Selective central vascular ligation (D3 lymphadenectomy) in patients undergoing minimally invasive complete mesocolic excision for colon cancer: optimizing the risk–benefit equation
Aim Complete 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...
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Veröffentlicht in: | Colorectal disease 2020-01, Vol.22 (1), p.53-61 |
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creator | Sammour, T. Malakorn, S. Thampy, R. Kaur, H. Bednarski, B. K. Messick, C. A. Taggart, M. Chang, G. J. You, Y. N. |
description | Aim
Complete 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.
Method
A 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.
Results
Of 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.
Conclusion
With 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. |
doi_str_mv | 10.1111/codi.14794 |
format | Article |
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Complete 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.
Method
A 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.
Results
Of 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.
Conclusion
With 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.</description><identifier>ISSN: 1462-8910</identifier><identifier>EISSN: 1463-1318</identifier><identifier>DOI: 10.1111/codi.14794</identifier><identifier>PMID: 31356721</identifier><language>eng</language><publisher>England: Wiley Subscription Services, Inc</publisher><subject>Adenocarcinoma ; Adenocarcinoma - diagnostic imaging ; Adenocarcinoma - surgery ; Aged ; Body mass ; Body mass index ; central vascular ligation ; CME ; Colectomy - adverse effects ; Colectomy - methods ; Colon cancer ; Colonic Neoplasms - diagnostic imaging ; Colonic Neoplasms - surgery ; complete mesocolic excision ; Complications ; Computed tomography ; Databases, Factual ; Female ; Health risks ; Humans ; Ligation - adverse effects ; Ligation - methods ; Lymph Node Excision - adverse effects ; Lymph Node Excision - methods ; lymph nodes ; Lymph Nodes - diagnostic imaging ; Lymph Nodes - surgery ; lymphadenectomy ; Male ; Mesenteric Arteries - surgery ; Mesenteric Veins - surgery ; Mesocolon - blood supply ; Mesocolon - surgery ; Middle Aged ; Morbidity ; Nodes ; Prospective Studies ; Risk Assessment ; Tomography, X-Ray Computed ; Treatment Outcome</subject><ispartof>Colorectal disease, 2020-01, Vol.22 (1), p.53-61</ispartof><rights>Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland</rights><rights>Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.</rights><rights>Copyright © 2020 The Association of Coloproctology of Great Britain and Ireland</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c3934-1a0a82d859f28d722cb4ff3f72fa3966fc35802813c6a3375a391d1f3aab55fa3</citedby><cites>FETCH-LOGICAL-c3934-1a0a82d859f28d722cb4ff3f72fa3966fc35802813c6a3375a391d1f3aab55fa3</cites><orcidid>0000-0002-4918-8871</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://onlinelibrary.wiley.com/doi/pdf/10.1111%2Fcodi.14794$$EPDF$$P50$$Gwiley$$H</linktopdf><linktohtml>$$Uhttps://onlinelibrary.wiley.com/doi/full/10.1111%2Fcodi.14794$$EHTML$$P50$$Gwiley$$H</linktohtml><link.rule.ids>314,780,784,1417,27924,27925,45574,45575</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/31356721$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Sammour, T.</creatorcontrib><creatorcontrib>Malakorn, S.</creatorcontrib><creatorcontrib>Thampy, R.</creatorcontrib><creatorcontrib>Kaur, H.</creatorcontrib><creatorcontrib>Bednarski, B. K.</creatorcontrib><creatorcontrib>Messick, C. A.</creatorcontrib><creatorcontrib>Taggart, M.</creatorcontrib><creatorcontrib>Chang, G. J.</creatorcontrib><creatorcontrib>You, Y. N.</creatorcontrib><title>Selective central vascular ligation (D3 lymphadenectomy) in patients undergoing minimally invasive complete mesocolic excision for colon cancer: optimizing the risk–benefit equation</title><title>Colorectal disease</title><addtitle>Colorectal Dis</addtitle><description>Aim
Complete 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.
Method
A 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.
Results
Of 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.
