Gastrocolic Ligament Lymph Node Dissection for Transverse Colon and Hepatic Flexure Colon Cancer: Risk of Nodal Metastases and Complications in a Large-Volume Center

Prevention of delayed gastric emptying after right colectomy with extended lymphadenectomy: A randomized controlled trial

BACKGROUND

Delayed gastric emptying sometimes occurs after right colectomy with extended lymphadenectomy. The aim of this randomized controlled trial is to evaluate the effect on delayed gastric emptying after performing a fixation of the stomach to the retrogastric tissue to return the stomach to a physiological position after right colectomy with lymphadenectomy, including gastrocolic lymph nodes dissection for proximal transverse colon cancer.

METHODS

From January 2015 to December 2020, patients undergoing right colectomy with extensive lymphadenectomy for proximal transverse colon cancer were randomly assigned to either the gastropexy group or the conventional group. In the gastropexy group, the posterior wall of the stomach, at the level of the antrum, was sutured to the retrogastric tissue to prevent the abnormal shape that the gastric antrum acquires together with the duodeno-pancreatic complex, the shape that leads to an obstruction of the antrum region and to the delay in emptying the gastric contents.

RESULTS

Mean age, sex, comorbidities, and right colectomy procedures were similar in the 2 groups. Delayed gastric emptying developed in twelve patients in the conventional group (38.7%) versus 4 patients (12.1%) in the gastropexy group (P = .014). The total number of complications was higher in the conventional group (14 complications) than in the gastropexy group (7 complications). According to univariate analysis, gastropexy significantly lowered the risk of delayed gastric emptying (P = .014). Overall morbidity was 9.7% in the conventional group versus none in the gastropexy group. Postoperative hospitalization was longer in the conventional group (7.61 ± 3.26 days) than in the gastropexy group (6.24 ± 1.3 days; P = .006).

CONCLUSION

Gastropexy decreases the occurrence of delayed gastric emptying after right colectomy with extended lymphadenectomy for proximal transverse colon cancer.

Infrapyloric (No. 206) and greater curvature (No. 204) lymph node metastasis in adenocarcinoma located in the right half of the transverse colon (InCLART Study): protocol for a multicentre prospective observational study

INTRODUCTION

In the case of right-sided transverse colon cancer (RTCC) and hepatic flexure colon cancer (HFCC), there is a potential connection of lymph drainage between mesentery and greater omentum. However, most previous reports have been limited case series with No. 206 and No. 204 lymph node (LN) dissection for RTCC and HFCC.

METHODS AND ANALYSIS

The InCLART Study is a prospective observational study aiming to enrol 427 patients with RTCC and HFCC treated at 21 high-volume institutions in China. The prevalence of infrapyloric (No. 206) and greater curvature (No. 204) LN metastasis and short-term outcomes will be investigated in a consecutive series of patients with T2 or deeper invasion RTCC or HFCC, following the principle of complete mesocolic excision with central vascular ligation. Primary endpoints were performed to identify the prevalence of No. 206 and No. 204 LN metastasis. Secondary analyses will be used to estimate prognostic outcomes, intraoperative and postoperative complications, the consistency of preoperative evaluation and postoperative pathological results of LN metastasis.

ETHICS AND DISSEMINATION

Ethical approval for the study has been granted by the Ruijin Hospital Ethics Committee (approval number: 2019-081) and has been or will be approved successively by each participating centre's Research Ethics Board. The findings will be disseminated in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03936530; https://clinicaltrials.gov/ct2/show/NCT03936530).

Laparoscopic extended right hemicolectomy versus laparoscopic transverse colectomy for mid-transverse colon cancer: a multicenter retrospective study from Kanagawa Yokohama Colorectal Cancer (KYCC) study group

PURPOSE

The laparoscopic surgery approach for mid-transverse colon cancer (MTC) varies depending on tumor characteristics and the guidelines implemented by each surgeon; the optimal surgical procedure for MTC has not been established. This study aimed to compare the surgical outcomes of laparoscopic extended right hemicolectomy (Lap-ERHC) and laparoscopic transverse colectomy (Lap-TC) for MTC.

METHODS

This was a multicenter, retrospective study. We surveyed eight hospitals, by questionnaire, on MTC surgery policies and retrospectively compared the short- and long-term surgical outcomes for patients with MTC who underwent Lap-ERHC or Lap-TC between January 2008 and December 2019.

