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Introducción: La escisión completa del mesocolon con linfadenectomía D3 (CME-D3) mejora los resultados de los pacientes operados por cáncer del colon. Reconocer adecuadamente la anatomía vascular es fundamental para evitar complicaciones. Objetivo: El objetivo primario fue determinar la prevalencia de las variaciones anatómicas de la arteria mesentérica superior (AMS) y sus ramas en relación a la vena mesentérica superior (VMS). El objetivo secundario fue evaluar la asociación entre las distintas variantes anatómicas y el sexo y la etnia de lo pacientes. Diseño: Estudio de corte transversal. Material y métodos: Se incluyeron 225 pacientes con cáncer del colon derecho diagnosticados entre enero 2017 y diciembre de 2020. Dos radiólogos independientes describieron la anatomía vascular observada en las tomografías computadas. Según la relación de las ramas de la AMS con la VMS, la población fue dividida en 2 grupos y subdividida en 6 (1a-c, 2a-c). Resultados: La arteria ileocólica fue constante, transcurriendo en el 58,7% de los casos por la cara posterior de la VMS. La arteria cólica derecha, presente en el 39,6% de los pacientes, cruzó la VMS por su cara anterior en el 95,5% de los casos. La variante de subgrupo más frecuente fue la 2a seguida por la 1a (36,4 y 24%, respectivamente). No se encontró asociación entre las variantes anatómicas y el sexo u origen étnico. Conclusión: Las variaciones anatómicas de la AMS y sus ramas son frecuentes y no presentan un patrón predominante. No hubo asociación entre las mismas y el sexo u origen étnico en nuestra cohorte. El reconocimiento preoperatorio de estas variantes mediante angiotomografía resulta útil para evitar lesiones vasculares durante la CME-D3. (AU)
Background: Complete mesocolic excision with D3 lymphadenectomy (CME-D3) improves the outcomes of patients operated on for colon cancer. Proper recognition of vascular anatomy is essential to avoid complications. Aim: Primary outcome was to determine the prevalence of anatomical variations of the superior mesenteric artery (SMA) and its branches in relation to the superior mesenteric vein (SMV). Secondary outcome was to evaluate the association between these anatomical variations and sex and ethnicity of the patients. Design: Cross-sectional study. Material and methods: Two hundred twenty-fivepatients with right colon cancer diagnosed between January 2017 and December 2020 were included. Two independent radiologists described the vascular anatomy of computed tomography scans. The population was divided into 2 groups and subdivided into 6 groups (1a-c, 2a-c), according to the relationship of the SMA and its branches with the SMV. Results: The ileocolic artery was constant, crossing the SMV posteriorly in 58.7% of the cases. The right colic artery, present in 39.6% of the patients, crossed the SMV on its anterior aspect in 95.5% of the cases. The most frequent subgroup variant was 2a followed by 1a (36.4 and 24%, respectively). No association was found between anatomical variants and gender or ethnic origin. Conclusions: The anatomical variations of the SMA and its branches are common, with no predominant pattern. There was no association between anatomical variations and gender or ethnic origin in our cohort. Preoperative evaluation of these variations by computed tomography angi-ography is useful to avoid vascular injuries during CME-D3. (AU)
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Aged, 80 and over , Colonic Neoplasms/surgery , Colon, Ascending/anatomy & histology , Colon, Ascending/blood supply , Lymph Node Excision , Mesocolon/surgery , Argentina , Tomography, X-Ray Computed/methods , Cross-Sectional Studies , Mesenteric Artery, Superior/anatomy & histology , Sex Distribution , Colectomy/methods , Ethnic Distribution , Anatomic Variation , Mesenteric Veins/anatomy & histologyABSTRACT
