RESUMEN

BACKGROUND: One of the approaches to distal sigmoid colon cancer surgical treatment is segmental colonic resection with vascular preservation of left colic artery (LCA). D3 lymph node dissection may technically vary according to different vascular anatomy. This study aims to show the approaches to D3 lymph node dissection with LCA preservation for distal sigmoid colon cancer according to different patterns of inferior mesenteric artery (IMA) branching. METHODS: CT angiography with 3D reconstruction was routinely performed to identify the IMA branching pattern. Laparoscopic distal sigmoid colon resection with D3 lymph node dissection and left colic artery preservation in standardized fashion was performed in all cases. Data, including clinical, intraoperative, and short-term surgical outcomes, is presented as median numbers (Me) and interquartile range (IQR). RESULTS: Twenty-six patients with distal sigmoid colon cancer were treated with laparoscopic distal sigmoid colon resection. The approach to D3 lymph node dissection varied according to different anatomical variations. There was one conversion (3.8%) and one anastomotic leakage (3.8%) in patients with high BMI. At the same time, there was a high apical lymph node count (Me 3 (IQR 2-5), min-max 0-10) due to the skeletonization of the IMA. CONCLUSIONS: The technical aspects of D3 lymph node dissection with left colic artery preservation may vary in different types of LCA and sigmoid artery branching patterns regardless of the standardized anatomical landmarks. The anatomical features should be considered when performing vascular-sparing lymph node dissection.

Asunto(s)

RESUMEN

BACKGROUND: Colon cancer is a global health concern, ranking fifth in both new diagnoses and deaths among tumors worldwide. Surgical intervention remains the primary treatment for localized cases, with a historical evolution marked by a focus on short-term outcomes. While Japan pioneered radical tumor removal with a systematic categorization of lymph nodes (D1, D2, D3), the dissemination of Japanese practices to the West was delayed until 90th of last century. Discrepancies between Japanese D3 dissection and the CME with CVL principle persist, with variations in longitudinal margins and recommended procedures. Non-randomized trials indicate the superiority of D3 over D2, but a consensus is lacking. METHODS: This prospective, international, multicenter, randomized controlled trial employs a two-arm, parallel-group, open-label design to rigorously compare the 5-year overall survival outcomes between D2 and D3 lymph node dissection in stage II-III right colon cancer. Building on prior studies, the trial aims to address existing knowledge gaps and provide a comprehensive evaluation of the outcomes associated with D3 dissection. The study population comprises patients with right colon cancer, ensuring a focused investigation into the specific context of this disease. The trial design emphasizes its global scope and collaboration across multiple centers, enhancing the generalizability of the findings. DISCUSSION: This study's primary objective is to elucidate the potential superiority in 5-year overall survival benefits of D3 lymph node dissection compared to the conventional D2 approach in patients with stage II-III right colon cancer. By examining this specific subset of patients, the research aims to contribute valuable insights into optimizing surgical strategies for improved long-term outcomes. The trial's international and multicenter nature enhances its applicability across diverse populations. The outcomes of this study may inform future guidelines and contribute to the ongoing discourse surrounding the standardization of colon cancer surgery, particularly in the context of right colon cancer. TRIAL REGISTRATION: ClinicalTrials.gov NCT03200834. Registered on June 27, 2017.

Asunto(s)

RESUMEN

OBJECTIVE: To evaluate surgical and oncological results of standard and extended lymph node dissection (D2 and D3) in patients with colon cancer. MATERIAL AND METHODS: We analyzed treatment outcomes in 74 patients with colon cancer stage T1-4aN0-2M0 who underwent right- and left-sided hemicolectomy, resection of sigmoid colon with standard and extended lymph node dissection (D2 and D3). RESULTS: Surgical approach and level of D3 lymph node dissection did not increase intra- and postoperative morbidity. Laparoscopic interventions were followed by significantly lower intraoperative blood loss and earlier gas discharge. Metastatic lesion of apical lymph nodes was observed in 5 out of 36 patients who underwent D3 lymph node dissection (13.8%), and metastases in regional lymph nodes rN1-2 were found in all these patients. Overall 5-year survival was 86%. Disease-free and overall 5-year survival were similar after D2 and D3 lymph node dissection. CONCLUSION: D3 lymph node dissection is safe for colon cancer. Metastatic lesions of apical lymph nodes during D3 lymph node dissection were detected only in patients with lesions of regional lymph nodes (rN1-2). Disease-free and overall 5-year survival were similar after D2 and D3 lymph node dissection.