RESULTS

A total of 129 patients were enrolled, of whom 35 underwent Lap-ERHC and 94 underwent Lap-TC. There were no significant differences in tumor progression between the two groups. Operation time was significantly longer (202 min vs. 185 min, p = 0.026). We observed a higher complication rate (≥ grade 3) in the Lap-ERHC group than in the Lap-TC group (11.4% vs. 3.2%, p = 0.086). Three patients (8.6%) who underwent Lap-ERHC developed anastomotic leakage; none of the patients who underwent Lap-TC had this complication (p = 0.018). The 3-year overall survival rates (stage I: 100% vs. 91.9%, p = 0.64; stage II: 100% vs. 95.5%, p = 0.46; stage III: 100% vs. 88.2%, p = 0.91, respectively) were similar between the two groups.

CONCLUSION

Lap-ERHC for MTC has the same long-term outcomes as Lap-TC. However, Lap-ERHC for MTC has a higher complication rate. Therefore, Lap-TC may be recommended for patients with MTC.

TRIAL REGISTRATION

UMIN000042674.

Extended Lymphadenectomy for Proximal Transverse Colon Cancer: Is There a Place for Standardization?

Background and Objectives: Complete mesocolon excision and high vascular ligation have become a standard procedure in the treatment of colon cancer. The transverse colon has certain embryological and anatomical particularities which require special attention in case of oncological surgeries. Proximal transverse colon cancer (TCC) can metastasize to the lymph nodes in the gastrocolic ligament. The aim of this study is to assess the tumor involvement of these lymph nodes and to determine the applicability of gastrocolic ligament lymph nodes dissection as the standard approach for proximal transverse colon cancer. Materials and Methods: this study analyzes the cases of patients admitted to the Surgery Department, diagnosed with proximal transverse colon cancer, with tumor invasion ≥ T2 and for which complete mesocolon excision with high vascular ligation and lymphadenectomy of the gastrocolic ligament (No. 204, 206, 214v) were performed. Results: A total of 43 cases operated during 2015−2020 were included in the study. The median total number of retrieved central lymph nodes was 23 (range, 12−38), that had tumor involvement in 22 cases (51.2%). Gastrocolic ligament tumor involvement was found in 5 cases (11.6%). The median operation time was 180 min, while the median blood loss was 115 mL (range 0−210). The median time of hospitalization was 6 days (range, 5−11). Grade IIIA in the Clavien-Dindo classification was noticed in 3 patients, with no mortality. Upon Kaplan−Meier analysis, tumors > T3 (p < 0.016) and lymph node ratio < 0.05 (p < 0.025) were statistically significant. Conclusions: lymph node dissection of the gastrocolic ligament in patients with advanced proximal transverse colon cancer may improve the oncological outcome in T3/T4 tumors, and therefore standardization could be feasible

Novel nomogram for predicting risk of early postoperative small bowel obstruction after right colectomy for cancer

Background

Early postoperative small bowel obstruction (EPSBO) is a common complication after colorectal cancer surgery. Few studies have specifically studied risk factors for early small bowel obstruction after right colectomy, especially in establishing predictive models. The purpose of the current study was to establish an effective nomogram to predict the incidence of EPSBO after right colectomy.

Methods

The current study retrospectively analyzed data from a total of 424 patients who underwent right colectomy in a local hospital from January 2014 to March 2021. A logistic regression model was used to identify potential risk factors for EPSBO after right colectomy. A nomogram was established by independent risk factors, and the prediction performance of the model was evaluated using an area under the receiver operating characteristic (ROC) curve and calibration chart.

Results

A total of 45 patients (10.6%) developed early small bowel obstruction after right colectomy. Male sex, history of abdominal surgery, open surgery, long operative time, anastomotic leakage, and preoperative albumin were closely related to EPSBO. Analysis of postoperative rehabilitation indices showed that EPSBO remarkably slowed the postoperative rehabilitation speed of patients. Multivariate logistic regression analysis showed that male sex, open surgery, operative time, and anastomotic leakage were independent risk factors (P < 0.05), and the operation time had the greatest impact on EPSBO. On the basis of multivariate logistic regression, a nomogram was constructed, which showed moderate accuracy in predicting EPSBO, with a C-statistic of 0.716. The calibration chart showed good consistency between the predicted probability and ideal probability.

Conclusion

The current study constructed a nomogram based on the clinical data of patients who underwent right colectomy, which had moderate predictability and could provide reference value for clinicians to evaluate the risk of EPSBO.