Objective:To analyze the efficacy and safety of cranial approach priority, counterclockwise sequential comple mesocolic excision in laparoscopic right hemicolectomy.Methods:From Jan. 2020 to Dec. 2020, 30 patients with right colon cancer in Department of Gastrointestinal Surgery were retrospectively analyzed. Laparoscopic radical right hemicolectomy was performed via the approach of complete mesocolic excision. The general clinicopathological data of the patients, perioperative data such as operation time, intraoperative blood loss, number of cases of hemorrhage caused by Henle trunk and subordinate branch injury, whether or not converted to open surgery, postoperative pathological data (TNM staging, total number of dissected lymph nodes and the number of metastatic lymph nodes) , postoperative recovery (exhaust time, the time of fluid intake, drainage tube removal and hospital stay) , and complications (such as bleeding, anastomotic leakage, secondary surgery, lymphatic leakage, pulmonary infection, abdominal infection, incision infection, etc) were recorded. Follow-up was performed by telephone or outpatient in 1 year after surgery.Results:The total operation time was (197.80±31.20) minutes, ranging from 150 to 275 minutes, and the intraoperative blood loss was (58.33±30.30) ml, ranging from 10 to 100 ml. There were no cases of intraoperative Henle stem and branch injury bleeding or conversion to open surgery. Postoperative exhaust time was (2.97±0.67) d, ranging from 2 to 4d; postoperative fluid intake time was (3.67±0.76) d, ranging from 3 to 5d; postoperative drainage tube removal time was (6.60±4.00) d, ranging from 4 to 25 days; postoperative hospital stay was (7.87±3.94) days, ranging from 5 to 26 days. pTNM staging: 9 cases of stage I, 5 cases of stage IIA, 1 case of stage IIB, 6 cases of stage IIIA, 4 cases of stage IIIB, and 5 cases of stage IIIC. The total number of lymph nodes dissected was (29.50±8.18) , ranging from 19 to 51; the number of metastatic lymph nodes was (1.40±1.77) , ranging from 0 to 6. Postoperative complications included incision infection in 1 case, anastomotic leakage in 1 case, lymphatic leakage in 2 cases, and lung infection in 1 case. No tumor recurrence or metastasis was found during follow-up, and no patient died.Conclusion:Cranial approach priority, counterclockwise sequential complete mesocolic excision is safe and effective in laparoscopic right hemicolectomy.
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Laparoscopic radical resection of left hemicolon cancer is difficult in lymph node dissection, splenic flexure dissociation and digestive tract reconstruction. The high resolution recognition ability of 4K laparoscopic system can help complete mesocolic excision and neuroprotec-tion of the left colon. The authors discuss the key points of 4K totally laparoscopic radical resection of left hemicolon cancer and intraperitoneal overlap digestive reconstruction through surgical examples.
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Colorectal cancer is the fourth most malignant tumors in China, among which the left hemicolon cancer accounts for about 5%?6%. Due to the complex anatomy around the left hemicolon, being adjacent to the pancreas, spleen, kidney, ureter and other important organs, its vascular and nerve distribution is variably distributed, leading difficulties in laparoscopic radical surgery for left hemicolon cancer. In surgical practice, the 4K laparoscopic system has shown its features of high-definition amplification, good color reproduction, and clear anatomy, etc. However, there is still no clear consensus on its application in the radical resection for the left hemicolon cancer. The authors summarize clinical practice, explore the technique key points of 4K laparoscopic D 3 resection with complete mesocolic excision for the left hemicolon cancer.
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4K laparoscopy brings opportunities and challenges to the development of rectal surgery. 4K laparoscopy can truly provide the structure of abdominal and pelvic fascia, so that surgeons can see more subtle anatomical structure. The clear and real picture under 4K laparoscopic system can reduce visual fatigue of surgeons, which make the operation easier and safer. Radical resection of right colon cancer includes complete mesocolic excision and D 3 lymphadenectomy. Through 4K laparoscopic system, surgeons can easily observe the fascia structure of right mesocolon and its mesenteric bed, distinguish the vascular anatomical relationship at the mesenteric root, which make D 3 lymphadenectomy safer with dissection of lymph nodes completely. The authors comprehensively analyze the related research progress at home and abroad, and systematically elaborate the region of dissection and significance of 4K laparoscopic right hemicolectomy for right colon cancer.
