Objective Total mesorectal excision (TME) as proposed by R.J. Heald more than 20 years ago, is nowadays accepted worldwide for optimal rectal cancer surgery. This technique is focused on an intact package of the tumour and its main lymphatic drainage.

This concept can be translated into colon cancer surgery, as the mesorectum is only part of the mesenteric planes which cover the colon and its lymphatic drainage like envelopes. According to the concept of TME for rectal cancer, we perform a concept of complete mesocolic excision (CME) for colonic cancer. This technique aims at the separation of the mesocolic from the parietal plane and true central ligation of the supplying arteries and draining veins right at their roots.

Method  Prospectively obtained data from 1329 consecutive patients of our department with RO-resection of colon cancer between 1978 and 2002 were analysed. Patient data of three subdivided time periods were compared.

Results  By consequent application of the procedure of CME, we were able to reduce local 5-year recurrence rates in colon cancer from 6.5% in the period from 1978 to 1984 to 3.6% in 1995 to 2002. In the same period, the cancer related 5-year survival rates in patients resected for cure increased from 82.1% to 89.1%.

Conclusion  The technique of CME in colon cancer surgery aims at a specimen with intact layers and a maximum of lymphnode harvest. This is translated into lower local recurrence rates and better overall survival.

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Standardized surgery for colonic cancer: complete mesocolic excision and central ligation--technical notes and outcome.

INTRODUCTION: The UK Medical Research Council CLASICC trial assessed the safety and efficacy of laparoscopically assisted surgery in comparison with open surgery for colorectal cancer. The results of the 5-year follow-up analysis are presented. METHODS: Five-year outcomes were analysed and included overall and disease-free survival, and local, distant and wound/port-site recurrences. Two exploratory analyses were performed to evaluate the effect of age (70 years or less, or more than 70 years) on overall survival between the two groups, and the effect of the learning curve. RESULTS: No differences were found between laparoscopically assisted and open surgery in terms of overall survival, disease-free survival, and local and distant recurrence. Wound/port-site recurrence rates in the laparoscopic arm remained stable at 2.4 per cent. Conversion to open operation was associated with significantly worse overall but not disease-free survival, which was most marked in the early follow-up period. The effect of surgery did not differ between the age groups, and surgical experience did not impact on the 5-year results. CONCLUSION: The 5-year analyses confirm the oncological safety of laparoscopic surgery for both colonic and rectal cancer. The use of laparoscopic surgery to maximize short-term outcomes does not compromise the long-term oncological results. REGISTRATION NUMBER: ISRCTN74883561 (http://www.controlled-trials.com).

Five‐year follow‐up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer

Purpose The plane of surgery in colonic cancer has been linked to patient outcome although the optimal extent of mesenteric resection is still unclear. Surgeons in Erlangen, Germany, routinely perform complete mesocolic excision (CME) with central vascular ligation (CVL) and report 5-year survivals of higher than 89%. We aimed to further investigate the importance of CME and CVL surgery for colonic cancer by comparison with a series of standard specimens. Methods The fresh photographs of 49 CME and CVL specimens from Erlangen and 40 standard specimens from Leeds, United Kingdom, for primary colonic adenocarcinoma were collected. Precise tissue morphometry and grading of the plane of surgery were performed before comparison to histopathologic variables. Results CME and CVL surgery removed more tissue compared with standard surgery in terms of the distance between the tumor and the high vascular tie (median, 131 v 90 mm; P .0001), the length of large bowel (median, 314 v 206 mm; P .0001), and ileum removed (median, 83 v 63 mm; P .003), and the area of mesentery (19,657 v 11,829 mm 2 ; P .0001). In addition, CME and CVL surgery was associated with more mesocolic plane resections (92% v 40%; P .0001) and a greater lymph node yield (median, 30 v 18; P .0001). Conclusion Surgeons in Erlangen routinely practicing CME and CVL surgery remove more mesocolon and are more likely to resect in the mesocolic plane when compared with standard excisions. This, along with the associated greater lymph node yield, may partially explain the high 5-year survival rates reported in Erlangen. J Clin Oncol 28:272-278. © 2009 by American Society of Clinical Oncology

Complete Mesocolic Excision With Central Vascular Ligation Produces an Oncologically Superior Specimen Compared With Standard Surgery for Carcinoma of the Colon

Background:
Laparoscopic resection is used widely in the management of colorectal cancer; however, the data on long-term outcomes, particularly those related to rectal cancer, are limited. The results of long-term follow-up of the UK Medical Research Council trial of laparoscopically assisted versus open surgery for colorectal cancer are presented.

