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The rationale behind complete mesocolic excision (CME) and a central vascular ligation for colon cancer in open and laparoscopic surgery

Proceedings of a consensus conference

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International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Background

It has been evident for a while that the result after resection for colon cancer may not have been optimal. Several years ago, this was showed by some leading surgeons in the USA but a concept of improving results was not consistently pursued. Later, surgeons in Europe and Japan have increasingly adopted the more radical principle of complete mesocolic excision (CME) as the optimal approach for colon cancer. The concept of CME is a similar philosophy to that of total mesorectal excision for rectal cancer and precise terminology and optimal surgery are key factors.

Method

There are three essential components to CME. The main component involves a dissection between the mesenteric plane and the parietal fascia and removal of the mesentery within a complete envelope of mesenteric fascia and visceral peritoneum that contains all lymph nodes draining the tumour area (Hohenberger et al., Colorectal Disease 11:354–365, 2009; West et al., J Clin Oncol 28:272–278, 2009). The second component is a central vascular tie to completely remove all lymph nodes in the central (vertical) direction. The third component is resection of an adequate length of bowel to remove involved pericolic lymph nodes in the longitudinal direction.

Result

The oncological rationale for CME and various technical aspects of the surgical management will be explored.

Conclusion

The consensus conference agreed that there are sound oncological hypotheses for a more radical approach than has been common up to now. However, this may not necessarily apply in early stages of the tumour stage. Laparoscopic resection appears to be equally well suited for resection as open surgery.

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References

  1. Hohenberger W, Weber K, Matzel K, Papadopoulos, Merkel S (2009) Standardized surgery for colonic cancer: complete mesocolic excision and central ligation – technical notes and outcome. Color Dis 11:354–365

    Article  CAS  Google Scholar 

  2. West NP, Hohenberger W, Weber K, Perrakis A, Finan PJ, Quirke P (2009) Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol 28:272–278

    Article  PubMed  Google Scholar 

  3. Bertelsen CA, Bols B, Ingeholm P, Jansen JE, Neuenschwander AU, Vilandt J (2011) Can the quality of colonic surgery be improved by standardization of surgical technique with complete mesocolic excision? Colorectal Dis 13:1123–1129

    Article  PubMed  CAS  Google Scholar 

  4. Heald RJ, Ryall RD (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1:1479–1482

    Article  PubMed  CAS  Google Scholar 

  5. Wibe A, Møller B, Norstein J, Carlsen E, Wiig JN, Heald RJ, Langmark F, Myrvold HE, Søreide O, Norwegian Rectal Cancer Group (2002) A national strategic change in treatment policy for rectal cancer—implementation of total mesorectal excision as routine treatment in Norway. A national audit. Dis Colon Rectum 45(7):857–866

    Article  PubMed  Google Scholar 

  6. Storli K, Lindboe CF, Kristoffersen C, Kleiven K, Søndenaa K (2010) Lymph node harvest in colon cancer specimens depends on tumour factors, patients and doctors, but foremost on specimen handling. APMIS 119:127–134

    Article  PubMed  Google Scholar 

  7. Kobayashi H, Higuchi T, Uetake H, Iida S, Ishikawa T, Ishiguro M, Sugihara K (2012) Resection with en bloc removal of regional lymph node after endoscopic resection for T1 colorectal cancer. Ann Surg Oncol 19(13):4161–4167

    Article  PubMed  Google Scholar 

  8. Messenger DE, Driman DK, Kirsch R (2012) Developments in the assessment of venous invasion in colorectal cancer: implications for future practice and patient outcome. Hum Pathol 43(7):965–973

    Article  PubMed  Google Scholar 

  9. Morikawa T, Tanaka N, Kuchiba A, Nosho K, Yamauchi M, Hornick JL, Swanson RS, Chan AT, Meyerhardt JA, Huttenhower C, Schrag D, Fuchs CS, Ogino S (2012) Predictors of lymph node count in colorectal cancer resections. Arch Surg 147:715–723

    Article  PubMed Central  PubMed  Google Scholar 

  10. Mroczkowski P, Schmidt U, Sahm M, Gastinger I, Lippert H, Kube R (2012) Prognostic factors assessed for 15,096 patients with colon cancer in stages I and II. World J Surg 36:1693–1698