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Objective: To investigate the anatomic characteristics of the right retroperitoneal fascia and its surgical implementation while performing complete mesocolic excision (CME) for right colon cancer. Methods: A descriptive study was carried out. (1) Clinicopathological data and surgical videos of 17 non-consecutive patients undergoing laparoscopic right hemicolectomy (extended right hemicolectomy) with CME for right colon cancer at Department of Colorectal Surgery of Union Hospital, Fujian Medical University between January 2020 and October 2020 were retrospectively collected. The construction of right retroperitoneal fascia was observed from caudal dorsal direction and caudal ventral direction. (2) Three postoperative specimens from 3 cases undergoing laparoscopic right hemicolectomy with CME for right colon cancer in June 2020 were prospectively included to observe anatomy and examine histology. (3) Five abdominal cadaver specimens from the Department of Anatomy of Fujian Medical University were enrolled, including 3 males and 2 females. Anatomical observation and histological studies were performed from the cranial approach and the caudal dorsal approach. Masson staining was used to examine the histology. Results: (1) Surgical video observation: The typical structure of right retroperitoneal fascia could be observed in all the 17 patients. The fascia was a rigid barrier between the posterior space of the ascending colon and the anterior pancreaticoduodenal space behind the transverse colon. The right retroperitoneal fascia should be sharply cut to communicate between the two spaces to avoid entering the right mesocolon by mistake. The severed ventral stump of the right retroperitoneal fascia ran along the dorsal side of the right hemicolon to the lateral side, and the dorsal stump covered the level of the duodenum caudally, and continued to move downward, covering the surface of Gerota's fascia. (2) Observation of 3 surgical specimens: The dorsal side of the right mesocolon was smooth and intact, which could be anchored in the corresponding area of the lateral edge of the duodenum. The ventral stump of the right retroperitoneal fascia could be seen, which attached to the dorsal side of the right mesocolon semi-circularly. Masson staining observation: The ventral stump of the right retroperitoneal fascia ran cephalad, fused with the dorsal side of the right mesocolon tightly and curled. The caudal side of confluence and the dorsal side of the right mesocolon presented a bilobed structure. (3) Anatomy of 5 cadaveric specimens: The right retroperitoneal fascia was a thin fascia structure, which was a rigid barrier between the anterior pancreaticoduodenal space behind the transverse colon and the posterior space of the ascending colon. The ventral stump of the right retroperitoneal fascia (including the dorsal side of the right mesocolon), the dorsal stump of the right retroperitoneal fascia (including part of the duodenal wall) and the dorsal side of the right mesocolon were retrieved for histological examination. The ventral stump of the right retroperitoneal fascia fused with the dorsal side of the right mesocolon by the cephalic side, and the dorsal side of the right hemi-mesocolon on the fusion level by caudal side gradually separated into a double-layer loose fascial structure. The dorsal stump of the right retroperitoneal fascia covered the surface of the duodenum level, moved on from the ventral side to the surface of the prerenal fascia, and continued to the caudal side. Conclusions: The right retroperitoneal fascia is a rigid barrier between the anterior pancreaticoduodenal space behind the transverse colon and the posterior space of the ascending colon. The Toldt fascia formed by fusion with the dorsal lobe of the right colon travels to the edge of the descending and horizontal part of the duodenum and separates again. The right retroperitoneal fascia is attached to the edge of the duodenum, reversing and running on the surface of the prerenal fascia, while the dorsal lobe of the right colon runs in front of the pancreas and duodenum, and shifts to the pancreaticoduodenal fascia. During the operation, this fascia should be identified and cut to penetrate the anterior pancreaticoduodenal space behind the transverse colon and the posterior ascending colon space, which helps to ensure the integrity of the dorsal side of the right hemi-mesocolon.
Subject(s)
Female , Humans , Male , Abdominal Wall , Colectomy , Colonic Neoplasms/surgery , Fascia , Laparoscopy , Mesocolon/surgery , Retrospective StudiesABSTRACT
The mesentery is a continuous unity and the operation of digestive carcinoma is the process of mesenteric resection. This paper attempts to simplify the formation process of all kinds of fusion fascia in the process of digestive tract embryogenesis, and to illuminate the continuity of fusion fascia with a holistic concept. This is helpful for beginners to reversely dissect the fusion fascia and maintain the correct surgical plane during operation, and to achieve the purpose of complete mesenteric resection.
Subject(s)
Humans , Colonic Neoplasms/surgery , Gastrointestinal Neoplasms/surgery , Laparoscopy , Mesentery/surgery , MesocolonABSTRACT
D3 lymphadenectomy and complete mesocolic excision (CME) for colon cancer, which have been introduced to China for more than 10 years, are two major surgical principles worldwide. However, there are still many different opinions and misunderstandings about the core principles of D3 and CME, especially the similarities and differences between them. However, few articles have been published to discuss these issues specifically. Domestic scholars' understandings about D3 lymphadenectomy and CME for right hemicolectomy are quite different. Two different concepts including "D3/CME" and "D3+CME" have become mainstream views. The former equate D3 with CME and the latter seems to regard them as totally different principles. There is no consensus on which one is more reasonable. Therefore, this article aims to discuss the similarities and differences between D3 and CME for right hemicolectomy in perspectives of the theoretical background, surgical principles, extent of surgery and oncological outcomes. We believed that D3 and CME do not belong to the same concept, and that the scope of CME surgery for right-sided colon cancer is greater than and includes the scope of D3 surgery, and that D3 and CME are not complementary.