Methods:
A total of 794 patients from 27 UK centres were randomized to laparoscopic or open surgery in a 2:1 ratio between 1996 and 2002. Long-term follow-up data were analysed to determine differences in survival outcomes and recurrences for intention-to-treat and actual treatment groups.

Results:
Median follow-up of all patients was 62·9 (interquartile range 22·9 − 92·8) months. There were no statistically significant differences between open and laparoscopic groups in overall survival (78·3 (95 per cent confidence interval (c.i.) 65·8 to 106·6) versus 82·7 (69·1 to 94·8) months respectively; P = 0·780) and disease-free survival (DFS) (89·5 (67·1 to 121·7) versus 77·0 (63·3 to 94·0) months; P = 0·589). In colonic cancer intraoperative conversions to open surgery were associated with worse overall survival (hazard ratio (HR) 2·28, 95 per cent c.i. 1·47 to 3·53; P < 0·001) and DFS (HR 2·20, 1·31 to 3·67; P = 0·007). In terms of recurrence, no significant differences were observed by randomized procedure. However, at 10 years, right colonic cancers showed an increased propensity for local recurrence compared with left colonic cancers: 14·7 versus 5·2 per cent (difference 9·5 (95 per cent c.i. 2·3 to 16·6) per cent; P = 0·019).

Conclusion:
Long-term results continue to support the use of laparoscopic surgery for both colonic and rectal cancer. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

https://bjssjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/bjs.8945

Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer

Importance Primary tumor location is emerging as an important prognostic factor owing to distinct biological features However, the side of origin of colon cancer (CC) still does not represent a prognostic parameter when deciding for adjuvant or palliative chemotherapy Objective To determine the prognostic role of left vs right-sidedness of primary tumor location in patients with CC Data Sources We searched PubMed, EMBASE, The Cochrane Library, Web of Science, LILACS, CINAHL, and SCOPUS for prospective or retrospective studies reporting data on overall survival for left-sided colon cancer (LCC) compared with right-sided colon cancer (RCC) Study Selection Studies were selected if: (1) side of CC was reported among variables entered into survival analysis, (2) survival information was available (overall survival [OS] was reported in the article as hazard ratio (HR) according to multivariate analysis, (3) articles were published in the English language Data Extraction and Synthesis Data were pooled using HRs for OS of LCC vs RCC according to fixed or random-effects models Subgroup analysis and multivariate random-effects model meta-regression was also implemented adjusting for stage distribution, sample size, race, year of publication, type and quality of studies, and adjuvant chemotherapy Main Outcomes and Measures HRs for OS (the primary outcome measure) were pooled to provide an aggregate value In this analysis, all HRs with 95% CIs were pooled to obtain prognostic information on the location of the primary tumor (left vs right location site of CC) independent of other common clinicopathological covariates Results An analysis was made from the 66 studies conducted It included 1 437 846 patients with a median follow-up of 65 months Left sided primary tumor location was associated with a significantly reduced risk of death (HR, 082; 95% CI, 079-084; P Conclusions and Relevance Based on these results, CC side should be acknowledged as a criterion for establishing prognosis in all stages of disease It should be considered when deciding treatment intensity in metastatic settings, and should represent a stratification factor for future adjuvant studies

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Prognostic Survival Associated With Left-Sided vs Right-Sided Colon Cancer: A Systematic Review and Meta-analysis

Purpose Over recent years, patient outcomes after colon cancer resection have not improved to the same degree as for rectal cancer. Japanese D3 resection and European complete mesocolic excision (CME) with central vascular ligation (CVL) are both based on sound oncologic principles. Expert surgeons using both techniques report impressive outcomes as compared with standard surgery. We aimed to independently compare the physical appearances and quality of specimens resected using both techniques in major institutions in Japan and Germany. Methods A series of resections for primary colon cancer from one European and two Japanese centers were independently assessed in terms of the plane of surgery, physical characteristics, and lymph node yields. Results Mesocolic plane resection rates from both series were high; however, Japanese D3 specimens were significantly shorter (162 v 324 mm, P < .001), resulting in a smaller amount of mesentery (8,309 v 17,957 mm2, P < .001) and nodal yield (median, 18 v 32, P < .00...

