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CT and operative images for evaluation of right colectomy with extended D3 mesenterectomy anterior and posterior to the mesenteric vessels

  • J. M. NesgaardEmail author
  • B. V. Stimec
  • B. Edwin
  • A. O. Bakka
  • D. Ignjatovic
  • The Right Colectomy for Cancer (RCC) Study Group
original article

Summary

Background

Surgical techniques like complete mesocolic excision (CME) and D3 mesenterectomy, D3 refering to the N3 lymph node groups central in the mesentery removed at surgery, were introduced without proper evaluation of the lymphadenectomy. The aim of this study was to measure the vascular stumps and evaluate the extent and quality of lymphadenectomy after right colectomy with extended D3 mesenterectomy anterior/posterior to the mesenteric vessels. We also compared the investigation methods.

Methods

Residual vascular stumps were measured using three-dimensional (3D) reconstructed anatomy from follow-up computed tomography (CT) datasets and images taken during surgery. The quality of central lymphadenectomy was evaluated on the images.

Results

In total, 31 patients (15 females), median age 67 years (50–78), with stage I (n = 7), stage II (n = 13), and stage III (n = 11) disease, were operated. Tumor locations were: 14 (45%) in the cecum, ten (32%) in the ascending colon, three (10%) in the hepatic flexure, and four (13%) in the transverse colon. The middle colic artery (MCA) was divided at its origin (13 patients) or its right branch (18 patients). Median lengths (range) of residual vascular stumps measured on 3D reconstructed CT and photographic images taken during surgery were: right colic artery: 0.0 mm (0.0–1.8)/0.0 mm (0.0–1.1), ileocolic artery: 0.0 mm (0.0–7.2)/0.0 mm (0.0–3.0), ileocolic vein: 0.0 mm (0.0–7.5)/0.0 mm (0.0–0.0), MCA: 0.0 mm (0.0–18.1)/1.0 mm (0.0–8.0), and right branch of the MCA: 0.0 mm (0.0–1.8)/0.0 mm (0.0–2.0). There was no significant difference between average lengths measured with the two techniques. The extent of lymphadenectomy was deemed acceptable in all patients. No differences in stump lengths were found in patients with different vascular crossing patterns in the central mesentery and presumably different degree of difficulty at surgery.

Conclusion

The results demonstrate very short residual vascular stumps and together with operative photographs provide objective evidence for superior lymphadenectomy in right colectomy with extended D3 mesenterectomy.

Keywords

Right colectomy Colonic neoplasm/surgery Mesentery/blood supply Digestive arteries D3 resection 

Notes

The Right Colectomy for Cancer (RCC) Study Group

Prof. Tom Oresland MD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway; Arne Engebreth Færden MD, PhD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway; Yngve Thorsen, MD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway; Prof. Solveig Andersen MD, Akershus University Hospital, Department of Pathology, University in Oslo, Norway; Anne Negaard, MD, PhD, Akershus University Hospital, Department of Radiology, University in Oslo, Norway; Russel Jacobsen MD, Department of Vascular Surgery, Vestfold Hospital Trust, Tonsberg, Norway; Kari Mette Langerød von Brandis MD, Department of Radiology, Vestfold Hospital Trust, Tonsberg, Norway; Tania Hansen, Department of Radiology, Vestfold Hospital Trust, Tonsberg, Norway; Pål Suhrke MD, Department of Pathology, Vestfold Hospital Trust, Tonsberg, Norway; Christer-Daniel Willard, medical student, University in Oslo, Norway; Javier Luzon MD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway; Bjarte Tidemann Andersen MD, Department of Digestive Surgery, Vestfold Hospital Trust, Tonsberg, Norway; Robin Gaupset MD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway; Prof. Roberto Bergamaschi MD, Division of Colorectal Surgery, Westchester Medical Center, New York Medical College, NY, USA; Frieder Pulling MD, Vizeralchirurgie Klinicum, Karlsruhe, Germany; Joerg Baral MD, Vizeralchirurgie Klinicum, Karlsruhe, Germany; Marcos Gomez Ruiz MD, Coloproctologia Cirugia Colorectal—Cirurgia General y Ap. Digestivo Hospital Universario Marques de Valdecilla, Spain; Baris Sevinc MD, Dep. Of General Surgery, Medical Park Usak Hospital, Usac, Turkey; Jonas Lindstrøm, Health Services Research Unit, Akershus University Hospital, Norway; Ariba Ehsan Sheikh MD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway; Tine Strømmen MD, Akershus University Hospital, Department of Digestive Surgery, University in Oslo, Norway.