    Article  PubMed  Google Scholar 

  11. Kaplan RN, Rafii S, Lyden D (2006) Preparing the “soil”: The premetastatic niche. Cancer Res 66(23):11089–11093

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  12. Oppenheimer SB (2006) Cellular basis of cancer metastasis: a review of fundamentals and new advances. Acta Histochem 108(5):327–334

    Article  PubMed  CAS  Google Scholar 

  13. Hagness M, Foss A, Line P-D et al (2013) Liver transplantation for nonresectable liver metastases from colorectal cancer. Ann Surg 257(5):800–8006

    Article  PubMed  Google Scholar 

  14. Titu LV, Tweedle E, Rooney PS (2008) High tie of the inferior mesenteric artery in curative surgery for left colonic and rectal cancers. Dig Surg 25:148–157

    Article  PubMed  CAS  Google Scholar 

  15. Rouffet F, Hay JM, Vacher B, Fingerhut A, Elhadad A, Flamant Y, Mathon C, Gainant A (1994) Curative resection for left colonic carcinoma: hemicolectomy vs. segmental colectomy. A prospective controlled, multicentre trial. Dis Colon Rectum 37:651–659

    Article  PubMed  CAS  Google Scholar 

  16. Ovrebo K, Rokke O (2010) Extended lymph node dissection in colorectal cancer surgery. Reliability and reproducibility in assessments of operative reports. Int J Colorectal Dis 25(2):213–222

    Article  PubMed  Google Scholar 

  17. West NP, Hohenberger W, Finan PJ, Quirke P (2009) Mesocolic plane surgery: an old but forgotten technique? Colorectal Dis 11:988–989

    Article  PubMed  CAS  Google Scholar 

  18. Enker WE, Laffer UT, Block GE (1979) Enhanced survival of patients with colon and rectal cancer is based upon wide anatomic resection. Ann Surg 190(3):350–360

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  19. Turnbull RB Jr (1975) Current concepts in cancer. Cancer of the GI tract: colon, rectum, anus. The no-touch isolation technique of resection. JAMA 231:1181–1182

    Article  PubMed  Google Scholar 

  20. Tsai H-L, Lu C-H, Hsieh J-S et al (2007) The prognostic significance of total lymph node harvest in patients with T2-4N0M0 colorectal cancer. J Gastrointest Surg 11:660–665

    Article  PubMed  Google Scholar 

  21. Rosenberg R, Engel J, Bruns C, Heitland W, Hermes N, Jauch KW, Kopp R, Putterich E, Ruppert R, Schuster T, Friess H, Holzel D (2010) The prognostic value of lymph node ratio in a population-based collective of colorectal cancer patients. Ann Surg 251(6):1070–1078

    Article  PubMed  Google Scholar 

  22. Kim JC, Lee KH, Yu CS, Kim HC, Kim JR, Chang HM et al (2004) The clinicopathological significance of inferior mesenteric lymph node metastasis in colorectal cancer. Eur J Surg Oncol 30:271–279

    Article  PubMed  CAS  Google Scholar 

  23. Chok KS, Law WL (2007) Prognostic factors affecting survival and recurrence of patients with pT1 and pT2 colorectal cancer. World J Surg 31:1485–1490

    Article  PubMed  Google Scholar 

  24. Færden AE, Sjo OH, Bukholm IR, Andersen SN, Svindland A, Nesbakken A, Bakka A (2011) Lymph node micrometastases and isolated tumor cells influence survival in stage I and II colon cancer. Dis Colon Rectum 54(2):200–206

    Article  PubMed  Google Scholar 

  25. Horn A, Dahl O, Morild I (1991) Venous and neural invasion as predictors of recurrence in rectal adenocarcinoima. Dis Colon Rectum 34:798–804

    Article  PubMed  CAS  Google Scholar 

  26. Quirke P, Morris EJ (2007) Reporting colorectal cancer. Histopathology 50:103–112

    Article  PubMed  CAS  Google Scholar 

  27. Morris EJ, Maughan NJ, Forman D, Quirke P (2007) Identifying stage III colorectal cancer patients: the influence of the patient, surgeon, and pathologist. J Clin Oncol 25:2573–2579

