoperatively and at 3,6,12,and 18 mo postoperatively.RESULTS Prior to surgery,57 patients answered the questionnaire,and 47 responded at three months,52 at 6 mo,52 at 12 mo,and 25 at 18 mo postoperatively.Most scales of quality of life and bowel function improved significantly over time.Urgency persisted to a high degree throughout the period without a significant change over time.The use of medications for defecation was about 10%over the entire period.Gas(P=0.023)and fecal frequency(P<0.001)increased,and bowel dysfunction group(P=0.028)was more common among patients taking medication.At six months,resected bowel and colon lengths were significantly different as a risk factor between the dysfunction group and the no dysfunction group[odd ratio(OR):1.095,P=0.026;OR:1.147,P=0.031,respectively]in univariate analysis,but not in multivariate analysis.CONCLUSION Despite D3 lymphadenectomy,most bowel symptoms improved over time after right-sided colectomy using a minimally invasive approach,and continuous medication was needed in only approximately 10%of patients.

Laparoscopic vs open extended right hemicolectomy for colon cancer

AIM: to evaluate the feasibility, safety, and oncologic outcomes of laparoscopic extended right hemicolectomy (LERH) for colon cancer. METHODS: Since its establishment in 2009, the Southern Chinese Laparoscopic Colorectal Surgical Study (SCLCSS) group has been dedicated to promoting patients' quality of life through minimally invasive surgery. The multicenter database was launched by combining existing datasets from members of the SCLCSS group. The study enrolled 220 consecutive patients who were recorded in the multicenter retrospective database and underwent either LERH (n = 119) or open extended right hemicolectomy (OERH) (n = 101) for colon cancer. Clinical characteristics, surgical outcomes, and oncologic outcomes were compared between the two groups. RESULTS: There were no significant differences in terms of age, gender, body mass index (BMI), history of previous abdominal surgery, tumor location, and tumor stage between the two groups. The blood loss was lower in the LERH group than in the OERH group [100 (100-200) mL vs 150 (100-200) mL, P < 0.0001]. The LERH group was associated with earlier first flatus (2.7 +/- 1.0 d vs 3.2 +/- 0.9 d, P < 0.0001) and resumption of liquid diet (3.6 +/- 1.0 d vs 4.2 +/- 1.0 d, P < 0.0001) compared to the OERH group. The postoperative hospital stay was significantly shorter in the LERH group (11.4 +/- 4.7 d vs 12.8 +/- 5.6 d, P = 0.009) than in the OERH group. The complication rate was 11.8% and 17.6% in the LERH and OERH groups, respectively (P = 0.215). Both 3-year overall survival [LERH (92.0%) vs OERH (84.4%), P = 0.209] and 3-year disease-free survival [LERH (84.6%) vs OERH (76.6%), P = 0.191] were comparable between the two groups. CONCLUSION: LERH with D3 lymphadenectomy for colon cancer is a technically feasible and safe procedure, yielding comparable short-term oncologic outcomes to those of open surgery. (C) 2014 Baishideng Publishing Group Inc. All rights reserved.

Laparoscopic vs open complete mesocolic excision with central vascular ligation for colon cancer: A systematic review and meta-analysis