Subject(s)
Humans , Colectomy/methods , Colonic Neoplasms/surgery , Laparoscopy , Lymph Node Excision/methods , Mesocolon/surgeryABSTRACT
Objective@#To investigate the Clavien-Dindo (CD) classification of complications after complete mesocolic excision (CME) in laparoscopic radical resection of right-sided hemicolon cancer and its influencing factors.@*Methods@#A retrospective case-control study was performed. Inclusion criteria: (1) the adenocarcinoma located at colon from cecum to hepatic flexure; (2) laparoscopic right hemicolectomy with CME was completed. Exclusion criteria: (1) patients had severe organ dysfunction before operation; (2) tumor invaded adjacent organs or developed distant organ metastasis; (3) emergency surgery; (4) failure of laparoscopic surgery, and conversion to laparotomy; (5) without complete clinical data. Finally, clinical data of 141 patients in our hospital form March 2015 to February 2019 were retrospectively analyzed. CD grading standard was used to evaluate postoperative complications. Univariate and multivariate logistic regression analyse were used to analyze the factors that might affect the complications. Survival analysis was conducted by grouping the indicators with statistically significant difference in multivariate analysis. Kaplan-Meier method was used to draw the survival curve and log-rank test was used to analyze the difference.@*Results@#Of the 141 patients, 89 were male and 52 were female with mean age of (61.8±11.0) years. All the operations completed successfully. A total of 37 postoperative complications were developed in 26 (18.4%) patients had postoperative 37 cases of complications, mainly including 7 delayed incision healing, 6 diarrhea, and 5 respiratory dysfunction. According to CD classification standard, grade I, II, and IV a complication rates were 40.5% (15/37), 56.8% (21/37), and 2.7% (1/37) respectively. Univariate analysis showed that age ≥ 65 years (χ2=4.338, P=0.037), BMI ≥ 28 kg/m2 (χ2=5.971, P=0.015), and preoperative hemoglobin < 100 g/L (χ2=3.985, P=0.046) were risk factors of postoperative complications. Multivariate analysis testified that age ≥ 65 years (OR=7.991, 95%CI: 2.203 to 28.983, P=0.002) and body mass index (BMI) ≥ 28 kg/m2 (OR=4.231, 95%CI: 1.034 to 17.322, P=0.045) were independent risk factors for complications after laparoscopic CME surgery for right-sided hemicolon cancer. All the patients were followed up for median time of 24 (1-48) months. The log-rank test showed that there were no significant differences in the cumulative survival rate between patients of age < 65 years and age ≥ 65 years (χ2=0.986, P=0.321), and between those with BMI < 28 kg/m2 and BMI ≥ 28 kg/m2 (χ2=0.370, P=0.543).@*Conclusions@#The main complications after CME in laparoscopic radical resection of right hemicolon cancer are CD grade I and II. Elderly and obesity are independent risk factor for postoperative complications. Before the operation, reasonable preventive measures should be taken for the elderly and the obese in order to reduce postoperative complications.
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Objective To investigate the application value of superior mesenteric artery (SMA)-oriented complete mesocolic excision (CME) in the treatment of right colon cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 955 patients with right colon cancer who were admitted to the First Affiliated Hospital of Nanjing Medical University from January 2013 to June 2018 were collected.There were 514 males and 441 females,aged from 18 to 96 years,with a median age of 65 years.Of the 955 patients,377 undergoing SMA-oriented CME of right colon with the lymph node dissection along the left boundary of SMA were allocated into SMA-oriented group,and 578 undergoing superior mesenteric vein (SMV)-oriented CME of right colon with the lymph node dissection along the left boundary of SMV were allocated into SMV-oriented group.Observation indicators:(1) intraoperative and postoperative conditions;(2) postoperative complications;(3) postoperative pathological examinations;(4) follow-up and survival situations.Follow-up was performed by telephone interview and outpatient examination once every 3-6 months within 2 years after surgery and once a year after 2 years up to January 2019,using tumor recurrence and metastasis or death as the end point.Follow-up included physical examination and tumor marker test,including carcino embryonic antigen,CA19-9,chest and abdomen CT examination and enteroscopy.Measurement data