Asunto(s)

RESUMEN

OBJECTIVE: To examine the impact of a combined craniocaudal approach on pain and complications during laparoscopic D3 lymph node dissection in clients diagnosed with right colon cancer (RCC). METHODS: 100 RCC patients were divided into Group A and Group B. Both groups underwent laparoscopic D3 lymph node dissection, with Group A undergoing an intermediate approach and Group B undergoing a combined head and tail approach. Two groups of patients' perioperative (surgical time, intraoperative blood loss, number of lymph node dissection) indicators, postoperative recovery (postoperative exhaust time, postoperative hospital stay, drainage tube removal time) indicators, perioperative pain level (VAS scores 1, 3, and 5 days following surgery), and incidence of complications (vascular injury, intestinal obstruction, anastomotic bleeding, incision infection), and the therapeutic efficacy [CEA, CA19-9] indicators were compared. RESULTS: Clients in the B team had substantially shorter operating times and considerably fewer intraoperative hemorrhage than those in the A team. The VAS grades of clients in the B team were considerably lower than those in the A team the day following surgery. Clients in the B team experienced vascular injury at a substantially lower rate than those in the A team. The overall incidence rate of problems did not differ statistically significantly between the A team and the B team. Following therapy, teams A and B's CEA and CA19-9 levels were considerably lower than those of the same team prior to therapy. CONCLUSION: Combined craniocaudal technique can significantly reduce intraoperative bleeding, postoperative pain, and the risk of sequelae from vascular injuries.

RESUMEN

BACKGROUND/AIM: The extent of lymphadenectomy appropriate for patients with cT2 colorectal cancer (CRC) remains controversial. This study was conducted to compare the survival outcomes of patients with cT2 CRC after D3 or D2 lymph node dissection (LND). PATIENTS AND METHODS: Qualifying subjects (N=590) had undergone radical colorectal resections for cT2 CRC and were grouped according to tumor histological type as either well-differentiated (WDA) or non-well-differentiated (nWDA) adenocarcinoma. Each group was further stratified into D3 or D2 LND according to the extent of lymph node dissection. Propensity score matching (PSM) was applied to balance potential confounding factors, and identify independent prognostic risk factors using Cox regression analysis. Primary outcome measures were overall survival (OS), cancer-specific survival, (CSS) and relapse-free survival rate (RFS). RESULTS: Prior to PSM, OS and CSS differed significantly (p=0.001 and p=0.021, respectively) for D3 and D2 LND subsets in the nWDA group. Estimated hazard ratios (HRs) for OS and CSS were 3 [95% confidence interval (CI)=1.3-6.8; p=0.0084] and 3.2 (95%CI=1-10; p=0.047), respectively, in the D3 LND subset. After matching, significant differences in OS (p=0.007) and CSS (p=0.012) were also observed, with corresponding estimated HRs of 4 (95%CI=1.2-14; p=0.028) and 16 (95%CI=1.2-220; p=0.034). In the WDA group, D2 and D3 LND procedures displayed similar favorable prognoses before and after matching. Postoperative complications emerged as independent risk factors for prognosis in the WDA group of patients with cT2 CRC. CONCLUSION: D3 LND improved survival outcomes in patients with non-well-differentiated cT2 CRC. In patients with well-differentiated cT2 adenocarcinoma, D3 LND was preferred to reduce perioperative complications.