    Article  PubMed  Google Scholar 

  28. Park IJ, Choi G-S, Kang BM, Lim KH, Jun SH (2009) Lymph node metastasis patterns in right-sided colon cancers: is segmental resection of these tumors oncologically safe? Ann Surg Oncol 16:1501–1506

    Article  PubMed  Google Scholar 

  29. Toyota S, Ohta H, Anazawa S (1995) Rationale for extent of lymph node dissection for right colon cancer. Dis Colon Rectum 38:705–711

    Article  PubMed  CAS  Google Scholar 

  30. Hashiguchi Y, Hase K, Ueno H, Mochizuki H, Shinto E, Yamamoto J (2011) Optimal margins and lymphadenectomy in colonic cancer surgery. Br J Surg 98:1171–1178

    Article  PubMed  CAS  Google Scholar 

  31. Kotake K, Honjo S, Sugihara K, Hashiguchi Y, Kato T, Kodaira S, Muto T, Koyama Y (2012) Number of lymph nodes retrieved is an important determinant of survival of patients with stage II and stage III colorectal cancer. Jap J Clin Oncol 42(1):29–35

    Article  Google Scholar 

  32. Kobayashi H, Ueno H, Hashiguchi Y, Mochizuki H (2006) Distribution of lymph node metastasis is a prognostic index in patients with stage III colon cancer. Surgery 139:516–522

    Article  PubMed  Google Scholar 

  33. Yada H, Sawai K, Taniguchi H, Hoshima M, Katoh M, Takahashi T (1997) Analysis of vascular anatomy and lymph node metastases warrants radical segmental bowel resection for colon cancer. World J Surg 21:109–115

    Article  PubMed  CAS  Google Scholar 

  34. Kang J, Hur H, Min BS, Kim NK, Lee KY (2011) Prognostic impact of inferior mesenteric artery lymph node metastasis in colorectal cancer. Ann Surg Oncol 18(3):704–710

    Article  PubMed  Google Scholar 

  35. Merrie AEH, Phillips LV, Yun K, McCall JL (2001) Skip metastases in colon cancer: assessment by lymph node mapping using molecular detection. Surgery 129:684–691

    Article  PubMed  CAS  Google Scholar 

  36. Tan KY, Kawamura YJ, Mizokami K, Sasaki J, Tsujinaka S, Maeda T, Nobuki M, Konishi F (2010) Distribution of the first metastatic lymph node in colon cancer and its clinical significance. Color Dis 12:44–47

    Article  CAS  Google Scholar 

  37. Watanabe T, Itabashi M, Shimada Y et al (2012) Japanese Society for cancer of the colon and rectum (JSCCR) guidelines 2010 for the treatment of colorectal cancer. Int J Clin Oncol 17:1–29

    Article  PubMed  Google Scholar 

  38. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM, MRC CLASICC trial group (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365(9472):1718–1726

    Article  PubMed  Google Scholar 

  39. Sobin LGM, Wittekind C (eds) (2009) International Union Against Cancer TNM Classification of Malignant Tumours, 7th edn. Wiley-Blackwell, Hoboken

    Google Scholar 

  40. Ueno H, Mochizuki H, Shirouzu K, Kusumi T, Yamada K, Ikegami M, Kawachi H, Kameoka S, Ohkura Y, Masaki T, Kushima R, Takahashi K, Ajioka Y, Hase K, Ochiai A, Wada R, Iwaya K, Nakamura T, Sugihara K (2012) JSCCR. Multicenter study for optimal categorization of extramural tumor deposits for colorectal cancer staging. Ann Surg 255:739–746

    Article  PubMed  Google Scholar 

  41. Ueno H, Mochizuki H, Shirouzu K, Kusumi T, Yamada K, Ikegami M, Kawachi H, Kameoka S, Ohkura Y, Masaki T, Kushima R, Takahashi K, Ajioka Y, Hase K, Ochiai A, Wada R, Iwaya K, Nakamura T, Sugihara K (2011) JSCCR. Actual status of distribution and prognostic impact of extramural discontinuous cancer spread in colorectal cancer. J Clin Oncol 29:1–7

