Defining the extent of mesenterectomy in right colectomy: a controversy

Stool dynamics after extrinsic nerve injury during right colectomy with extended D3-mesenterectomy

INTRODUCTION

To improve oncological outcome in right colon cancer surgery, an extended mesenterectomy (D3) is under evaluation. In this procedure, all tissue anterior and posterior to the superior mesenteric vessels from the middle colic to ileocolic artery origin is removed, causing injury to the superior mesenteric nerve plexus. The aim was to study the effects of this injury on bowel dynamics and quality of life (QoL).

METHODS

Patients undergoing right colectomy with conventional D2- and extended D3-mesenterectomy were asked to record stool number and consistency for 60 d after surgery and complete questionnaires regarding QoL and bowel function (BF) before and after recovery from surgery. We compared early postoperative stool dynamics and long-term QoL in the groups and presented graphs depicting the temporal profile of stool numbers and consistency.

RESULTS

Thirty-three patients operated with a D3-resection and 12 patients with a D2-resection participated. The results revealed significantly higher stool numbers in the D3-group until day 26, with significantly more loose-watery stools until day 40. The most pronounced difference was found on day 9 (Mean difference in the total number of stools: 2.25 stools/day, p=.004. Mean difference in loose-watery stools/day: 2.81 p<.001). About 25% in the D2- and 69.7% in the D3-group reported having more than three stools/day in the early postoperative phase. There were no differences in long-term QoL and BF between the groups except in stool consistency (p=.039).

DISCUSSION/CONCLUSIONS

Denervation following extended D3-mesenterectomy leads to transitory reduced consistency and increased frequency. It does not affect long-term QoL or BF.

Complete mesocolic excision for colonic cancer

INTRODUCTION

Complete mesocolic excision for colonic cancer is similar in concept to total mesorectal excision for rectal cancer. This review aims to provide the embryological and anatomical rationale behind CME, and to review the current literature on CME, relative to the feasibility via laparoscopy, the oncological adequacy and outcomes.

EVIDENCE ACQUISITION

A literature search was performed at the end of 2017 according the PRISMA guidelines for systematic reviews. Of 3980 articles found, we analyzed 96 articles. Of note, many case series had overlapping populations; there were five review articles, two consensus conference proceedings, six comparative but only one randomized trial.

EVIDENCE SYNTHESIS

The embryonic and anatomical rationale is well described. CME is feasible via laparoscopy, which may facilitate dissection and anatomic precision: no statistically significant differences were found when compared to open CME regarding overall survival. However, morbidity may be higher in the hands of non-expert laparoscopic surgeons.

CONCLUSIONS

Oncological adequacy can be obtained with laparoscopic CME, with increased lymph node retrieval. However, until now, there is no formal proof that CME improves local recurrence or survival.