Asunto(s)

RESUMEN

OBJECTIVE: To develop and describe a technique of primary retroperitoneal approach for vessel-sparing D3-lymph node dissection in the left colon and rectal cancer surgery; to evaluate the short-term results of the first series of patients treated with a new minimally invasive method. MATERIAL AND METHODS: The first 10 patients with adenocarcinoma of the left colon and rectum, who underwent surgical treatment using the retroperitoneal approach with vessel-sparing D3 lymph node dissection, were included in the study. The primary retroperitoneal approach involved mobilization of the left side of the colon, D3 lymph node dissection with skeletonization of inferior mesenteric artery (IMA) and selective ligation of afferent vessels from retroperitoneal space using SILS access system at the first steps of surgery. Intersection of visceral and parietal peritoneum, as well as intersection of mesentery within the bowel resection borders was performed laparoscopically. Surgical specimen was removed through retroperitoneal access incision. RESULTS: Duration of retroperitoneal stage with lymph node dissection was 100 min (70.0-115.0). There were 28.5 (22-37) regional lymph nodes removed during vessel-sparing D3 lymph node dissection with IMA skeletalization, 3 (1-4) metastatic regional lymph nodes and 3.5 (2-5) apical nodes. In 4 out of 10 patients, we damaged visceral peritoneum during retroperitoneal dissection. Two patients developed Clavien-Dindo grade 1-2 complications. Mean postoperative hospital stay was 8 days (5-12). CONCLUSION: We developed retroperitoneal vessel-sparing D3 lymph node dissection for the treatment of left colon and rectal cancer. Initial results demonstrated safety and feasibility of this approach.

Asunto(s)

RESUMEN

Background: Adequate blood supply is one of the key factors for colorectal anastomosis healing. Various variants of vascular anatomy often come as a surprise to surgeons during operations. Objectives: The aims of this study were to carry out a comparative analysis of three-dimensional-computed tomography (3D-CT) angiography data with intraoperative data and a detailed analysis of variants of the anatomy of splenic flexure. Material and methods: In this study, we included 103 patients (56 males and 47 females; mean age 64.2 ± 11.6) with the left-sided colon and rectal cancer who underwent preoperative 3D-CT angiography at Ternopil University Hospital between 2016 and 2022. Results: According to the recently proposed classification, there are four types of blood supply to the splenic flexure of the colon: Our analysis showed that type 1 was found in 83 (80.6%) patients, type 2 in 9 (8.7%), type 3 in 10 (9.7%), and type 4 in 1 (1%). All patients underwent local left radical hemicolectomy with resection of complete mesocolic excision (CME), central vascular ligation (CVL) and resección (R0). Seven cases were operated laparoscopically; and the median quantity of removal lymph nodes was 21.54 ± 7.32. Positive lymph nodes were revealed in 24.3% cases. AL was diagnosed in one patient. Conclusions: Careful pre-operative analysis of vascular anatomy on 3D-CT angiography will assess the vascularization of the splenic flexure of the colon, reduce intraoperative time to identify structures, and develop a personalized strategy for surgery which potentially can reduce the risk of anastomotic leakage.

Antecedentes: El suministro de sangre adecuado es uno de los factores clave para la curación de la anastomosis colorrectal. Varias variantes de la anatomía vascular a menudo sorprenden a los cirujanos durante las operaciones. Objetivo: Realizar un análisis comparativo de los datos de la angiografía tridimensional por tomografía computarizada (3D-TC) con los datos intraoperatorios y un análisis detallado de las variantes de la anatomía del ángulo esplénico. Método: Se incluyeron en el estudio 103 pacientes con cáncer de colon y recto del lado izquierdo que se sometieron a una angiografía 3D-TC preoperatoria en el Hospital Universitario de Ternopil. Resultados: De acuerdo con la clasificación propuesta recientemente, existen cuatro tipos de irrigación del ángulo esplénico del colon. Nuestro análisis mostró que el tipo 1 se encontró en 83 (80.6%) pacientes, el tipo 2 en 9 (8.7%), el tipo 3 en 10 (9.7%) y el tipo 4 en 1 (1%). Todos los pacientes fueron sometidos a hemicolectomía radical izquierda local con resección de escisión mesocólica completa (CME), ligadura vascular central (CVL) y resección (R0). Siete pacientes fueron operados por vía laparoscópica. La mediana de ganglios extirpados fue de 21.54 ± 7.32. Se revelaron ganglios linfáticos positivos en el 24.3% de los casos. Se diagnosticó fuga anastomótica en un paciente. Conclusiones: El análisis preoperatorio cuidadoso de la anatomía vascular en la angiografía 3D-TC evaluará la vascularización del ángulo esplénico del colon, reducirá el tiempo intraoperatorio para identificar estructuras y desarrollará una estrategia personalizada para la cirugía.