Analysis of 20 patients with laparoscopic extended right colectomy

BACKGROUND

Currently, the standard surgical procedure for right colon cancer is complete mesocolic excision. Whether preventive extended lymph node dissection for colon cancer located in the hepatic flexure or right transverse colon should be performed remains controversial because the safety and effectiveness of the operation have not been proven, and infrapyloric lymph nodes (No. 206) and lymph nodes in the greater curvature of the stomach (No. 204) have not been strictly defined and distinguished as surgical indicators in previous studies.

AIM

To analyze the metastatic status of infrapyloric lymph nodes and lymph nodes of the greater curvature of the stomach and perioperative complications and systematically evaluate the feasibility and safety of laparoscopic extended right colectomy using prospective data collected retrospectively.

METHODS

The study was a clinical study. Twenty patients with colon cancer who underwent laparoscopic extended right colon resection in our hospital from June 2020 to May 2021 were included.

RESULTS

Among the patients who underwent extended right colon resection, there were no intraoperative complications or conversion to laparotomy; 2 patients had gastrocolic ligament lymph node metastasis, and 5 patients had postoperative complications. The patients with postoperative complications received conservative treatment.

CONCLUSION

Laparoscopic extended right colon resection is safe. However, malignant tumors located in the liver flexure or the right-side transverse colon are more likely to metastasize to the gastrocolic ligament lymph nodes, and notably, the incidence of gastroparesis was high. The number of patients was small, and the follow-up time was short. It is necessary to further increase the sample size to evaluate the No. 204 and No. 206 lymph node metastasis rates and the long-term survival impact.

Infrapyloric lymph node dissection in right hemicolectomy for colon cancer: Should prophylactic resection be recommended?

BACKGROUND AND OBJECTIVES

Infrapyloric lymph node dissection in right colon cancer patients remains controversial. We aimed to investigate the pattern of infrapyloric lymph node metastasis in right colon cancer patients.

METHODS

Clinical and pathological data of 140 colon cancer patients who underwent radical right hemicolectomy and infrapyloric lymph node dissection were retrospectively examined. Patient characteristics, intraoperative conditions, postoperative recovery information, postoperative pathological findings, and follow-up data were examined.

RESULTS

About 19, 44, 73, and 4 patients had tumors located in the cecum, ascending colon, hepatic flexure, and right side of the transverse colon, respectively. The median number of harvested lymph nodes and that of positive lymph nodes were 24 (16-30) and 1 (0-7.75), respectively. The lymph node metastasis rate was 41.43% (58/140). The corresponding values for infrapyloric lymph nodes were 3 (1-4), 0 (0-0), and 0.71% (1/140), respectively. The median follow-up duration was 19 (0-65) months in 131 (93.6%) patients. The 5-year overall and disease-free survival rates were 86.3% and 73.5%, respectively.

CONCLUSION

Given the low rate of infrapyloric lymph node metastasis in right colon cancer, lymph node dissection is recommended in patients with locally advanced colon cancer at the hepatic flexure and those with suspected infrapyloric lymph node metastasis.

Gastrocolic ligament lymph-node dissection may increase the incidence of delayed gastric emptying after colon cancer surgery with D3 lymphadenectomy

PURPOSE

Delayed gastric emptying (DGE) is associated with prolonged hospital stay and higher healthcare costs. This study aimed to investigate the risk factors for DGE after D3 radical resection for colon cancer and to build a nomogram for this complication.

METHODS

We analyzed, retrospectively, 1160 consecutive patients who underwent surgery with D3 lymphadenectomy for colon cancer between January, 2012 and June, 2018. A multivariate logistic regression analysis was used to identify the risk factors for DGE and to build a DGE nomogram model.

RESULTS

There were ten, six and four patients with DGE classified as grades A, B and C, respectively, representing a DGE rate of 1.7%. Multivariate analysis revealed that age (P = 0.001), dissection of the gastrocolic ligament lymph nodes (GCLNs) (P = 0.001), surgical duration (P = 0.017) and preoperative hemoglobin level (P = 0.016) were independent risk factors, and were included to build a predictive model for DGE. The therapeutic index of GCLN dissection was approximately half that of D3 lymphadenectomy (2.9 vs. 5.6).

CONCLUSIONS

DGE is more likely to develop in patients aged > 75 years, those with a preoperative hemoglobin < 90 g/L, those with a surgical duration > 210 min, and those who undergo GCLN dissection. The nomogram may facilitate the stratification of patients at risk for DGE following D3 lymphadenectomy for colon cancer. Assessing long-term outcomes will help to evaluate the survival benefit of GCLN dissection in the future, to avoid unnecessary dissection and reduce the incidence of DGE.