Initial experience of laparoscopic right hemicolectomy with complete mesocolic excision in Singapore: a case series

Propensity-score-matched analysis of D2 and D3 right hemicolectomy for colon cancer

BACKGROUND

Complete mesocolic excision with D3 lymph node dissection in right-sided colon cancer is associated with improved oncological outcomes, but can potentially be associated with higher rates of complications compared to conventional D2 right hemicolectomy. This study aims to evaluate the oncological and perioperative outcomes of patients who underwent D3 right hemicolectomy, comparing to conventional right hemicolectomy.

METHODS

From 2015 to 2020, 360 patients underwent right hemicolectomy for colonic malignancies. Data was retrospectively analysed from a prospectively collected database. A propensity-score-matched analysis was performed between the two groups to evaluate their outcomes.

RESULTS

About 88(24.4%) patients underwent D3 right hemicolectomy, with the rest undergoing D2 right hemicolectomy. After propensity-matched analysis, D3 right hemicolectomy had a higher lymph node yield (median of 26 versus 23, p = 0.005), lower overall recurrence rate (11.7% versus 25.7%, p = 0.03), and lower overall mortality rate (14.5% versus 30.1%, p = 0.02) There were no significant differences in the complication rates. There were no anastomotic leaks. D3 right hemicolectomy was associated with an improved 3-year disease-free survival (DFS) with a hazard ratio of 0.63 (P = 0.21), and also an improved 3-year overall survival (OS) with a hazard ratio of 0.68 (P = 0.31).

CONCLUSION

D3 right hemicolectomy is associated with a higher lymph node yield, without increasing morbidity or mortality. It is also associated with significantly lower recurrence and overall mortality rates in this study. Short term 3-year DFS and OS also trend towards favouring D3 right hemicolectomy. However, this study is limited by the small sample size and retrospective nature.

Right hemicolectomy with complete mesocolic excision is safe, leads to an increased lymph node yield and to increased survival: results of a systematic review and meta-analysis

BACKGROUND

The introduction of complete mesocolic excision (CME) for right colon cancer has raised an important discussion in relation to the extent of colic and mesenteric resection, and the impact this may have on lymph node yield. As uncertainty remains regarding the usefulness of and indications for right hemicolectomy with CME and the benefits of CME compared with a traditional approach, the purpose of this meta-analysis is to compare the two procedures in terms of safety, lymph node yield and oncological outcome.

METHODS

We performed a systematic review of the literature from 2009 up to March 15th, 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two hundred eighty-one publications were evaluated, and 17 met the inclusion criteria and were included. Primary endpoints analysed were anastomotic leak rate, blood loss, number of harvested lymph nodes, 3- and 5-year oncologic outcomes. Secondary outcomes were operating time, conversion, intraoperative complications, reoperation rate, overall and Clavien-Dindo grade 3-4 postoperative complications.

RESULTS

In terms of safety, right hemicolectomy with CME is not inferior to the standard procedure when comparing rates of anastomotic leak (RR 0.82, 95% CI 0.38-1.79), blood loss (MD -32.48, 95% CI -98.54 to -33.58), overall postoperative complications (RR 0.82, 95% CI 0.67-1.00), Clavien-Dindo grade III-IV postoperative complications (RR 1.36, 95% CI 0.82-2.28) and reoperation rate (RR 0.65, 95% CI 0.26-1.75). Traditional surgery is associated with a shorter operating time (MD 16.43, 95% CI 4.27-28.60) and lower conversion from laparoscopic to open approach (RR 1.72, 95% CI 1.00-2.96). In terms of oncologic outcomes, right hemicolectomy with CME leads to a higher lymph node yield than traditional surgery (MD 7.05, 95% CI 4.06-10.04). Results of statistical analysis comparing 3-year overall survival and 5-year disease-free survival were better in the CME group, RR 0.42, 95% CI 0.27-0.66 and RR 0.36, 95% CI 0.17-0.56, respectively.

CONCLUSIONS

Right hemicolectomy with CME is not inferior to traditional surgery in terms of safety and has a greater lymph node yield when compared with traditional surgery. Moreover, right-sided CME is associated with better overall and disease-free survival.

Right-side colectomy with complete mesocolic excision vs conventional right-side colectomy in the treatment of colon cancer: a systematic review and meta-analysis

BACKGROUND

This meta-analysis aims to investigate the role of complete mesocolic excision (CME) in the treatment of right-side colon cancer when compared with standard right-side hemicolectomy, focusing on oncological outcomes, mortality and morbidity rates.

MATERIALS AND METHODS

A systematic literature search was performed on MEDLINE and EMBASE archives, including studies on CME in right-side colon cancer. Primary outcomes were five-year disease-free survival and five-year overall survival. Secondary outcomes investigated were mortality and morbidity rates, intraoperative blood loss, anastomotic leakage, postoperative ileus, day of postoperative flatus, pulmonary infection, duration of hospital stay and number of lymph nodes harvested.

RESULTS

Seventeen studies have been included in this meta-analysis for a total of 3918 patients. The five-year disease-free survival (DFS) and overall survival (OS) results improved in the CME group with respect to conventional right-side colectomy with an OR 1.88 (95% CI 1.02-3.45) and OR 2.77 (95% CI 1.33-5.74), respectively. The incidence of mortality and morbidity was comparable between the two groups. Moreover, conventional surgery time was faster than CME (MD 33.69 min, 95% CI 12.79-54.59), while no significant differences were reported in mean blood loss and hospital stay. Furthermore, the CME group showed a higher mean number of harvested lymph nodes (MD 7.08 lymph nodes 95% CI 4.90-9.27).