Asunto(s)

RESUMEN

BACKGROUND: D3 lymph node dissection with left colic artery (LCA) preservation in rectal cancer surgery seems to have little effect on reducing postoperative anastomotic leakage. So we first propose D3 lymph node dissection with LCA and first sigmoid artery (SA) preservation. This novel procedure deserves further study. METHODS: Rectal cancer patients who underwent laparoscopic D3 lymph node dissection with LCA preservation or with LCA and first SA preservation between January 2017 and January 2020 were retrospectively assessed. The patients were categorized into two groups: the preservation of the LCA group and the preservation of the LCA and first SA group. A 1:1 propensity score-matched analysis was performed to decrease confounding. RESULTS: Propensity score matching yielded 56 patients in each group from the eligible patients. The rate of postoperative anastomotic leakage in the preservation of the LCA and first SA group was significantly lower than that in the LCA preservation group (7.1% vs. 0%, P=0.040). No significant differences were observed in operation time, length of hospital stay, estimated blood loss, length of distal margin, lymph node retrieval, apical lymph node retrieval, and complications. A survival analysis showed patients' 3-year disease-free survival (DFS) rates of group 1 and group 2 were 81.8% and 83.5% (P=0.595), respectively. CONCLUSION: D3 lymph node dissection with LCA and first SA preservation for rectal cancer may help reduce the incidence of anastomotic leakage without compromising oncological outcomes compare with D3 lymph node dissection with LCA preservation alone.

Asunto(s)

RESUMEN

PURPOSE: To investigate oncologic outcomes including overall survival and disease-free survival depending on the extent of lymphadenectomy (D3 versus D2) by comparing D3 and D2 lymphadenectomy in patients with clinical stage 2/3 right colon cancer. METHODS: Consecutive series of patients who underwent radical resection for right colon cancer at our three hospitals between January 2015 and June 2018 were retrospectively analyzed. Study cohorts were divided into two groups: D3 group and D2 group. Oncologic, pathologic, and perioperative outcomes of the two groups were compared. RESULTS: A total of 295 patients (167 in the D2 group and 128 in the D3 group) were included in this study. Patients' characteristics showed no significant difference between the two groups. The median number of harvested lymph nodes was significantly higher in the D3 group than in the D2 group. The rate of complications was not significantly different between the two groups except for chyle leakage, which was more frequent in the D3 group. Five-year disease-free survival was 90.2% (95% CI: 84.8-95.9%) in the D3 group, which was significantly (p = 0.028) higher than that (80.5%, 95% CI: 74-87.5%) in the D2 group. There was no significant difference in overall survival between the two groups. CONCLUSION: Our results indicate that D3 lymphadenectomy is associated with more favorable 5-year disease-free survival than D2 lymphadenectomy for patients with stage 2/3 right-sided colon cancer. D3 lymphadenectomy might improve oncologic outcomes in consideration of the recurrence rate.

Asunto(s)

