Komplette Mesokolische Exzision (CME) Ergebnisse und Ausblicke

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1 Komplette Mesokolische Exzision (CME) Ergebnisse und Ausblicke Werner Hohenberger Chirurgische Universitätsklinik Erlangen Friedrich-Alexander-Universität Erlangen-Nürnberg

2 Colon Cancer Cancer related 5-Years Survival Related to Periods : 90,2% : 87,2% : 84,6% : 83,6% : 82,1% Stages I-III, R0, Erlangen Registry

3 Standardised Surgery for Colonic Cancer: Complete mesocolic excision (CME) and central ligation Technical notes and outcome Hohenberger W.,Matzel K.E., Merkel S., Papadopoulos T., Weber K. Colorectal Dis 2009, 11:

4 Colon Cancer Cancer related Survival o o o o o o Surg. Department Univ. Hosp. Erlangen postop. mortality excluded, , stage I-III

5 Outcome of Colon versus Rectal Cancer (5 yr relative survival) Data from ISD % Colon Rectum courtesy Prof. R J C Steele / Dundee

6 Colorectal Cancer Resections Tayside (n= 1992) Significant Hazard ratios l T4 vs T (p =0.041) l l l l l N1 vs N (p=0.000) N2 vs N (p=0.000) Rectum vs R colon 0.57 (p=0.001) L colon vs R colon 0.68 (p=0.019) Screening 0.48 (p=0.003) courtesy Prof. R J C Steele / Dundee

7 Colon Cancer Lomgterm Oncologic Outcome Challenging Cases Stage III T 4 tumors Emergencies

8 Colon Cancer Survival Stage III 5-years survival Middle Franconia (n=1513) 54 % German Study Group (n=9329) 59 % right c. 58 % left c. Erlangen 79,5 % ( , n=204) Japan (n=2808) 81,9 % USA ( high volume centers ) 44,0 %

9 Editioral Colonic surgery for cancer: a new paradigm While these advances were being made in rectal cancer Surgery for colonic cancer has been left untouched. Najib Haboubi, Colorectal Disease 2003, 11; , 2009

10 Surgery for Colon Cancer Complete Mesocolic Excicion (CME) What the term includes Preservation of the mesocolic plane by sharp dissection off the parietal plane (turning embryology back) Regional and central lymphnode dissection with central tie of supplying arteries

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12 Visceral plane (mesentery) kidney aorta Somatic (parietal) plane liver stomach spleen

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14 Complete Mesocolic Excision (CME) Planes Mesenteric plane from Rohen, Yokochi Schattauer 1983, modified

15 Colon Cancer Surgery Planes and Package

16 Colon anatomy: embryology, lymphatic drainage, mesocolon Microscopic anatomy Mesentery serosal lining vein artery lymphatic vessel lymphe node serosal lining Similarity to mesorectum...

17 Courtesy Prof. Solveig Anderson/Oslo

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19 MRC CLASICC trial Courtesy of Phil Quirke

20 Colon Cancer Surgery Planes and Package

21 Methods tissue morphometry C A = Distance from tumour to high tie A B B = Distance from nearest bowel wall to high tie C = Length of large intestine D D = Cross sectional area of mesentery Leeds Institute of Molecular Medicine Pathology and Tumour Biology

22 Colon Cancer Specimens Tissue Morphometry based on photo documentation (ant. / post. aspect) length of colon resected length of vascular pedicle distance from tumour to central resection margin area of mesentry resected volume N. West, JClinOncol 2010 Imagescope version 10 (Aperio, California, USA)

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24 Colon Cancer Surgery Quality of Specimens N. West et al, JCO 2012

25 Running mean distance (mm) Morphometry Tumour to high tie (p<0.0001) Erlangen Leeds Number of cases Leeds Institute of Molecular Medicine Pathology and Tumour Biology

26 Lymph node dissection

27 Colon Cancer Central Tie right branch of middle colic artery dissected, ready to clamp right colic artery ilecolic artery superior mesenteric artery