Conflict of interest

J.M. Nesgaard, B.V. Stimec, B. Edwin, A.O. Bakka, and D. Ignjatovic declare that they have no competing interests.

References

  1. 1.
    Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg. 1998;133(8):894–9.CrossRefGoogle Scholar
  2. 2.
    Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation—technical notes and outcome. Colorectal Dis. 2009;11(4):354–64. discussion 64–65.CrossRefGoogle Scholar
  3. 3.
    Bertelsen CA, Neuenschwander AU, Jansen JE, et al. Disease-free survival after complete mesocolic excision compared with conventional colon cancer surgery: a retrospective, population-based study. Lancet Oncol. 2015;16(2):161–8.CrossRefGoogle Scholar
  4. 4.
    Liang JT, Lai HS, Huang J, Sun CT. Long-term oncologic results of laparoscopic D3 lymphadenectomy with complete mesocolic excision for right-sided colon cancer with clinically positive lymph nodes. Surg Endosc. 2015;29(8):2394–401.CrossRefGoogle Scholar
  5. 5.
    Bergamaschi R, Schochet E, Haughn C, Burke M, Reed JF 3rd, Arnaud JP. Standardized laparoscopic intracorporeal right colectomy for cancer: short-term outcome in 111 unselected patients. Dis Colon Rectum. 2008;51(9):1350–5.CrossRefGoogle Scholar
  6. 6.
    Toyota S, Ohta H, Anazawa S. Rationale for extent of lymph node dissection for right colon cancer. Dis Colon Rectum. 1995;38(7):705–11.CrossRefGoogle Scholar
  7. 7.
    Nesgaard JM, Stimec BV, Bakka AO, Edwin B, Ignjatovic D. Navigating the mesentery: a comparative pre- and per-operative visualization of the vascular anatomy. Colorectal Dis. 2015;17(9):810–8.CrossRefGoogle Scholar
  8. 8.
    Nesgaard JM, Stimec BV, Bakka AO, Edwin B, Ignjatovic D. Navigating the mesentery: Part II. Vascular abnormalities and a review of the literature. Colorectal Dis. 2016;19(7):656–66.CrossRefGoogle Scholar
  9. 9.
    Nesgaard JM, Stimec BV, Soulie P, Edwin B, Bakka AO, Ignjatovic D. Defining minimal clearances for adequate lymphatic resection relevant to right colectomy for cancer: a post-mortem study. Surg Endosc. 2018;32(9):3806–12.  https://doi.org/10.1007/s00464-018-6106-3.CrossRefPubMedGoogle Scholar
  10. 10.
    Spasojevic M, Stimec BV, Dyrbekk, et al. Lymph node distribution in the D3 area of the right mesocolon: implications for an anatomically correct cancer resection. A postmortem study. Dis Colon Rectum. 2013;56(12):1381–7.CrossRefGoogle Scholar
  11. 11.
    Munkedal DLE, Rosenkilde M, Tonner Nielsen D, Sommer T, West NP, Laurberg S. Radiological and pathological evaluation of the level of arterial division after colon cancer surgery. Colorectal Dis. 2017;19(7):O238–O45.CrossRefGoogle Scholar
  12. 12.
    Spasojevic M, Stimec BV, Gronvold LB, Nesgaard JM, Edwin B, Ignjatovic D. The anatomical and surgical consequences of right colectomy for cancer. Dis Colon Rectum. 2011;54(12):1503–9.CrossRefGoogle Scholar
  13. 13.
    Kaye TL, West NP, Jayne DG, Tolan DJ. CT assessment of right colonic arterial anatomy pre and post cancer resection—a potential marker for quality and extent of surgery? Acta Radiol. 2016;57(4):394–400.CrossRefGoogle Scholar
  14. 14.