RESUMEN

BACKGROUND: The extent of lymphadenectomy in patients with pT2 colorectal cancer (CRC) remains controversial. This study aimed to elucidate the effects of D3 and D2 lymph node dissection (LND) on survival in patients diagnosed with pT2 CRC. METHODS: This was a retrospective cohort study from a high-volume cancer center in Japan. From April 2007 to December 2020, 6273 patients with primary CRC were included in the study; among these, 616 patients diagnosed with pT2 CRC underwent radical colorectal resection. Propensity score matching (PSM) was applied to balance potential confounding factors, and a total of 104 matched pairs were extracted from the entire cohort. Independent risk factors associated with prognosis were determined by Cox regression analysis. The main outcome measures were overall survival (OS) and cancer-specific survival (CSS). RESULTS: Before PSM, there was a statistically significant difference across the cohort in OS and CSS (p = 0.000 and 0.013) between D3 and D2 LND groups; the estimated hazard ratio (HR) was 2.2 (95% confidence interval (CI), 1.1-4.4, p = 0.031) for OS in the D3 LND and 4.4 (95% CI, 1.7 to 11, p = 0.0027) for CSS (p = 0.013). There was also a significant difference (p = 0.024) in OS between the D3 and D2 LND groups in the matched cohort, with an estimated HR for OS of 3.3 (95% CI, 1.2 to 9.1, p = 0.024) and an estimated HR for CSS of 7.2 (95% CI, 1.6 to 33, p = 0.011). CONCLUSIONS: D3 LND had a significant survival advantage in the treatment of pT2 CRC. The results of this study provide a theoretical basis for the application of D3 LND in radical surgery for preoperative T2 CRC.

Asunto(s)

RESUMEN

PURPOSE: This study aimed to compare the short- and long-term outcomes of laparoscopic D3 lymph node (LN) dissection between ligation of the inferior mesenteric artery (IMA) (LIMA) and preservation of the IMA (PIMA) for descending colon cancer using propensity score-matched analysis. METHODS: This retrospective study included 101 patients with stage I-III descending colon cancer who underwent laparoscopic D3 LN dissection with LIMA (n = 60) or PIMA (n = 41) at a single center between January 2005 and March 2022. After propensity score matching, 64 patients (LIMA, n = 32; PIMA, n = 32) were included in the analysis. The primary endpoint was the long-term outcomes, and the secondary endpoint was the surgical outcomes. RESULTS: In the matched cohort, no significant difference was noted in the surgical outcomes, including the operative time, estimated blood loss, number of harvested LNs, number of harvested LN 253, and complication rate. The long-term outcomes were also not significantly different between the LIMA and PIMA groups (3-year recurrence-free survival, 72.2% vs. 75.6%, P = 0.862; 5-year overall survival, 69.8% vs. 63.4%, P = 0.888; 5-year cancer-specific survival, 84.2% vs. 82.8%, P = 0.607). No recurrence of LN metastasis was observed around the IMA root. CONCLUSION: Laparoscopic D3 dissection in PIMA was comparable to that in LIMA regarding both short- and long-term outcomes. The optimal LN dissection for descending colon cancer should be investigated in future large-scale studies.

Asunto(s)

RESUMEN

Background: Laparoscopic complete mesocolic excision (CME) with D3 lymph node dissection for the right colon is becoming popular, but still technically challenging. Several articulating laparoscopic instruments had been introduced to reduce technical difficulties; however, those were not practical. This study aimed to report the first clinical experience of using ArtiSential®, a new laparoscopic articulating instrument in laparoscopic complete mesocolic with D3 lymph node dissection for right colon cancer. Patients and Methods: This was a retrospective, single-institution, consecutive case study. From October 2018 to March 2020, a total of 33 patients underwent laparoscopic right hemicolectomy using ArtiSential®, a new articulating instrument. We compared the short-term outcomes of patients who underwent surgery using ArtiSential® (AG) to the conventional instrument (CG). Results: In total, there were 33 cases in AG and 43 cases in CG. There were no significant differences in operation time (141.0 ± 22.5 vs. 156.0 ± 50.6 min, P = 0.09), mean estimated blood loss (46.8 ± 36.2 vs. 100.8 ± 300.6 ml, P = 0.31) and intra-operative and post-operative complications. However, the number of harvested lymph nodes was higher and the length of hospital stay was shorter in AG than in CG (32.6 ± 12.2 vs. 24.6 ± 7.4, P < 0.01 and 3.0 ± 1.2 vs. 4.1 ± 2.2 days, P = 0.01, respectively). Conclusions: Laparoscopic CME with D3 lymph node dissection for right colon cancer using ArtiSential®, the new articulating laparoscopic instrument is safe and technically feasible.