CONCLUSION

Complete mesocolic excision of the right-side colectomy improves oncological outcomes without increasing mortality and morbidity rates compared to standard right-side hemicolectomy. CME should therefore be routinely performed in the treatment of right-side colon cancer.

Complete mesocolic excision versus conventional hemicolectomy in patients with right colon cancer: a systematic review and meta-analysis

PURPOSE

Complete mesocolic excision (CME) has introduced a promising surgical approach for treatment of right colon cancer. However, benefits of CME are still a matter of debate. We conducted a systematic review and meta-analysis to assess safety and long-term outcomes of CME versus conventional right hemicolectomy (CRH).

METHODS

We systematically searched MEDLINE, the Cochrane Database of Systematic Reviews, Scopus, Web of Science, and Embase for retrieving studies comparing CME with CRH in right colon cancer. After data extraction from the included studies, meta-analysis was performed to compare postoperative complications, anastomotic leakage, 30-day mortality, number of lymph node yield, disease-free survival (DFS), and overall survival (OS).

RESULTS

Eight studies met the inclusion criteria with a total of 1871 patients enrolled. No difference was observed in postoperative complications (OR 1.13, 95% CI 0.88-1.47, p = 0.34). CME was associated with significantly higher number of lymph nodes retrieved (MD 9.17, CI 4.67-13.68, p < 0.001). CME also improved 3-year OS (OR 1.57, 95% CI 1.17-2.11, p = 0.003), 5-year OS (OR 1.41, 95% CI 1.06-1.89, p = 0.02), and 5-year DFS (OR 1.99, 95% CI 1.29-3.07, p = 0.002). A sub-group analysis for patients with stage III colon cancer showed no significant impact of CME on 3-year and 5-year OS (OR 2.47, 95% CI 0.86-7.06, p = 0.09; OR 1.23, 95% CI 0.78-1.94, p = 0.38).

CONCLUSION

Although with limited evidence, CME shows similar postoperative complication rates and an improved survival outcome compared with CRH.

Comparing complete mesocolic excision versus conventional colectomy for colon cancer: A systematic review and meta-analysis

Conventional colectomy, and the Japanese Society for Cancer of the Colon and Rectum (JSCCR) D2 Lymphadenectomy (LND2), are currently considered standard of care for surgical management of colon cancer. Colectomy with complete mesocolic excision (CME) and JSCCR D3 Lymphadenectomy (LND3) are more radical alternative approaches and provide a greater degree of lymph nodal clearance. However, controversy exists over the long-term benefits of CME/LND3 over non-CME colectomies (NCME)/LND2. In this study, we performed a systematic review and meta-analysis to compare the surgical, pathological, and oncological outcomes of CME/LND3 with NCME/LND2. Embase, Medline and CENTRAL databases were searched from inception until May 15, 2020, in accordance with PRISMA guidelines. Studies were included if they compared curative intent CME/LND3 with NCME/LND2. Weighted mean differences (WMD) and odds ratios (OR) were estimated for continuous and dichotomous outcomes respectively. Out of 1310 unique citations, 106 underwent full-text review, and 30 were included for analysis. In total, 21,695 patients underwent resection for colon cancer. 11,625 received CME/LND3, and 10,070 underwent NCME/LND2. No significant differences were found in post-operative morbidity and mortality. Both overall and disease-free survival favored CME/LND3 (5-year OS: OR = 1.29; 95% CI 1.02 to 1.64, p = 0.03; 5-year DFS: OR = 1.61; 95% CI 1.14 to 2.28; p = 0.007). This is the first systematic review and meta-analysis to demonstrate that CME/LND3 has superior long-term survival outcomes compared to NCME/LND2.

Robotic Complete Mesocolic Excision (CME) is a safe and feasible option for right colonic cancers: short and midterm results from a single-centre experience

BACKGROUND

Complete mesocolic excision (CME) for right colon cancers has traditionally been an open procedure. Surgical adoption of minimal access CME remains limited due to the technical challenges, training gaps and lack of level-1 data for proven benefits. Currently there is limited published data regarding the clinical results with the use of robotic CME surgery. Aim To report our experience, results and techniques, highlighting a clinical and oncological results and midterm oncological outcomes for robotic CME.

AIM

To report our experience, results and techniques, highlighting a clinical and oncological results and midterm oncological outcomes for robotic CME.

METHODS

All patients undergoing standardised robotic CME technique with SMV first approach between January 2015 and September 2019 were included in this retrospective review of a prospectively collected database. Patient demographics, operative data and clinical and oncological outcomes were recorded.

RESULTS

Seventy-seven robotic CME resections for right colonic cancers were performed over a 4-year period. Median operative time was 180 (128-454) min and perioperative blood loss was 10 (10-50) ml. There were 25 patients who had previous abdominal surgery. Median postoperative hospital stay was 5 (3-18) days. There was no conversion to open surgery in this series. Median lymph node count was 30 (10-60). Three (4%) patients had R1 resection. There was one (1%) local recurrence in stage III disease and 4(5%) distal recurrence in stage II and stage III. There was no 30- or 90-day mortality. Three-year disease-free survival was 100%, 91.7% and 92% for stages I, II and III, respectively. Overall survival was 94%.

CONCLUSIONS

Robotic CME is feasible, effective and safe. Good oncological results and improved survival are seen in this cohort of patients with a standardised approach to robotic CME.