with skewed distribution were described as M (P25,P75),and comparison between groups was done using the Mann-Whitney U test.Count data were described as absolute numbers or percentages,and comparison between groups was analyzed using the chi square test.Ordinal data were analyzed using the rank sum test.Kaplan-Meier method was used to calculate survival time and rate,and draw survival curve.Log-rank test was used for survival analysis.Patients with loss to follow-up were involved in survival analysis as censored data.Results (1) Intraoperative and postoperative conditions:the operation time,volume of intraoperative blood loss,duration of postoperative hospital stay were 100 minutes (90 minutes,110 minutes),50.0 mL (50.0 mL,70.0 mL),8 days (8 days,10 days) in the SMA-oriented group,and 110 minutes (90 minutes,135 minutes),50.0 mL (50.0 mL,122.5 mL),10 days (8 days,12 days) in the SMV-oriented group,showing significant differences between the two groups (Z=-5.400,-5.799,-7.461,P＜0.05).After the exclusion of 47 patients unsuitable for defecation analysis because of postoperative complications,365 in the SMA-oriented group and 543 in the SMV-oriented group were analyzed.The time to first defecation,the maximum number and the median number of daily defecation postoperatively were 5 days (3 days,5 days),2.0 (1.0,2.5),1.0 (1.0,1.0) in the SMA-oriented group,which showed no significant difference from 4 days (3 days,5 days),2.0 (1.0,3.0),1.0 (1.0,1.0) in the SMV-oriented group (Z=-1.622,-1.541,-1.024,P＞ 0.05).(2) Postoperative complications:cases with postoperative complications,cases with incisional liquefaction or infection,cases with anastomostic leakage,cases with delayed gastric emptying,cases with intra-abdominal bleeding,cases with complete or incomplete ileus,cases with anastomostic bleeding,cases with intra-abdominal infection,cases with disruption of wound,the number of death were 55,10,3,3,2,2,1,1,1,1 in the SMA-oriented group,which showed no significant difference from 83,30,13,4,3,8,3,6,2,3 in the SMV-oriented group,respectively (x2 =0.045,3.662,2.926,0.034,0.001,1.604,0.352,1.873,0.048,0.352,P＞0.05).There were 32 of 377 patients in the SMA-oriented group and 14 of 578 in the SMV-oriented group with chylous leakage,showing a significant difference between the two groups (x2 =18.312,P＜ 0.05).Patients with chylous leakage were improved after conservative treatment,without reoperation.Patients with other complications were improved after anti-infection,fluid infusion,and reoperation.Four of 955 patients died after surgery.(3) Postoperative pathological examinations:patients with stage Ⅰ,stage Ⅱ,and stage Ⅲ (pathological TNM staging),patients with high-differentiation,mid-differentiation,and low-differentiation (tumor differentiation degree),length of intestine specimen,number of positive lymph nodes,maximum tumor diameter,patients with cancer nodules,patients with vascular invasion,patients with perineural invasion were 57,174,146,30,174,173,23 cm (21 cm,26 cm),0 (0,2),5.0 cm (3.0 cm,6.0 cm),37,81,53 in the SMA-oriented group,which showed no difference from 66,280,232,33,303,242,23 cm (21 cm,25 cm),0 (0,2),5.0 cm (3.5 cm,6.0 cm),80,108,82 in the SMV-oriented group (Z=-1.020,-0.216,-0.243,-0.220,-0.814,x2=3.441,1.127,0.003,P＞0.05).The number of harvested lymph nodes was 22.0 (17.0,27.0) and 18.0 (15.0,22.0) in the SMA-oriented group and SMV-oriented group,respectively,with a significant difference between the two groups (Z=-7.800,P＜0.05).There were 202 patients extracted for further analysis.The number of harvested lymph nodes and harvested central lymph nodes was 25.0 (20.0,31.3),5.0 (3.0,8.0) of 166 patients in the SMA-oriented group,and 21.5 (18.0,28.8),1.5 (0,4.5) of 36 patients in the SMV-oriented group,respectively,showing significant differences between the two groups (Z =-1.995,-4.309,P＜0.05).(4) Follow-up and survival situations:840 of 955 patients including 346 in the SMA-oriented group and 494 in the SMV-oriented group were followed up for 1.0-73.2 months,with a median time of 31.5 months.SMA-oriented group had a higher 5-year overall survival rate than SMV-oriented group (91.8％ vs.84.9％,x2 =4.384,P＜0.05),but had no significant difference in the 5-year tumor-free survival rate compared with the SMV-oriented group (84.4％ vs.78.2％,x2=2.158,P＞0.05).Conclusion Compared with SMV-oriented CME of right colon,SMA-oriented CME of right colon is safe and feasible,with larger number of harvested lymph nodes,which can achieve complete lymph node dissection.