    Article  Google Scholar 

  42. Nagtegaal ID, Quirke P (2007) Colorectal tumour deposits in the mesorectum and pericolon; a critical review. Histopathology 51:141–149

    Article  PubMed  CAS  Google Scholar 

  43. Nelson H, Petrelli N, Carlin A, Couture J, Fleshman J, Guillem J, Miedema B, Ota D, Sargent D (2001) Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst 93(8):583–596

    Article  PubMed  CAS  Google Scholar 

  44. Fielding LP, Fenoglio-Preiser CM, Freedman LS (1992) The future of prognostic factors in outcome prediction for patients with cancer. Cancer 70(9):2367–2377

    Article  PubMed  CAS  Google Scholar 

  45. Le Voyer TE, Sigurdson ER, Hanlon AL, Mayer RJ, Macdonald JS, Catalano PJ et al (2003) Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol 21(15):2912–2919

    Article  PubMed  Google Scholar 

  46. Maughan NJ, Morris E, Forman D, Quirke P (2007) The validity of the Royal College of Pathologists' colorectal cancer minimum dataset within a population. Br J Cancer 97(10):1393–1398

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  47. Hogan AM, Winter DC (2009) Complete mesocolic excision—a marker of surgical quality? J Gastrointest Surg 13:1889–1891

    Article  PubMed  Google Scholar 

  48. Baxter NN, Ricciardi R, Simunovic M, Urbach DR, Virnig BA (2010) An evaluation of the relationship between lymph node number and staging in pT3 colon cancer using population-based data. Dis Colon Rectum 53(1):65–70

    Article  PubMed  Google Scholar 

  49. Hida J, Okuno K, Yasutomi M et al (2005) Number versus distribution in classifying regional lymph node metastases from colon cancer. J Am Coll Surg 201:217–222

    Article  PubMed  Google Scholar 

  50. Storli KE, Søndenaa K, Bukholm IRK, Nesvik I, Bru T, Furnes B, Hjelmeland B, Iversen KB, Eide GE (2011) Overall survival after resection for colon cancer in a national cohort study was affected by TNM stage, lymph node ration. Int J Colorectal Dis 26:1299–1307

    Article  PubMed Central  PubMed  Google Scholar 

  51. Sjo OH, Merok MA, Svindland A et al (2010) Prognostic impact of lymph node harvest and lymph node ratio in patients with colon cancer. Dis Colon Rectum 55:307–315

    Article  Google Scholar 

  52. Kobayashi H, Enomoto M, Higuchi T, Uetake H, Iida S, Ishikawa T, Ishiguro M, Kato S, Sugihara K (2011) Clinical significance of lymph node ratio and location of nodal involvement in patients with right colon cancer. Dig Surg 28(3):190–197

    Article  PubMed  Google Scholar 

  53. West NP, Kobayashi H, Takahashi K, Perrakis A, Weber K, Hohenberger W, Sugihara K, Quirke P (2012) Understanding optimal colonic cancer surgery: comparison of Japanese D3 resection and European complete mesocolic excision with central vascular ligation. J Clin Oncol 30(15):1763–1769

    Article  PubMed  Google Scholar 

  54. Jamieson JK, Dobson JF (1909) The lymphatics of the colon. Ann Surg 50:1077–1090

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  55. Japanese Society for Cancer of the Colon and Rectum (2009) Japanese Classification of Colorectal Carcinoma (2nd English edn). Kanehara, Tokyo

    Google Scholar 

  56. Jinnai D (1983) General rules for clinical and pathological studies on cancer of the colon, rectum and anus. Jpn J Surg 13:557–573

    Article  Google Scholar 

  57. Chang GJ (2013) Emphasizing surgery for colon cancer. Editorial Dis Colon Rectum 56:805–807

    Article  Google Scholar 

  58. Taranu T, Taranu T, Varlam H et al (1998) The arterial system of the greater omentum. Rev Med Chir Soc Med Nat 102:139–142

    CAS  Google Scholar 

  59. Kobayashi H, Mochizuki H, Sugihara K et al (2007) Characteristics of recurrence and surveillance tools after curative resection for colorectal cancer: a multicenter study. Surgery 141:67–75

