Complete mesocolic excision

Complete Mesocolic Excision – CME

Complete Mesocolic Excision – CME

Principle• Based upon TME (Total Mesorectal

Excision) principle Prof. RJ Heald– Surgical technique rectal cancer – “The holy plane” of rectal cancer– Sharp dissection between the

visceral fascia (mesorectum) and parietal fascia (Waldeyer - Denonvilliers)

– Specimen with lymphovascular entity of rectum and mesorectum

– Initial rectal tumorspread confined (lymphatic spread)

Complete Mesocolic excision - CME

Principle

• TME principle• Less local pelvic

recurrences 3%• Improved rate

curative resections• Improved survival

and tumor-free survival

Complete Mesocolic Excision - CME

Principle• TME principle


Article

Complete Mesocolic Excision

Colonic cancer• Embryological planes between

visceral and parietal (retroperitoneal) fascia present around colon

• Sharp dissection visceral plane from retroperitoneal

• Intact surgical specimen of colon and mesocolon including possible initial lymphatic spread

• Lymphatic spread follows colonic arteries in mesocolon – high tie central origin – maximal harvest regional lymph nodes

• Improved oncological outcome ?


Method• Separation visceral plane from the parietal one– Right colon– Mobilization of duodenum with pancreatic head– Mesenteric root up to SMA/SMV – optimal exposure


Method• Separation visceral plane from the parietal one– Right colon


Method• Separation visceral plane from the parietal one– Left colon– Mobilisation splenic

flexure, mesocolon descending colon, sigmoid

– Dissected off retroperitoneal plane including prerenal fat, ureter, vesicular/ovarian vessels


Method• Separation visceral plane from

the parietal one– Transverse colon– Detachment greater

omentum– Division two layers

transverse mesocolon at lower edge pancreas


Method• Lymph spread first pericolic

• Subsequently towards central arteries

• Lymph node dissection– Hepatic flexure 5 % head

pancreas, 4 % epiploic arcade

– Transverse colon epiploic arcade

– Splenic flexure inferior edge pancreatic tail

– Sigmoid sigmoidal arteries


Method• Lymph node dissection


Method• Central ligation supplying vessels

• Right colon


Method

• Central ligation supplying vessels• Right colon

• Ileocolic / right colic vessels• Central origin SMA / SMV• Preservation autonomic plexus• Incision mesenterial plane covering

SMV• Right colic vein => superior

gastroepiploic vein divided• Lymph nodes pancreatic head

• Caecum / ascending colon• Above vessels + right branches middle colic vessels


Method• Superior gastroepiploic vein


Method

• Central ligation supplying vessels• Transverse colon

• Central ligation middle colic artery / vein• Central tie right gastroepiploic artery• Hepatic flexure transsection close splenic flexure• Splenic flexure transsection close sigmoid

• Descending colon• Central tie left ascending colonic artery• Preservation root IMA – dissection lymph nodes origin


Method

• Central ligation supplying vessels• Middle descending colon / sigmoid

• Division root IMA / IMV

• Transsection distally upper 1/3 rectum

• Transsection proximally between left transverse colon / distal descending colon


Patients• Prospective study• University Hospital Erlangen, Germany• 1438 patients between 1978 and 2002• Inclusion criteria

– Solitary invasive (at least submucosa) colon carcinoma (>16 cm from anal verge)

– No other history of previous or synchronous malignancies

– No carcinoma because of FAP, UC or Crohn's

– No neo-adjuvant treatment; Stage I-III


Patients• Exclusion criteria– 109 patients (7,6 %)– 37 patients no R0-resection (2,6 %)– 42 patients surgical mortality (2,9 %)– 30 patients tumour status unknown to

recurrence (2,1 %)• 1329 patients analysed• Median follow-up 103 months (1-335)• WHO tumour classification / 6th TNM

classification


Patients• Outcome assessment

– Cancer-related survival• Death with locoregional or

distant metastases– Rate locoregional recurrence– Amount lymph node harvest– Postoperative complications and

mortality

• Comparison three time periods 1978-1984 / 1985-1994 / 1995-2002


Results• 80,3 % uneventful post-op

course• 4,7 % re-operation

(anastomotic leak)• Post-operative mortality 3,1

%• Emergencies (9,5 %) higher

rate complications 34,4 % - 17 %

• Complication rate between surgeons 11,7 % - 35,5 %


Results• Lymph node harvest• Median number 32 (2 – 169)• Influence nodes on prognosis• 682 N0 patients

• Median 29 (2-106)• < 28 (n=314) 5 year survival 90,7 % (95% CI 87,4

- 94,0)• > 28 (n=368) 5 year survival 96,3 % (95% CI 94,3

– 98,3), P=0,018• 383 Lymph node positive patients

• < 28 64,6 % (n=145, CI 56,6 – 72,6)• > 28 71,7 % (n=238, CI 65,8 – 77,6) P=0,088


Results

• 5 year-rate of locoregional recurrence 4,9 %

• Improvement recurrence rate during 1978-1984 (6,5%) to 1995-2002 (3,6%)

• Recurrence rate increased higher pT or pN


Results


Results• CME principle with production of an intact

lymphovascular entity (colon and mesocolon – dissection between visceral and parietal fascia) and high central ligation of supplying vessels• Improved 5-year cancer related survival (82,1% -

89,1%) • Reduced local 5-year recurrence rate (6,5% - 3,1%)• Prognostic factors

• Harvested lymph nodes• pN, pT, extramural invasion, emergency

presentation• Institution


Discussion• CME principle with production of an intact

lymphovascular entity (colon and mesocolon – dissection between visceral and parietal fascia) and high central ligation of supplying vessels• Maximizing lymph node harvest

(correlates prognosis => improved survival)

• Intact fascial layer (prognostic relevance)

• Important provide integrity viseral mesocolic layer along specimen - danger tumour dissemination

• Central vascular ligation maximizes node harvest


Discussion• CME principle with production of an intact

lymphovascular entity (colon and mesocolon – dissection between visceral and parietal fascia) and high central ligation of supplying vessels• Right colon mobilisation mesenteric root and

duodenum with pancreatic head• Right colonic flexure pancreatic head metastases• Transverse colon and splenic flexure mobilisation

gastroepiploic arcade and dissection inferior edge pancreas

Thank you

Complete mesocolic excision

Health & Medicine

Transcript of Complete mesocolic excision