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OBJECTIVE: To compare dorsal-and-medial hybrid approach and medial-to-lateral approach in laparoscopic right hemicolectomy with complete mesocolic excision(CME). METHODS: Patients undergone laparoscopic right hemicolectomy in Department of Gastrointestinal Surgery in Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine from July 2017 to April 2018 were prospectively included.Patients were divided into two groups:dorsal group and medial group. Clinical and pathological data were collected and compared between the two groups. RESULTS: There were 35 patients in medial group and 40 patients in dorsal group. No significant differences were found between the two groups in baseline characteristics,perioperative outcomes and pathological results. No significant difference was found between the two groups in length of bowel(24 cm vs. 22 cm),A line distance(9.8 cm vs.9.4 cm),B line distance(9.0 cm vs. 8.5 cm),area of mesentery(112.4 cm~2 vs. 109.0 cm~2),total lymph node count(19 vs.19),lymph node adequate ratio(97.1% vs. 97.5%)and CME ratio(80% vs. 85%). Obesity was found to be an independent risk factor of CME ratio(P=0.019). CONCLUSION: Dorsal-and-medial hybrid approach and medial-to-lateral approach are comparable in safety,feasibility and effectiveness in laparoscopic right hemicolectomy with complete mesocolic excision. Randomized clinical trials with larger sample size are needed.
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OBJECTIVE: To investigate the feasibility and short-term outcomes of laparoscopic D3 lymphadenectomy along the left of SMA for right colon cancer.METHODS: The clinical data of 134 patients with right colon cancer admitted from June 2015 to March 2017 in Department of Gastrointestinal Surgery,Ruijin Hospital,Shanghai Jiao Tong University School of Medicine were analyzed retrospectively. A total of 57 patients received the laparoscopic D3 lymphadenectomy along the left of SMA and 77 patients received the laparoscopic D3 lymphadenectomy along the left of SMV.RESULTS: There was no statistical difference between the two groups in operation time,intra-operative blood loss,time of liquid intake and post-operative hospital stay,but the SMA group had a longer duration of tube drainage and larger total volume of drainage[(471.4±285.6)mL vs.(352.2±305.7)mL,(7.0±4.9)d vs.(5.7±2.0)d,P=0.02 和 P=0.03]. The SMA group harvested more lymph nodes than the SMV group(26.5±6.7 vs. 21.3±7.8,P<0.0001). However,the SMA group had a higher rate of post-operative complications(28.1% vs. 13.0%, P=0.04).CONCLUSION: Laparoscopic D3 lymphadenectomy along the left side of SMA for right colon cancer is feasible but had a higher rate of post-operative complications.
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Objective: To compare the short-term clinical efficacy and feasibilities between complete mesocolic excision (CME) and tra-ditional radical resection in emergency surgery for patients with colon cancer. Methods: Clinical data for 53 cases of colon cancer treat-ed by emergency surgery between January 2011 and December 2017 in Civil Aviation General Hospital were analyzed. On the basis of the entry time and various operation procedures, the 53 patients were assigned into two groups: the CME group (n=25) that under-went CME in May 2014 or later and the traditional operative group (n=28) that underwent traditional radical resection before May 2014. Distal and proximal colonic and intestinal lavage were performed in all patients. The short-term clinical effects of these different methods were analyzed. Results: The number of excised lymph nodes in the CME group and traditional group was 31.7±2.9 and 19.5± 4.2, respectively, and the difference between the groups was statistically significant (P<0.05). The operation time of the two groups was (176.0±42.3) min and (157.5±33.5) min and the blood loss was (148.7±74.0) mL and (128.9±50.0) mL, respectively. The length of hospital stay of the two groups was (27.2±10.4) days and (23.1±6.3) days and the first flatus time was (75.0±3.3) h and (75.3±3.7) h, re-spectively. The difference between the two groups in these parameters was not statistically significant (P>0.05). In addition, there was no significant differences in pathological staging, postoperative complications, or mortality between the CME group and traditional op-erative group (P>0.05). Conclusions: The short-term clinical efficacy of CME is similar to that of traditional radical cancer surgery with the advantage of more extensive lymph node dissection. CME can be used safely in patients with colon cancer undergoing an emergen-cy operation.