    Article  PubMed  Google Scholar 

  60. Hida K, Hasegawa S, Kinjo Y et al (2012) Open versus laparoscopic resection of primary tumor for incurable stage IV colorectal cancer: a large multicenter consecutive patients cohort study. Ann Surg 255(5):929–934

    Article  PubMed  Google Scholar 

  61. Ruo L, Cougoutas C, Paty PB, Guillem JG, Cohen AM, Wong WD (2003) Elective bowel resection for incurable stage IV colorectal cancer: prognostic variables for asymptomatic patients. J Am Coll Surg 196:722–728

    Article  PubMed  Google Scholar 

  62. Foxtrot Collaborative Group (2012) Feasibility of preoperative chemotherapy for locally advanced, operable colon cancer: the pilot phase of a randomised controlled trial. Lancet Oncol 13:1152–1160

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  63. West NP, Morris EJA, Rotimi O, Cairns A, Finan PJ, Quirke P (2008) Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study. Lancet Oncol 9:857–865

    Article  PubMed  Google Scholar 

  64. Bagshaw PF, Allardyce RA, Frampton CM et al (2012) Long-term outcomes of the Australasian randomized clinical trial comparing laparoscopic and conventional open surgical treatments for colon cancer. The Australasian laparoscopic colon cancer study trial. Ann Surg 256:915–919

    Article  PubMed  Google Scholar 

  65. Storli KE, Søndenaa K, Furnes B, Eide GE (2013) Outcome after introduction of complete mesocolic excision (CME) for colon cancer improved similarly for open and laparoscopic surgical treatments. Dig Surg. doi:10.1159/000354580

    PubMed  Google Scholar 

  66. Ohtani H, Tamamori Y, Arimoto Y, Nishiguchi Y, Maeda K, Hirakawa K (2011) A meta-analysis of the short- and long-term results of randomized controlled trials that compared laparoscopy-assisted and conventional open surgery for colorectal cancer. J Cancer 2:425–434

    Article  PubMed Central  PubMed  Google Scholar 

  67. Green BL, Marshall HC, Collinson F, Quirke P, Guillou P, Jayne DG, Brown JM (2013) Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer. Br J Surg 100(1):75–82

    Article  PubMed  CAS  Google Scholar 

  68. Bilimoria KY, Bentrem DJ, Merkow RP, Nelson H, Wag E, Ko CY, Soper NJ (2008) Laparoscopic-assisted vs. open colectomy for cancer: comparison of short-term outcomes from 121 hospitals. J Gastrointest Surg 12:2001–2009

    Article  PubMed  Google Scholar 

  69. Hewett PJ, Allardyce RA, Bagshaw PF, Frampton CM, Frizelle FA, Rieger NA, Smith JS, Solomon MJ, Stephens JH, Stevenson ARL (2008) Short-term outcomes of the Australasian randomized clinical study comparing laparoscopic and conventional open surgical treatments for colon cancer. Ann Surg 248:728–738

    Article  PubMed  Google Scholar 

  70. Poon JTC, Law W-L, Fan JKM, Lo OSH (2009) Impact of the standardized medial-to-lateral approach on outcome of laparoscopic colorectal resection. World J Surg 33:2177–2182

    Article  PubMed  Google Scholar 

  71. Sjövall A, Granath F, Cedermark B, Glimelius B, Holm T (2007) Loco-regional recurrence from colon cancer: a population-based study. Ann Surg Oncol 14(2):432–440

    Article  PubMed  Google Scholar 

  72. Bonnet S, Berger A, Hentati N, Abid B, Chevallier JM, Wind P, Delmas V, Douard R (2012) High tie versus low tie vascular ligation of the inferior mesenteric artery in colorectal cancer surgery: impact on the gain in colon length and implications on the feasibility of anastomoses. Dis Colon Rectum 55(5):515–521

    Article  PubMed  CAS  Google Scholar 

  73. Buchanan GN, Malik A, Parvaiz A, Sheffield JP, Kennedy RH (2008) Laparoscopic resection for colorectal cancer. Br J Surg 95:893–902

    Article  PubMed  CAS  Google Scholar 

  74. Ding J, Liao G, Xia Y, Zhang Z, Pan Y, Liu S, Zhang Y, Yan Z (2013) Medial versus lateral approach in laparoscopic colorectal resection: a systematic review and meta-analysis. World J Surg 37:863–872