    Prevot F, Sabbagh C, Deguines JB, et al. Are there any surgical and radiological correlations to the level of ligation of the inferior mesenteric artery after sigmoidectomy for cancer? Anat Anz. 2013;195(5):467–74.CrossRefGoogle Scholar
  15. 15.
    Helsedirektoratet. Nasjonalt handlingsprogram med retningslinjer for diagnostikk, behandling og oppfølgning av tykk- og endetarmskreft. 2013. p. 37–39 and 120–123.Google Scholar
  16. 16.
    Stimec BV, Andersen BT, Benz SR, Fasel JHD, Augestad KM, Ignjatovic D. Retromesenteric course of the middle colic artery-challenges and pitfalls in D3 right colectomy for cancer. Int J Colorectal Dis. 2018;33(6):771–7.  https://doi.org/10.1007/s00384-018-2987-9.CrossRefPubMedGoogle Scholar
  17. 17.
    Nakajima K, Inomata M, Akagi T, et al. Quality control by photo documentation for evaluation of laparoscopic and open colectomy with D3 resection for stage II/III colorectal cancer: Japan Clinical Oncology Group Study JCOG 0404. Jpn J Clin Oncol. 2014;44(9):799–806.CrossRefGoogle Scholar
  18. 18.
    Gaupset R, Nesgaard JM, Kazaryan AM, Stimec BV, Edwin B, Ignjatovic D. Introducing anatomically correct CT-guided Laparoscopic right Colectomy with D3 anterior posterior extended mesenterectomy: initial experience and technical pitfalls. J Laparoendosc Adv Surg Tech A. 2018;  https://doi.org/10.1089/lap.2018.0059.CrossRefPubMedGoogle Scholar
  19. 19.
    Willard CD, Kjaestad E, Stimec BV, Edwin B, Ignjatovic D. Preoperative anatomical road mapping reduces variability of operating time, estimated blood loss, and lymph node yield in right colectomy with extended D3 mesenterectomy for cancer. Int J Colorectal Dis. 2019;34(1):151–60.  https://doi.org/10.1007/s00384-018-3177-5.CrossRefPubMedGoogle Scholar
  20. 20.
    West NP, Kobayashi H, Takahashi K, et al. Understanding optimal colonic cancer surgery: comparison of Japanese D3 resection and European complete mesocolic excision with central vascular ligation. J Clin Oncol. 1769;30(15):1763.CrossRefGoogle Scholar
  21. 21.
    Emmanuel A, Haji A. Complete mesocolic excision and extended (D3) lymphadenectomy for colonic cancer: is it worth that extra effort? A review of the literature. Int J Colorectal Dis. 2016;31(4):797–804.CrossRefGoogle Scholar
  22. 22.
    Killeen S, Mannion M, Devaney A, Winter DC. Complete mesocolic resection and extended lymphadenectomy for colon cancer: a systematic review. Colorectal Dis. 2014;16(8):577–94.CrossRefGoogle Scholar
  23. 23.
    Kotake K, Mizuguchi T, Moritani K, et al. Impact of D3 lymph node dissection on survival for patients with T3 and T4 colon cancer. Int J Colorectal Dis. 2014;29(7):847–52.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Gastrointestinal SurgeryVestfold Hospital TrustTonsbergNorway
  2. 2.Anatomy Sector, Department of Cellular Physiology and Metabolism, Faculty of MedicineUniversity of GenevaGenevaSwitzerland
  3. 3.Interventional Centre, Gastrointestinal and Pediatric SurgeryOslo University Hospital—RikshospitaletOsloNorway
  4. 4.Department of Digestive Surgery, Akershus University HospitalUniversity of OsloLorenskogNorway
  5. 5.Institute of Clinical MedicineUniversity of OsloOsloNorway

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