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According to multicenter randomized controlled trials, laparoscopic radical resection of colon cancer has the same short and long term clinical efficacy as traditional open surgery. In laparoscopic radical resection of right semicolon cancer, it is important to separate the embryonic plane of the root, and to ligate and cut off the central vascular roots. Only by separation along the membrane space can one achieve minimally invasive operation with no bleeding, and ensure the integrity of the excision of the mesangium and avoid damage of internal fascia and other organs. The mesangial distribution of the right semicolon is adjacent to the mesangium of the stomach and is connected to the mesentery of the small intestine. The pancreaticoduodenum locates between the right semicolon mesentery and the retroperitoneal subperitoneal fascia. In particular, the relationship between the anterior and posterior Treitz fascia of the pancreaticoduodenum and the Toldt space is complex, which is closely related to the feasibility of complete mesocolic excision(CME). This article introduces the distribution of intermembranous space and mesangial bed in the right semicolon, presenting the problem in CME surgery. In addition, there are key points in identifying the gap between the membranes based on the author’s experience and we propose a new evaluation criteria for membrane surgical specimens, which has certain guiding significance for radical CME surgery for right semicolon cancer.
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INTRODUCTION@#Laparoscopic colorectal surgery is increasingly performed worldwide due to its multiple advantages over traditional open surgery. In the surgical treatment of right-sided colonic tumours, the latest technique is laparoscopic right hemicolectomy with complete mesocolic excision (lapCME), which aims to lower the rate of local recurrence and maximise survival as compared to standard laparoscopic right hemicolectomy (lapS).@*METHODS@#We conducted a retrospective analysis of our initial experience with lapCME in Singapore General Hospital between 2012 and 2015. All procedures were performed by a single surgeon.@*RESULTS@#Nine patients underwent lapCME and 16 patients underwent lapS. Indication for lapCME was cancer in the right colon. None of the patients required conversion to open surgery, and all were discharged well. The number of lymph nodes resected in the lapCME group was significantly greater than in the lapS group (29 ± 15 vs. 19 ± 6; p = 0.02) during the study period, and the mean operation time was significantly longer for lapCME (237 ± 50 minutes vs. 156 ± 46 minutes; p = 0.0005). There were no statistically significant differences in terms of demographics, tumour stage, time taken for bowel to open postoperatively, time taken for patient to resume a solid diet postoperatively and length of hospital stay. Two patients who underwent lapS were re-admitted for intra-abdominal collections - one patient required radiology-guided drainage, while the other patient was managed conservatively.@*CONCLUSION@#Our initial experience with lapCME confirms the feasibility and safety of the procedure.
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Objective To evaluate the experience of laparoscopic complete mesocolic excision (CME) for right colon cancer.Methods 45 patients with right colon cancer underwent laparoscopic CME were selected as research subjects(laparoscopy group),and 40 patients with right colon cancer underwent open CME were selected as control group(open group).The clinical effects of the two groups were observed .Results All the 45 cases were successfully performed with laparoscopic CME and 40 specimens were evaluated pathologically as mesocolic plane surgery. The average time for passage of flatus in the laparoscopy group [(3.43 ±0.72)d] was less than that in the open group [(4.10 ±0.99)d,P =0.039,P <0.05].The average time of leaving bed [(3.39 ±0.66)d] in the laparoscopy group was significantly less than that in the open group [(4.20 ±0.79)d,P =0.005,P <0.05].The mean operative time of the laparoscopy group [(160.93 ±20.91)min] was longer than that of the open group [(103.00 ±24.29)min,P =0.000,P <0.05].The average number of total lymph nodes removed of the laparoscopy group [(23.16 ±8.21)] was higher than that of the open group [(19.06 ±7.48)],but the difference was not statistically significant between the two groups (P =0.102,P >0.05).The overall postoperative complication rate of the laparoscopy group was 13.33%,which was lower than 22.50% of the open group,but the difference was not statistically significant between the two groups(P =0.268,P >0.05).Conclusion Laparoscope complete mesocolic excision for right colon cancer is safe and feasible.