    Article  PubMed  Google Scholar 

  75. Gouvas N, Pechlivanides G, Zervakis N, Kafousi M, Xynos E (2012) Complete mesocolic excision in colon cancer surgery: a comparison between open and laparoscopic approach. Colorectal Dis 14:1357–1364

    Article  PubMed  CAS  Google Scholar 

  76. Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K (2010) Quantitative comparison of the difficulty of performing laparoscopic colectomy at different tumor locations. World J Surg 34:133–139

    Article  PubMed  Google Scholar 

  77. Temesi R, Sikorszki L, Bezsilla J, Botos A, Kovacs J, Tihanyi T (2012) Impact of positive intraabdominal lavage cytology on the long-term prognosis of colorectal cancer patients. World J Surg 36:2714–2721

    Article  PubMed  Google Scholar 

  78. West NP, Sutton KM, Ingeholm P et al (2010) Improving the quality of colon cancer surgery through a surgical education program. Dis Colon Rectum 53:1594–1603

    Article  PubMed  Google Scholar 

  79. VanDamme J-P, Bonte J (1990) Vascular anatomy in abdominal surgery. Thieme, Stuttgart

    Google Scholar 

  80. Lange JF, Komen N, Akkerman G, Nout E, Horstmanshoff H, Schlesinger F, Bonjer J, Kleinrensink GJ (2007) Riolan's arch: confusing, misnomer, and obsolete. A literature of the connection(s) between the superior and inferior mesenteric arteries. Am J Surg 193(6):742–748

    Article  PubMed  Google Scholar 

  81. Ignjatovic D, Sund S, Stimec B, Bergamaschi R (2007) Vascular relationships in right hemicolectomy for cancer: clinical implications. Tech Coloproctol 11(3):247–250

    Article  PubMed  CAS  Google Scholar 

  82. Spasojevic M, Stimec BV, Fasel JF, Terraz S, Ignjatovic D (2011) 3D relations between right colon arteries and the superior mesenteric vein: a preliminary study with multidetector computed tomography. Surg Endosc 25(6):1883–1886

    Article  PubMed  CAS  Google Scholar 

  83. Jin G, Tuo H, Sugiyama M, Oki A, Abe N, Mori T, Masaki T, Atomi Y (2006) Anatomic study of the superior right colic vein. Am J Surg 191:100–103

    Article  PubMed  Google Scholar 

  84. Yamaguchi S, Kuroyanagi H, Milsom JW, Sim R, Shimada H (2002) Venous anatomy of the right colon: precise structure of the major veins and gastrocolic trunk in 58 cadavers. Dis Colon Rectum 45(10):1337–1340

    Article  PubMed  Google Scholar 

  85. Ono C, Yoshinaga K, Enomoto M, Sugihara K (2002) Discontinuous rectal cancer spread in the mesorectum and the optimal distal clearance margin in situ. Dis Colon Rectum 45:744–749

    Article  PubMed  Google Scholar 

  86. Rosenberg R, Maak M, Schuster T, Becker K, Friess H, Gertler R (2010) Does a rectal cancer of the upper third behave more like a colon or a rectal cancer. Dis Colon Rectum 53(5):761–770

    Article  PubMed  Google Scholar 

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Acknowledgments

Albert Wolthuis, Ole Sjo, Chris Hunter, and Dejan Ignjatovic contributed to the conference in various ways and we are grateful for their contributions. The conference was sponsored by Covidien, K Storz AS, Johnson&Johnson, Olympus, and Endotech. Other contributors were Haraldsplass Deaconess Hospital and The Norwegian Medical Association. PQ and NPW are supported by Yorkshire Cancer Research, NPW by the Pathological Society of Great Britain & Ireland, and PQ by the CRUK and ECMC centres.