Understanding Optimal Colonic Cancer Surgery: Comparison of Japanese D3 Resection and European Complete Mesocolic Excision With Central Vascular Ligation

Background

The implementation of complete mesocolic excision (CME) for colonic cancer was accompanied by other important changes, including more patients with early diagnosis by screening and the introduction of adjuvant chemotherapy in patients with stage III disease. The contribution of CME remains unclear.



Methods

In this observational study, data from patients with stage I–III colonic carcinoma were analysed by comparing five time intervals: 1978–1984 (pre-CME), 1985–1994 (CME development), 1995–2002 (CME implementation), 2003–2009 (CME) and 2010–2014 (CME), with a special focus on indicators of process and outcome quality.



Results

During the observed periods, the median age of patients increased (from 65 to 67 years), there were more right-sided carcinomas (from 17·0 to 32·4 per cent), more stage I disease (from 14·0 to 27·7 per cent) and fewer patients with regional lymph node metastases (from 42·7 to 32·0 per cent). The proportion of patients with pN0 disease and at least 12 examined regional lymph nodes increased (from 84·8 to 100 per cent) as did the R0 resection rate (from 97·0 to 100 per cent). Overall morbidity increased, whereas the in-hospital mortality rate was stable (range 1·8–3·7 per cent). Use of adjuvant chemotherapy in stage III colonic carcinoma increased from 0 to 79 per cent. The improvement in outcome quality was more evident in stage III than in stage I–II tumours. In stage III, the 5-year locoregional recurrence rate decreased from 14·8 to 4·1 per cent (P = 0·046) and the 5-year cancer-related survival rate increased from 61·7 to 80·9 per cent (P = 0·010).



Conclusion

With CME, the quality indicators of process and outcome quality improved, especially in stage III colonic carcinoma. Adjuvant chemotherapy in stage III and multidisciplinary approaches in patients with metachronous distant metastases contributed to further outcome improvement.

Prognosis of patients with colonic carcinoma before, during and after implementation of complete mesocolic excision.

Background:
A cohort study was undertaken to investigate the long-term oncological outcome, late adverse effects and quality of life (QOL) after treatment for rectal cancer.

Methods:
This was an analysis of prospectively collected data from 268 consecutive patients with rectal carcinoma treated between 1995 and 1997 at the Department of Surgery, University Hospital Erlangen, Germany.

Results:
Median follow-up was 8·8 years. The overall 10-year survival rate was 48·1 per cent. Of 219 patients who had a curative resection, 67 developed recurrent disease and 13 had second malignancies. Seventy patients had either a permanent stoma or a late adverse effect. Anorectal dysfunction and small bowel obstruction were significantly more common among patients who had multimodal treatment (P < 0·001 and P = 0·049 respectively). Analysis of QOL in 97 long-term survivors showed that receiving chemoradiotherapy, a permanent stoma and lower-third rectal carcinoma were associated with significantly worse outcomes on several measures.

Conclusion:
Late adverse effects and recurrences occurred in a significant number of patients during long-term follow-up. QOL varied according to tumour location and treatment type. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Klaus Weber

Papers

Standardized surgery for colonic cancer: complete mesocolic excision and central ligation--technical notes and outcome.

Complete Mesocolic Excision With Central Vascular Ligation Produces an Oncologically Superior Specimen Compared With Standard Surgery for Carcinoma of the Colon

Understanding Optimal Colonic Cancer Surgery: Comparison of Japanese D3 Resection and European Complete Mesocolic Excision With Central Vascular Ligation

Prognosis of patients with colonic carcinoma before, during and after implementation of complete mesocolic excision.

Long-term outcomes and quality of life after rectal carcinoma surgery.