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Objective To investigate the local anatomical characteristics of the associated membrane and mesangial space in the complete mesocolic excision (CME) of right hemicolectomy and provide the surgical practical anatomical evidence to CME.Methods The experimental study was conducted.Department of Anatomy of Capital Medical University provided 20 adult cadavers.The surgical pictures came from Beijing Friendship Hospital of Capital Medical University.The local anatomy of CME in 20 cadavers was simulated after fascia perfusion.Observation indicators:(1) the local anatomy of the visceral fascia and parietal fascia was studied by simulating the operation of CME in cadaver specimens;(2) observing the integrity and barrier action of the visceral layer of the membrane after fascia perfusion solution freezing;(3) distribution and variation of superior vessels of rightsemi mesocolon.Results (1) The local anatomy of the visceral fascia and parietal fascia was studied by simulating the operation of CME in cadaver specimens:posterior lobe of the interposition mesocolon merged completely with visceral fascia,parietal fascia and front fascia of duodenum,and superior mesenteric vein (SMV) and superior mesenteric artery (SMA) were found.The ureters and reproductive vessels were covered with Gerota fascia,with a complete membrane structure.The specimens from simulated CME in 20 adult cadavers and CME of right hemicolectomy accorded with a requirement of CME.(2) Observing the integrity and barrier action of the visceral layer of the membrane after fascia perfusion solution freezing:posterior lobe of the right-semi mesocolon merged completely with visceral fascia,with a complete parietal fascia structure and without exudation of fascia perfusion solution.The right ureter and reproductive vessels were completely covered with Gerota fascia.The serosal surface of right-semi mesocolon maintained integity,with exudation of fascia perfusion solution.(3) Distribution and variation of superior vessels of right-semi mesocolon:major blood vessels of right-semi colon included superior mesenteric vessels,including SMA and SMV.The major branches of vessels included ileocolic artery,right colic artery,middle colic artery,right and left branches of middle colic artery,ileocolic vein,middle colic vein and gastrocolic stem.The gastrocolic stem and main stem of right colic artery had more variations.Conclusion The posterior lobe of the interposition mesocolon merges with fascia,and complete visceral fascia,can be separated,these provide anatomical evidences for safety and radical resection of right hemicolectomy based on following the principles of CME.
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Despite the continued development of radiotherapy and chemotherapy,surgery is still the first choice for the treatment of colorectal cancer.Complete mesocolic excision (CME) based on anatomy and embryology,the sharp separation is carried out along the embryonic development.A large number of clinical trials have confirmed that the operation can significantly reduce the local recurrence rate and improve survival rate.The technique may become a standardized surgery for colon cancer.To learn about the research progress of the application of complete mesocolic excision,this paper collected relevant literatures of CME for reviewing.
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Objective To explore regional anatomical features of fascia and spaces related to complete mesocolic excision (CME)dur-ing laparoscopic right hemicolectomy.Methods Observe and describe the regional anatomical features of related mesenterium,fascia and spaces through autopsy and somatoscopy.Results Superior mesenteric vein is the anatomic landmark in CME with medial access for laparo-scopic right hemicolectomy.Right mesocolon and ileal mesentery are the main mesenterium,and the fascia contains the prerenal fascia and the pancreatic fascia.The right retrocolic space and the colon transversum space are two important anatomical spaces,and their fusion fascia space served as a natural surgical plane.Conclusion There is a natural surgical plane which made of mesenterium,fascia and spaces be-tween mesocolon and prerenal fascia in CME during laparoscopic right hemicolectomy,and the surgery is feasible.
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Objective To evaluate the safety of laparoscopic complete mesocolic excision (CME) in radical resection for right colon cancer. Methods From January 2012 to June 2013, laparoscopic CME was performed in 40 patients with right colon cancer. Another group of 38 patients underwent traditional radical resection from January 2011 to December 2011.Surgical outcomes were compared between the two groups . Results The number of lymph nodes retrieved in the laparoscopic group ( 22.1 ±7.8 ) was significantly more than that in the traditional group (18.6 ±4.3, t =2.436, P =0.017).In patients with stage Ⅲ cancer, the laparoscopic group was associated with higher lymph node counts (23.0 ±6.0 vs.18.2 ±5.1, t=2.699, P=0.000), however, there were no significant differences in those with stage Ⅱ cancer between the two groups (t=0.758, P=0.454).There were no differences in operation time and intraoperative blood loss between the two groups (t=0.716, P=0.476;t=-1.547, P=0.126), but in the laparoscopic group the time to pelvic drainage tube removal , time to first flatus, time to liquid diet intake , duration of hospital stay, and postoperative complications were significantly better than those in the traditional group (t=-2.950, P=0.004;t=-5.767, P=0.000; t =-7.817, P =0.000; t =-6.065, P =0.000; χ2 =4.504, P =0.034). Conclusions CME technique in laparoscopic radical right hemicolectomy is feasible , safe, and effective.CME improves the surgical quality with keeping the integrity of mesocolon , more harvested lymph nodes , and not increasing surgical risks and postoperative complications .