Conclusion
With 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.</description><subject>Adenocarcinoma</subject><subject>Adenocarcinoma - diagnostic imaging</subject><subject>Adenocarcinoma - surgery</subject><subject>Aged</subject><subject>Body mass</subject><subject>Body mass index</subject><subject>central vascular ligation</subject><subject>CME</subject><subject>Colectomy - adverse effects</subject><subject>Colectomy - methods</subject><subject>Colon cancer</subject><subject>Colonic Neoplasms - diagnostic imaging</subject><subject>Colonic Neoplasms - surgery</subject><subject>complete mesocolic excision</subject><subject>Complications</subject><subject>Computed tomography</subject><subject>Databases, Factual</subject><subject>Female</subject><subject>Health risks</subject><subject>Humans</subject><subject>Ligation - adverse effects</subject><subject>Ligation - methods</subject><subject>Lymph Node Excision - adverse effects</subject><subject>Lymph Node Excision - methods</subject><subject>lymph nodes</subject><subject>Lymph Nodes - diagnostic imaging</subject><subject>Lymph Nodes - surgery</subject><subject>lymphadenectomy</subject><subject>Male</subject><subject>Mesenteric Arteries - surgery</subject><subject>Mesenteric Veins - surgery</subject><subject>Mesocolon - blood supply</subject><subject>Mesocolon - surgery</subject><subject>Middle Aged</subject><subject>Morbidity</subject><subject>Nodes</subject><subject>Prospective Studies</subject><subject>Risk Assessment</subject><subject>Tomography, X-Ray Computed</subject><subject>Treatment Outcome</subject><issn>1462-8910</issn><issn>1463-1318</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2020</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kUtuFDEQhi0EIiGw4QDIEpuA1MFl9zM7NOERKVIWwLrlcZcnDn507O5As-IOHIb7cBI8M4EFC7xxyfX5c8k_IU-BnUBer1QYzAmUTVfeI4dQ1qIAAe39Xc2LtgN2QB6ldM0Y1A20D8mBAFHVDYdD8vMDWlSTuUWq0E9RWnork5qtjNSajZxM8PT4TFC7uPFKDugzHdzyghpPx9zOlxKd_YBxE4zfUGe8cdLaJQPZtBMHN1qckDpMQQVrFMWvyqStWoeY-zZXSnqF8ZSGcTLOfNu6piuk0aTPv77_WOeHtZko3sy7mR6TB1rahE_u9iPy6e2bj6v3xcXlu_PV64tCiU6UBUgmWz60Vad5OzScq3WptdAN11J0da2VqFrGWxCqlkI0VT6FAbSQcl1VmTkix3vvGMPNjGnqnUkKrZUew5x6zuuGgSi7NqPP_0Gvwxx9nq7nQkDddayDTL3cUyqGlCLqfoz5w-LSA-u3cfbbOPtdnBl-dqec1w6Hv-if_DIAe-CLsbj8R9WvLs_O99Lf0Mmv6Q</recordid><startdate>202001</startdate><enddate>202001</enddate><creator>Sammour, T.</creator><creator>Malakorn, S.</creator><creator>Thampy, R.</creator><creator>Kaur, H.</creator><creator>Bednarski, B. K.</creator><creator>Messick, C. A.</creator><creator>Taggart, M.</creator><creator>Chang, G. J.</creator><creator>You, Y. N.</creator><general>Wiley Subscription Services, Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7T5</scope><scope>7TM</scope><scope>7TO</scope><scope>H94</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0002-4918-8871</orcidid></search><sort><creationdate>202001</creationdate><title>Selective central vascular ligation (D3 lymphadenectomy) in patients undergoing minimally invasive complete mesocolic excision for colon cancer: optimizing the risk–benefit equation</title><author>Sammour, T. ; Malakorn, S. ; Thampy, R. ; Kaur, H. ; Bednarski, B. K. ; Messick, C. A. ; Taggart, M. ; Chang, G. J. ; You, Y. N.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c3934-1a0a82d859f28d722cb4ff3f72fa3966fc35802813c6a3375a391d1f3aab55fa3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2020</creationdate><topic>Adenocarcinoma</topic><topic>Adenocarcinoma - diagnostic imaging</topic><topic>Adenocarcinoma - surgery</topic><topic>Aged</topic><topic>Body mass</topic><topic>Body mass index</topic><topic>central vascular ligation</topic><topic>CME</topic><topic>Colectomy - adverse effects</topic><topic>Colectomy - methods</topic><topic>Colon cancer</topic><topic>Colonic Neoplasms - diagnostic imaging</topic><topic>Colonic Neoplasms - surgery</topic><topic>complete mesocolic