RESUMEN

BACKGROUND: Previous research was yet to establish a definite operation for transverse colon cancer (TCC); surgical procedure was often dictated by the surgeon's preference in clinical practice. The main surgical methods could be summarized in two main points: segmental colectomy (transverse colectomy) and right hemicolectomy. METHOD: The first patient was a 78-year-old woman, who was diagnosed with right TCC. Computed tomography revealed a right TCC and a very long transverse colon; laparoscopic exploration revealed an enlarged apical lymph node surrounding the ileocolic vessels. We performed a segmental colectomy with extensive apical lymph node dissection along the superior mesenteric vessels and its main branches for her. To distinguish it from the previous radical operations for TCC, we called this operation a segmental colectomy with extensive D3 lymph node dissection. Then, this surgical intervention was performed on 8 other TCC patients. RESULTS: The total operating time was 158 min. Pathological examination confirmed 2 apical lymph node metastases; among them, one apical lymph node metastasis was in group No.203. For all 9 patients, the median operative time was 160 min (range, 140-185 min), the average number of lymph node retrieval was 30 (range, 25-39), and the average number of apical lymph node (No.203, No.213, and No.223) retrieval was 5.9 (range, 0-11). Because of the preservation of the ileocecal junction and part of the ascending colon, all patients recovered uneventfully after surgery, and long-term diarrhea, water-electrolyte imbalance, and other Clavien-Dindo grade III or greater postoperative complications did not occur. CONCLUSIONS: Our procedure combined the advantages of segmental colectomy and right hemicolectomy and gave consideration to oncological and functional outcomes. It may be an optimal choice for TCC patients with a very long transverse colon and preoperative diagnosis of lymph node metastasis.

Asunto(s)

RESUMEN

Objectives: Radical surgery for sigmoid colon cancer is commonly performed with complete mesocolic excision (CME) and apical lymph node dissection, reached by central vascular ligation (CVL) of the inferior mesenteric artery (IMA) and associated extended left colon resection. However, IMA branches can be ligated selectively according to tumor location with D3 lymph node dissection (LND), economic segmental colon resection and tumorspecific mesocolon excision (TSME) if IMA is skeletonized. This study aimed to compare left hemicolectomy with CME and CVL and segmental colon resection with selective vascular ligation (SVL) and D3 LND. Material and Methods: Patients (n= 217) treated with D3 LND for adenocarcinoma of the sigmoid colon between January 2013 and January 2020 were included in the study. The approach to vessel ligation, colon resection and mesocolon excision was based on tumor location in the study group, while in the comparison group, left hemicolectomy with routine CVL was performed. Survival rates were estimated as the primary endpoints of the study. Long- and short-term surgery-related outcomes were evaluated as the secondary endpoints of the study. Results: The studied approach to the IMA branch ligation was associated with a statistically significant decrease in intraoperative complication rates (2 vs 4, p= 0.024), operative procedure length (225.56 ± 80.356 vs 330.69 ± 175.488, p <0.001), and severe postoperative morbidity (6.2% vs 19.1%, p= 0.017). Meanwhile, the number of examined lymph nodes significantly increased (35.67 vs 26.69 per specimen, p <0.001). There were no statistically significant differences in survival rates. Conclusion: Selective IMA branch ligation and TSME resulted in better intraoperative and postoperative outcomes with no difference in survival rates.