Author information

Authors and Affiliations

  1. Department of Surgery, Haraldsplass Deaconess Hospital, POB 6165, 5892, Bergen, Norway

    K. Søndenaa & K. E. Storli

  2. Department of Clinical Medicine, University of Bergen, Bergen, Norway

    K. Søndenaa

  3. Pathology, Anatomy and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, England, UK

    P. Quirke & N. P. West

  4. Department of Surgery, University of Erlangen, Erlangen, Germany

    W. Hohenberger

  5. Department of Surgical Oncology, Tokyo Medical and Dental University, Tokyo, Japan

    K. Sugihara & H. Kobayashi

  6. Digestive Diseases, Cleveland Clinic, Cleveland, USA

    H. Kessler

  7. Department of Radiology, Royal Marsden Hospital, London, England, UK

    G. Brown & V. Tudyka

  8. Department of Surgery, University of Leuven, Leuven, Belgium

    A. D’Hoore

  9. Department of Surgery, St. Mark’s Hospital, Harrow, England, UK

    R. H. Kennedy

  10. Department of Surgery, Korea University, Anam Hospital, Seoul, South Korea

    S. H. Kim

  11. The Pelican Cancer Foundation, Basingstoke, England, UK

    R. Heald & B. Moran

  12. Department of Surgery, Oslo University Hospital, Oslo, Norway

    A. Nesbakken

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  1. K. Søndenaa
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Corresponding author

Correspondence to K. Søndenaa.

Appendix 1

Appendix 1

Controversies in segmental resections according to regional differences and personal opinions

The right colon

Caecum and proximal ascending colon

Europe: Most often right hemi-colectomy with right branch of MCA and mesenteric lymph node dissection on the right side of MCA. Usually, the ICA is ligated at the level of the SMV but if suspicion exists of proximal lymph node metastases at the root of ICA, the resection may be carried to this level.

Japan: Resection according to the cm-rule of the Japanese guidelines and presence of arteries. Mesenteric resection is carried along the axis of the SMV but not beyond this vein.

Distal ascending colon

E.: Right hemi-colectomy with right branch of MCA.

J.: Segmental resection according to the cm-rule of the Japanese guidelines. If the MCA is closer than 10 cm, the right branch is ligated.

Right flexure and right transverse colon

E.: Extended right hemi-colectomy including MCA with tension-free anastomosis to the left. Some advocate resection of lymph nodes in the lateral 10 cm of the right gastro-epiploic vascular curvature, the sub-pyloric, and lymph nodes over the pancreatic head.

J.: Segmental resection with right branch of MCA if MCA is more than 10 cm beyond tumour. If it is less than 10 cm, resection of the right branch of the MCA and 5 cm beyond but sparing the arcade and the left branch of MCA. Resection of the RCA, if present, is advocated if it is less than 10 cm from the tumour. Lymph nodes should be resected along the right side of the MCA.

Transverse colon

E: Resection of the transverse colon and MCA. If the resection is carried beyond the flexures, an anastomosis placed on the right may be considered. It is essential to avoid tension.

Some may resect the left gastro-epiploic arcade if the tumour is situated to the left of the MCA and nodes along the inferior aspect of the left pancreas.

J: Resection of MCA with bowel resection according to the cm-rule. Lymph nodes are resected to origin of resected vessels.

Descending colon

Descending colon

E.: Left hemi-colectomy to origin of LCA, first sigmoid branch if tumour is quite distal, and left branch of MCA. If IMA is ligated, sigmoid resection is necessary.

J.: Segmental resection according to guidelines of distance. The LCA is divided and lymph nodes dissected upwards from just above the aorta (about 1 cm).

Sigmoid colon and rectosigmoid

Sigmoid colon

E.: Sigmoid resection with ligation of IMA about 1 cm from aorta.

J.: Sigmoid resection with ligation of IMA distal to the LCA. Lymph nodes are dissected away from the aorta with the specimen from about 1 cm from aorta. Resection is carried down to the rectosigmoid intestine.

Recto-sigmoid intestine

E.: Resection is done similar to that for sigmoid and 5 cm beyond tumour

J.: Resection is done similar to that for sigmoid and 3 cm beyond tumour

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Søndenaa, K., Quirke, P., Hohenberger, W. et al. The rationale behind complete mesocolic excision (CME) and a central vascular ligation for colon cancer in open and laparoscopic surgery. Int J Colorectal Dis 29, 419–428 (2014). https://doi.org/10.1007/s00384-013-1818-2

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  • DOI: https://doi.org/10.1007/s00384-013-1818-2

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