excision</topic><topic>Complications</topic><topic>Computed tomography</topic><topic>Databases, Factual</topic><topic>Female</topic><topic>Health risks</topic><topic>Humans</topic><topic>Ligation - adverse effects</topic><topic>Ligation - methods</topic><topic>Lymph Node Excision - adverse effects</topic><topic>Lymph Node Excision - methods</topic><topic>lymph nodes</topic><topic>Lymph Nodes - diagnostic imaging</topic><topic>Lymph Nodes - surgery</topic><topic>lymphadenectomy</topic><topic>Male</topic><topic>Mesenteric Arteries - surgery</topic><topic>Mesenteric Veins - surgery</topic><topic>Mesocolon - blood supply</topic><topic>Mesocolon - surgery</topic><topic>Middle Aged</topic><topic>Morbidity</topic><topic>Nodes</topic><topic>Prospective Studies</topic><topic>Risk Assessment</topic><topic>Tomography, X-Ray Computed</topic><topic>Treatment Outcome</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Sammour, T.</creatorcontrib><creatorcontrib>Malakorn, S.</creatorcontrib><creatorcontrib>Thampy, R.</creatorcontrib><creatorcontrib>Kaur, H.</creatorcontrib><creatorcontrib>Bednarski, B. K.</creatorcontrib><creatorcontrib>Messick, C. A.</creatorcontrib><creatorcontrib>Taggart, M.</creatorcontrib><creatorcontrib>Chang, G. J.</creatorcontrib><creatorcontrib>You, Y. N.</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Immunology Abstracts</collection><collection>Nucleic Acids Abstracts</collection><collection>Oncogenes and Growth Factors Abstracts</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>MEDLINE - Academic</collection><jtitle>Colorectal disease</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Sammour, T.</au><au>Malakorn, S.</au><au>Thampy, R.</au><au>Kaur, H.</au><au>Bednarski, B. K.</au><au>Messick, C. A.</au><au>Taggart, M.</au><au>Chang, G. J.</au><au>You, Y. N.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Selective central vascular ligation (D3 lymphadenectomy) in patients undergoing minimally invasive complete mesocolic excision for colon cancer: optimizing the risk–benefit equation</atitle><jtitle>Colorectal disease</jtitle><addtitle>Colorectal Dis</addtitle><date>2020-01</date><risdate>2020</risdate><volume>22</volume><issue>1</issue><spage>53</spage><epage>61</epage><pages>53-61</pages><issn>1462-8910</issn><eissn>1463-1318</eissn><abstract>Aim
Complete 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.
Method
A 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.
Results
Of 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.
Conclusion
With 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.</abstract><cop>England</cop><pub>Wiley Subscription Services, Inc</pub><pmid>31356721</pmid><doi>10.1111/codi.14794</doi><tpages>9</tpages><orcidid>https://orcid.org/0000-0002-4918-8871</orcidid><oa>free_for_read</oa></addata></record> |
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subjects | Adenocarcinoma Adenocarcinoma - diagnostic imaging Adenocarcinoma - surgery Aged Body mass Body mass index central vascular ligation CME Colectomy - adverse effects Colectomy - methods Colon cancer Colonic Neoplasms - diagnostic imaging Colonic Neoplasms - surgery complete mesocolic excision Complications Computed tomography Databases, Factual Female Health risks Humans Ligation - adverse effects Ligation - methods Lymph Node Excision - adverse effects Lymph Node Excision - methods lymph nodes Lymph Nodes - diagnostic imaging Lymph Nodes - surgery lymphadenectomy Male Mesenteric Arteries - surgery Mesenteric Veins - surgery Mesocolon - blood supply Mesocolon - surgery Middle Aged Morbidity Nodes Prospective Studies Risk Assessment Tomography, X-Ray Computed Treatment Outcome |
title | Selective central vascular ligation (D3 lymphadenectomy) in patients undergoing minimally invasive complete mesocolic excision for colon cancer: optimizing the risk–benefit equation |
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