RESUMEN

BACKGROUND: D3 lymph node dissection is becoming the standard procedure for the treatment of advanced right colon cancer and has shown increasing evidence of its oncologic benefit. However, a clear indication for its application is lacking and data on this topic is unsatisfactory. Thus, the necessity for D3 lymph node dissection in clinical stage I right colon cancer remains controversial. METHODS: We retrospectively analyzed data from clinical stage I right colon cancer patients who underwent radical surgery at three hospitals of Korea university medical center between January 2015 and June 2018. We compared surgical complications and short-term oncologic outcomes between D2 and D3 lymph node dissections in these patients. RESULTS: Among 512 patients, 122 (23.8%) were clinical stage I. Of these, 88 and 34 patients received D2 and D3 lymph node dissection, respectively. There were no statistically significant differences in clinicopathologic variables and surgical outcomes between the two groups. Upstaging occurred in 16 patients (47.1%) in the D3 group and 23 patients (26.1%) in the D2 group. There were four recurrences in the D2 group but no recurrence in the D3 group. Log-rank tests showed no statistically significant difference in disease-free survival rates between the two groups (p = 0.210). CONCLUSION: There was no significant difference in disease-free survival rates between D2 and D3 lymph node dissection in clinical stage I right colon cancer patients. However, recurrence occurred in the D2 group. Efforts to improve the accuracy of clinical staging are required and more studies with better quality are needed.

Asunto(s)

RESUMEN

BACKGROUND: Complete mesocolic excision (CME) has been demonstrated to be a useful surgical procedure for advanced colon cancer. We previously reported on laparoscopic (Lap) CME with true central vascular ligation (CVL) for advanced right-sided colon cancer. Lap CME with true CVL is highly plausible from the perspective of surgical oncology. However, true CVL of the middle colic artery (MCA) may require extensive resection of the transverse colon. The Japanese Classification of Colorectal Cancer defines D3 as main lymph node dissection around the superior mesenteric artery (SMA), and true CVL is not listed as a required condition. Our institution has been performing a Lap procedure (Lap D3/modified CME) that consists of the dissection of main lymph nodes around the root of the MCA (#223LNs) while preserving the left branch of the MCA. Two videos of a Lap D3/modified CME are presented, and the short-term outcome is reported. METHODS: Lap D3/modified CME was defined as Lap ligation surgery at the root of the right branch of the MCA that preserves the MCA with #223LNs on the resection side. The present study retrospectively examined 11 cases of Lap D3/modified CME performed at the Tokyo Medical University Hospital between 2015 and 2020. When the SMA is difficult to visualize in Type V/A cases, the SMV is pulled using some silicone string, and the surrounding lymph nodes are dissected while visualizing the SMA. RESULTS: The median operating time was 289 min, and the median blood loss was 57 ml. The median total number of dissected lymph nodes was 38, and the median number of dissected #223LNs was three. No metastasis was found in the dissected #223LNs. CONCLUSION: Although this surgery can be performed safely, we believe that this surgery needs to be performed for suitable cases by a highly experienced and skilled surgical team.

Asunto(s)

RESUMEN

BACKGROUND: Complete mesocolic excision (CME) is known to be effective for colon cancer. However, in right-sided colon cancer, central vascular ligation (CVL) is not easy to perform. In particular, in patients in whom the superior mesenteric vein (SMV) runs on the ventral side of the superior mesenteric artery (SMA) (Type V/A), laparoscopic ligation of the artery at its root is extremely difficult compared with this procedure in patients in whom the SMA runs on the ventral side of the SMV (Type A/V). METHODS: We started performing laparoscopic CME with true CVL for right-sided colon cancer using the SMA as a landmark in 2015, and by 2019, we had completed it for 60 patients. To start, the mesocolon is opened well to the caudal side of the ileocolic vessels. The mesentery is then fully detached from the retroperitoneal tissue, after which the ileocolic vessels are ligated at their roots. D3 lymph node dissection of the lymph nodes around the SMA and SMV on the resection side is also performed using the SMA as a landmark, and depending on the location of the tumor, the roots of the right and middle colic vessels are ligated and divided. This study was conducted with the approval of the Tokyo Medical University Ethics Committee. All patients provided informed consent. RESULTS: The tumor was located in the cecum in 21 cases, the ascending colon in 33, and the transverse colon in 6. The mean operating time was 229 min and the mean volume of hemorrhage was 67 ml. There was one Clavien-Dindo Grade 3 or worse postoperative complication (ileus). There were no surgery-related or in-hospital deaths. CONCLUSION: This procedure can be performed comparatively safely. However, since it requires some skill, we consider that it should only be performed in suitable cases by teams with sufficient experience.

