Laparoscopic complete mesocolic excision with central vascular ligation for splenic flexure colon cancer: short- and long-term outcomes

Is radix ligation of the inferior mesenteric artery effective in Japanese-Style D3 radical lymph node dissection for sigmoid colon and rectal cancer surgery?-a single-center retrospective analysis since 2002

Background

The Japanese treatment guidelines recommend treatment of the root of the inferior mesenteric artery (IMA) (#253) to ensure ligation and dissection of the root of the IMA (#253) in descending colon cancer/sigmoid colon cancer deeper than in T2 [muscularis propria (MP)] cancer. However, #253 complete D3 dissection with IMA root ligation has been reported to increase postoperative complications, such as colonic ischemia, and to have a worse prognosis compared to IMA-preserving D3 system dissection. Therefore, we decided to compare complete IMA dissection with ligation and dissection of the IMA root and preserving the left colonic artery (LCA) preserving group.

Methods

A total of 172 patients with stage II/III primary sigmoid colorectal cancer who had undergone radical curative resection were categorized into two groups: the IMA root ligation group (#253 complete D3 dissection group) and the LCA preservation group (94/78 cases), in which the IMA root was preserved and either lymph node sampling dissection or peripheral ligation of the left colorectal artery bifurcation was performed. The 5-year recurrence-free survival (5Y-RFS) and 5-year overall survival (5Y-OS) rates were compared.

Results

The overall 5-year follow-up rate was 70.23%. 5Y-RFS and 5Y-OS were tested, and no significant differences were found. Similarly, there were no significant differences in the background factors. In the laparotomy/hand-assisted laparoscopic surgery (HALS)/laparoscopic surgery procedure, complete IMA ligation tended to be more common in the HALS group, whereas LCA preservation tended to be more prevalent in the laparoscopic surgery group. There were no significant differences in the postoperative complications between the groups. Anastomotic failure occurred in 6/3 patients in the IMA complete ligation/LCA preservation groups; bowel obstruction in 5/4; wound infection in 10/5; posterior hemorrhage in 1/4; dysuria in 5/1; and urinary tract infection (including cystitis) in 2/1. Postoperative cerebral infarction, ureteral injury, and thigh paresthesia were each observed in only one case in the complete ligation group.

Conclusions

These results showed no significant differences in the 5Y-OS or 5Y-RFS. There was no significant difference in prognosis between patients with and without lymph node dissection at the root of the IMA. Thus, there was no significant difference in prognosis between the complete IMA ligation and LCA preservation groups, with or without IMA dissection. There were no significant differences in complications in the complete ligation group; however, the number of cases seemed large. These results suggest that preservation of the IMA may be safe and effective for stage II/III lymph node dissection in primary sigmoid colorectal cancer.

Patterns of lymph node metastasis and long-term outcomes of splenic flexure colon cancer: a descriptive study from a Japanese high-volume center

PURPOSE

The pattern of lymph node metastasis and the appropriate extent of lymph node dissection in splenic flexure colon cancer remain unclear. This study aimed to describe the clinical characteristics, lymph node metastasis patterns, and oncological outcomes of patients with splenic flexure colon cancer.

METHODS

The data of patients with splenic flexure cancer diagnosed with pathological stages I-III were extracted from a hospital database. Lymph nodes were mapped and numbered according to the guidelines of the Japanese Society for Cancer of the Colon and Rectum. Five-year disease-free survival (DFS) and overall survival (OS) rates were estimated using the Kaplan-Meier method.

RESULTS

Among 151 patients, 37.1% had lymph node metastasis. The proportion of lymph node metastasis were 30.1% at station 221, 5.1% at station 222, 2.8% at station 223, 19.8% at station 231, 2.7% at station 232, and 0% at station 253. Among the 59 patients with an accessory middle colic artery, 19 had lymph node metastasis only at stations 221 (14/47) and 231 (5/47). The 5-year estimated DFS rates were 100% for stage I, 94.4% (95% CI, 83.6-98.2) for stage II, and 79.9% (95% CI, 65.6-88.8) for stage III. Ten patients experienced distant recurrence: liver (n = 5), peritoneum (n = 2), para-aortic lymph node (n = 2), and lung metastasis (n = 1). No local recurrence was observed.

CONCLUSION

In splenic flexure colon cancer, lymph node dissection around the IMA route may be omitted. Similarly, dissection along the left branch of the middle colic artery or the left colic artery may be unnecessary in the presence of an accessory middle colic artery.

A multicenter cohort study on mapping of lymph node metastasis for splenic flexural colon cancer

Aim

There have been no reports of searching for metastases to lymph nodes along the accessory middle colic artery (aMCA). The aim of this study was to investigate the metastasis rate of the aMCA for splenic flexural colon cancer.

Methods

Patients with histologically proven colon carcinoma located in the splenic flexure, clinically diagnosed as stage I-III were eligible for this study. Patients were retrospectively and prospectively enrolled. The primary endpoint was frequency of lymph node metastasis to the aMCA (station 222-acc and 223-acc). The secondary endpoint was the frequency of lymph node metastasis to the middle colic artery (MCA) (station 222-lt and 223) and left colic artery (LCA) (station 232 and 253).

Results

Between January 2013 and February 2021, a total of 153 consecutive patients were enrolled. The location of the tumor was 58% in the transverse colon and 42% in the descending colon. Lymph node metastases were observed in 49 cases (32%). The presence of aMCA rate was 41.8% (64 cases). The metastasis rates of stations 221, 222-lt, and 223 were 20.0%, 1.6%, and 0%, and stations 231, 232, and 253 were 21.4%, 1.0%, and 0%, respectively. The metastasis rates of stations 222-acc and 223-acc were 6.3% (95% confidence interval: 1.7%-15.2%) and 3.7% (95% confidence interval: 0.1%-19%), respectively.

Conclusions

This study identified the distribution of lymph node metastases from splenic flexural colon cancer. If the aMCA is present, this vessel should be targeted for dissection, taking into account the frequency of lymph node metastasis.

Comparison of clinical outcomes of single-incision versus multi-port laparoscopic surgery for descending colon cancer: a propensity score-matched analysis

BACKGROUND

The clinical impact of single-incision laparoscopic surgery (SILS) for descending colon cancer (DCC) is unclear. The aim of this study was to evaluate the clinical outcomes of SILS for DCC compared with multi-port laparoscopic surgery (MPLS).

METHODS

We retrospectively analyzed 137 consecutive patients with stage I-III DCC who underwent SILS or MPLS at two high-volume multidisciplinary tertiary hospitals between April 2008 and December 2018, using propensity score-matched analysis.

RESULTS

After propensity score-matching, we enrolled 88 patients (n = 44 in each group). SILS was successful in 97.7% of the matched cohort. Compared with the MPLS group, the SILS group showed significantly less blood loss and a greater number of harvested lymph nodes. Morbidity rates were similar between groups. Recurrence pattern did not differ between groups. No significant differences were found between groups in terms of 3-year disease-free and overall survivals.

CONCLUSION

SILS appears safe and feasible and can provide satisfactory oncological outcomes for patients with DCC.