AIM To compare the effectiveness of laparoscopic complete mesocolic excision (CME) with central vascular ligation (L-CME) with its open (O-CME) counterpart. METHODS We conducted an electronic search of the PubMed/MEDLINE, Excerpta Medica Database, Web of Science Core Collection, Cochrane Center Register of Controlled Trails, Cochrane Database of Systematic Reviews, SciELO, and Korean Journal databases from their inception until May 2017. We considered randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that included patients with colonic cancer comparing L-CME and O-CME. Primary outcomes included the quality of the resected specimen (lymph nodes retrieved, complete mesocolic plane excision, tumor to arterial high tie, resected mesocolon surface). Secondary outcomes included the three-year and five-year overall and disease-free survival rates, recurrence of the disease, surgical data, and postoperative morbidity and mortality. Two authors of the review screened the methodological quality of the eligible trials and independently extracted data from individual studies. RESULTS A total of one RCT and eleven CCTs (four from Europe and seven from Asia) met the inclusion criteria for the current meta-analysis. These studies involved 1619 patients in L-CME and 1477 patients in O-CME. The L-CME was associated with the same quality of the resected specimen, with no differences regarding the retrieved lymphnodes (MD = -1.06, 95%CI: -3.65 to 1.53, P = 0.42), and tumor to high tie distance (MD = 14.26 cm, 95%CI: -4.30 to 32.82, P = 0.13); the surface of the resected mesocolon was higher in the L-CME group (MD = 11.75 cm2, 95%CI: 9.50 to 13.99, P < 0.001). The L-CME was associated with a lower rate of blood transfusions (OR = 0.45, 95%CI: 0.27 to 0.75, P = 0.002), faster recovery of gastrointestinal function, and less postoperative overall complication rate. The L-CME approach was associated with a statistical significant better three-year overall (OR = 2.02, 95%CI: 1.31 to 3.12, P = 0.001, I2 = 28%) and disease-free (OR = 1.45, 95% CI: 1.00 to 2.10, P = 0.05, I2 = 0%) survival. CONCLUSION The laparoscopic approach offers the same quality of the resected specimen as the open approach in complete mesocolic excision with central vascular ligation for colon cancer. The laparoscopic complete mesocolic excision with central vascular ligation is superior in all perioperative results and at least non-inferior in long-term oncological outcomes.

Laparoscopic complete mesocolic excision: West meets East

Complete mesocolic excision is a relatively new concept in western literature. It follows the same concept of total mesorectal excision and units&#x02019; routinely performing complete mesocolic excisions have good pathological results as well as good improvements in overall survival, disease free survival and local recurrence. And yet unlike total mesorectal excision, uptake in the West has been relatively slow with many units sceptical of the true benefits gained by taking up a more technically challenging and potentially more morbid procedure when there is a paucity of literature to support these claims. This article reviews complete mesocolic excision for colon cancer, attempting to identify the risks and benefits of the technique and particularly looking at the reasons why its uptake has not been universal. It also discusses the similarities of a complete mesocolic excision to a colon resection with a D3 lymphadenectomy as well as the role of a laparoscopic approach to this technique. Considering a D3 lymphadenectomy has been the standard of care for stage II and III colon cancers in many of our Asian neighbours for over 20 years, combining this data with data on complete mesocolic excision may provide enough evidence to support or refute the need for complete mesocolic excisions. Maybe there might be lessons to be learnt from our colleagues in the east.

Recent trends from the results of clinical trials on gastric cancer surgery

The Japan Clinical Oncology Group has recently conducted large scale clinical trials with findings that have revealed pivotal strategies for the treatment of resectable gastric cancer surgery.These findings include the fact that D3 lymphadenectomy does not improve survival rates when compared to D2 lymphadenectomy,and it is not recommended for resectable gastric cancer.Also,a transhiatal approach is recommended,instead of the left thoraco-abdominal approach,for the treatment of adenocarcinoma of the esophago-gastric junction or gastric cardia which has invaded≤3 cm of the esophagus.Gastrectomy with splenectomy and bursectomy had been recommended as a part of the D2 lymphadenectomy.However,the results of the recent clinical trials revealed that splenectomy should be avoided in total gastrectomy with D2 lymphadenectomy for proximal gastric cancer and that bursectomy should be avoided in gastrectomy with D2 lymphadenectomy for resectable gastric cancer.Both splenectomy and bursec-tomy were found to be unable to improve survival,but instead increased operative morbidity.These trials revealed that the above-mentioned invasive and aggressive procedures did not provide sufficient survival benefits and that gastric cancer surgery may be trending from an“invasive to less invasive”and“aggressive to more conservative”approach.