Asunto(s)

RESUMEN

Laparoscopic D3 lymph node dissection for transverse colon cancer is technically demanding because of complicated anatomy. Here, we reviewed the vascular structure of the transverse mesocolon, explored the extent of the base of the transverse mesocolon, and evaluated the feasibility and oncological safety of D3 lymph node dissection. We retrospectively reviewed the clinical records of 42 patients with advanced transverse colon cancer who underwent curative surgery and D3 dissection at Kyushu University Hospital between January 2008 and December 2015. We examined the venous and arterial anatomy of the transverse mesocolon of each resection and compared surgical outcomes between patients who underwent laparoscopic D3 (Lap D3) and open D3 (Open D3) dissection. Patients included two with Stage I, 18 with Stage II, 20 with Stage III, and two with Stage IVA. Thirty-six (85.7%) and six (14.3%) patients underwent Lap D3 or Open D3, respectively. The tumor sizes of the Open D3 and Lap D3 groups were 7.8 and 3.7 cm, respectively (P < 0.001). The Lap D3 group had significantly less blood loss (26 mL vs 272 mL, P = 0.002). The other outcomes of the two groups were not significantly different, including 3-year overall survival (87.7% vs 83.3%, P = 0.385). We observed four patterns of the middle colic artery (MCA) arising from the superior mesenteric artery (SMA), and the frequency of occurrence of a single MCA was 64.3%. The right-middle colic vein (MCV) was present in 92.9% of resections and served as a tributary of the gastrocolic trunk, and 90.5% of the left MCVs drained into the superior mesenteric vein (SMV). The root of the transverse mesocolon was broadly attached to the head of the pancreas and to the surfaces of the SMV and SMA. Laparoscopic D3 lymph node dissection may be tolerated by patients with advanced transverse colon cancer.

Asunto(s)

RESUMEN

BACKGROUND: NSABP C-06 demonstrated the non-inferiority of oral adjuvant uracil and tegafur plus leucovorin (UFT/LV) to weekly fluorouracil and folinate (5-FU/LV) with respect to disease-free survival (DFS) for stage II/III colon cancer. This is the first report of JCOG0205, which compared UFT/LV to standard 5-FU/levofolinate (l-LV) for stage III colorectal cancer patients who have undergone Japanese D2/D3 lymph node dissection. METHODS: Patients were randomised to three courses of 5-FU/l-LV (5-FU 500 mg/m(2), l-LV 250 mg/m(2) on days 1, 8, 15, 22, 29, 36 every 8 weeks) or five courses of UFT/LV (UFT 300 mg m(-2)day(-1), LV 75 mg/day on days 1-28 every 5 weeks). The primary end-point was DFS. The sample size was 1100 determined with one-sided alpha of 0.05, power of 0.78 and non-inferiority margin of hazard ratio of 1.27. This trial is registered with UMIN-CTR (C000000193). FINDINGS: Between February 2003 and November 2006, 1,101 patients (1092 eligible patients) were randomised to 5-FU/l-LV (n=550) or UFT/LV (n=551). Median age: 61 years, colon/rectum: 67%/33%, number of positive nodes ⩽3/>3: 73%/27%, stage IIIa/IIIb: 75%/25%. The hazard ratio of DFS was 1.02 (91.3% confidence interval, 0.84-1.23), demonstrating the non-inferiority of UFT/LV (P=0.0236). Five-year overall survival (87.5%) was higher than that in NSABP C-06 (69.6%). Grade 3/4 toxicities were 8.4% neutropenia in 5-FU/l-LV and 8.7% alanine aminotransferase elevation in UFT/LV, respectively. The incidences of diarrhoea (9.6% versus 8.5%) and anorexia (4.0% versus 3.7%) were similar between the two arms. No treatment-related deaths were reported. INTERPRETATION: Adjuvant UFT/LV is non-inferior to standard 5-FU/l-LV with respect to DFS. UFT/LV should be an oral treatment option for patients with stage III colon cancer who have undergone Japanese D2/D3 lymph node dissection.

Asunto(s)