Complete Mesocolic Excision – CME
Complete Mesocolic Excision – CME
Principle• Based upon TME (Total Mesorectal
Excision) principle Prof. RJ Heald– Surgical technique rectal cancer – “The holy plane” of rectal cancer– Sharp dissection between the
visceral fascia (mesorectum) and parietal fascia (Waldeyer - Denonvilliers)
– Specimen with lymphovascular entity of rectum and mesorectum
– Initial rectal tumorspread confined (lymphatic spread)
Complete Mesocolic excision - CME
Principle
• TME principle• Less local pelvic
recurrences 3%• Improved rate
curative resections• Improved survival
and tumor-free survival
Complete Mesocolic Excision - CME
Principle• TME principle
Complete Mesocolic Excision - CME
Article
Complete Mesocolic Excision
Colonic cancer• Embryological planes between
visceral and parietal (retroperitoneal) fascia present around colon
• Sharp dissection visceral plane from retroperitoneal
• Intact surgical specimen of colon and mesocolon including possible initial lymphatic spread
• Lymphatic spread follows colonic arteries in mesocolon – high tie central origin – maximal harvest regional lymph nodes
• Improved oncological outcome ?
Complete Mesocolic Excision - CME
Method• Separation visceral plane from the parietal one– Right colon– Mobilization of duodenum with pancreatic head– Mesenteric root up to SMA/SMV – optimal exposure
Complete Mesocolic Excision - CME
Method• Separation visceral plane from the parietal one– Right colon
Complete Mesocolic Excision - CME
Method• Separation visceral plane from the parietal one– Left colon– Mobilisation splenic
flexure, mesocolon descending colon, sigmoid
– Dissected off retroperitoneal plane including prerenal fat, ureter, vesicular/ovarian vessels
Complete Mesocolic Excision - CME
Method• Separation visceral plane from
the parietal one– Transverse colon– Detachment greater
omentum– Division two layers
transverse mesocolon at lower edge pancreas
Complete Mesocolic Excision - CME
Method• Lymph spread first pericolic
• Subsequently towards central arteries
• Lymph node dissection– Hepatic flexure 5 % head
pancreas, 4 % epiploic arcade
– Transverse colon epiploic arcade
– Splenic flexure inferior edge pancreatic tail
– Sigmoid sigmoidal arteries
Complete Mesocolic Excision - CME
Method• Lymph node dissection
Complete Mesocolic Excision - CME
Method• Central ligation supplying vessels
• Right colon
Complete Mesocolic Excision - CME
Method
• Central ligation supplying vessels• Right colon
• Ileocolic / right colic vessels• Central origin SMA / SMV• Preservation autonomic plexus• Incision mesenterial plane covering
SMV• Right colic vein => superior
gastroepiploic vein divided• Lymph nodes pancreatic head
• Caecum / ascending colon• Above vessels + right branches middle colic vessels
Complete Mesocolic Excision - CME
Method• Superior gastroepiploic vein
Complete Mesocolic Excision - CME
Method
• Central ligation supplying vessels• Transverse colon
• Central ligation middle colic artery / vein• Central tie right gastroepiploic artery• Hepatic flexure transsection close splenic flexure• Splenic flexure transsection close sigmoid
• Descending colon• Central tie left ascending colonic artery• Preservation root IMA – dissection lymph nodes origin
Complete Mesocolic Excision - CME
Method
• Central ligation supplying vessels• Middle descending colon / sigmoid
• Division root IMA / IMV
• Transsection distally upper 1/3 rectum
• Transsection proximally between left transverse colon / distal descending colon
Complete Mesocolic excision - CME
Patients• Prospective study• University Hospital Erlangen, Germany• 1438 patients between 1978 and 2002• Inclusion criteria
– Solitary invasive (at least submucosa) colon carcinoma (>16 cm from anal verge)
– No other history of previous or synchronous malignancies
– No carcinoma because of FAP, UC or Crohn's
– No neo-adjuvant treatment; Stage I-III
Complete Mesocolic excision - CME
Patients• Exclusion criteria– 109 patients (7,6 %)– 37 patients no R0-resection (2,6 %)– 42 patients surgical mortality (2,9 %)– 30 patients tumour status unknown to
recurrence (2,1 %)• 1329 patients analysed• Median follow-up 103 months (1-335)• WHO tumour classification / 6th TNM
classification
Complete Mesocolic excision - CME
Patients• Outcome assessment
– Cancer-related survival• Death with locoregional or
distant metastases– Rate locoregional recurrence– Amount lymph node harvest– Postoperative complications and
mortality
• Comparison three time periods 1978-1984 / 1985-1994 / 1995-2002
Complete Mesocolic excision - CME
Complete Mesocolic excision - CME
Results• 80,3 % uneventful post-op
course• 4,7 % re-operation
(anastomotic leak)• Post-operative mortality 3,1
%• Emergencies (9,5 %) higher
rate complications 34,4 % - 17 %
• Complication rate between surgeons 11,7 % - 35,5 %
Complete Mesocolic excision - CME
Results• Lymph node harvest• Median number 32 (2 – 169)• Influence nodes on prognosis• 682 N0 patients
• Median 29 (2-106)• < 28 (n=314) 5 year survival 90,7 % (95% CI 87,4
- 94,0)• > 28 (n=368) 5 year survival 96,3 % (95% CI 94,3
– 98,3), P=0,018• 383 Lymph node positive patients
• < 28 64,6 % (n=145, CI 56,6 – 72,6)• > 28 71,7 % (n=238, CI 65,8 – 77,6) P=0,088
Complete Mesocolic excision - CME
Results
• 5 year-rate of locoregional recurrence 4,9 %
• Improvement recurrence rate during 1978-1984 (6,5%) to 1995-2002 (3,6%)
• Recurrence rate increased higher pT or pN
Complete Mesocolic excision - CME
Results
Complete Mesocolic excision - CME
Results• CME principle with production of an intact
lymphovascular entity (colon and mesocolon – dissection between visceral and parietal fascia) and high central ligation of supplying vessels• Improved 5-year cancer related survival (82,1% -
89,1%) • Reduced local 5-year recurrence rate (6,5% - 3,1%)• Prognostic factors
• Harvested lymph nodes• pN, pT, extramural invasion, emergency
presentation• Institution
Complete Mesocolic excision - CME
Discussion• CME principle with production of an intact
lymphovascular entity (colon and mesocolon – dissection between visceral and parietal fascia) and high central ligation of supplying vessels• Maximizing lymph node harvest
(correlates prognosis => improved survival)
• Intact fascial layer (prognostic relevance)
• Important provide integrity viseral mesocolic layer along specimen - danger tumour dissemination
• Central vascular ligation maximizes node harvest
Complete Mesocolic excision - CME
Discussion• CME principle with production of an intact
lymphovascular entity (colon and mesocolon – dissection between visceral and parietal fascia) and high central ligation of supplying vessels• Right colon mobilisation mesenteric root and
duodenum with pancreatic head• Right colonic flexure pancreatic head metastases• Transverse colon and splenic flexure mobilisation
gastroepiploic arcade and dissection inferior edge pancreas
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