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34 Colon Cancer Complete Mesocolic Excision (CME) Excess of lymph node harvest patients number of lymphnodes / pos. conventional central segment 1 10 / 0 5 / / 0 6 / / 2 3 / / 0 2 / / 1 2 / / 1 2 / / 0 2 / / 1 7 / / 0 6 / / 0 9 / / 0 6 / 1 Eiholm a. Ovesen 2010

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36 Resection of the greater omentum for transverse colon cancer

37 Small arteries from middle colic a. to transverse pancreatic a. inside the pancreas

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39 Transverse Colon Cancer Gastroepiploic Lymph Node Metastases 105 cases ( ) Mean of total LN (range) 41.5 (14-107) No. without gastroepiploic LN 21 (20.0 %) Mean of gastroepiploic LN (range) 3.8 (0-15) No. with gastroepiploic metastases (% of all) 3 (2.9 %) (% of all 38 pn+ patients) (8 %) No. with gastroepiploic tumour satellite 1 (1.0 %) A. Bartelsen Colorectal Dis. 2014

40 Transverse Colon Cancer Lymph Node Involvement Transverse colon Stage III gastroepiploic infrapancr. right p. and hepatic flexure (n=16) n= 6 n=1 - middle part (n=26) n=11 n=2 n=5 left p. and splenic flexure (n= 4) n= Chirurg. Univ.-Klinik Erlangen ; n=45 (Int J Colorectal Dis 2015)

41 Cancer of the Ascending Colon Optimized Lymph-Node Dissection

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45 Surgery for Colon Cancer Complete Mesocolic Excicion (CME) Postoperative Complications postop. morbidity 133/633 (21.0 %) anastomotic leak 11/610 (1.8 %) reoperations 25/633 (3.9) in hospital mortality 21/633 (3.3 %) Chirurg, Univ.-Klinik Erlangen, emergencies included

46 Surgery for Colon Cancer Complete Mesocolic Excicion (CME) Cancer related Survival Stage I 100 % II 91.3 % ( ) III 79.5 % ( ) Chirurg, Univ.-Klinik Erlangen, , R0

47 Transverse Colon Cancer Invasion of Duodenum a. Pancreas Acute Obstruction

48 Colon Cancer Emergencies at First Presentation elective cases 89.9 % emergencies (n=211) - obstruction 72.5% - perforation 27.5% - threatining bleeding extremely rare

49 Perforated Colon Cancer Postoperative Complications perforated no (n=1.206) yes (n=52/4.3 %) postop. morbidity 21.6 % 56 % reoperations 3.7 % 8 % anastomotic leak 40/1193 1/35) (3.3 %) (3 %)

50 Colon Cancer Emergencies Results from Erlangen Postop. Complications (n=79) morbidity 50.6 % sepsis 4 % leak 4 % (2/47) abscess 1 % bleeding 3 % mortality 13 %

51 Colon Cancer Emergencies Results from Erlangen Survival * (n=79) observed 47 % disease-free 51 % cancer related 77 % * postop. mortality excluded

52 Perforated Colon Cancer Overall Survival Surg. Department Univ.-Hospital Erlangen

53 Perforated Colon Cancer Observed Survival (Cox regression analysis) Stage I (n=274) 1.0 II (n=374) 1.2 III (n=295) 1.5 IV (n=269) 2.6 Sigmoid (n=540) 1.0 Residual colon (n=1.168) 1.4 <0.001 Perforation (n=44) 2.0 <0.001

54 Colon Cancer Local Recurrence

55 Colon Cancer Locoregional Recurrence Locoregional recurrence from colon cancer is a significant clinical problem Annika Sjövall et al, Annals Surg. Oncol. 14(2) 2006

56 Colon Cancer Locoregional Recurrence Literature Recurrence Moertel 1991 (Stage III) 20 % Read % Sjövall % Renehan % Elferink % Hatano 2013 (Stage II) 1.5 % Krarup %

57 Colon Cancer Locoregional Recurrence Reasons Lymph node (micro)metastases left behind Small distance tumour to transsection of mesocolon Multivisceral resection omitted

58 Colon Cancer R1,2 Resections Locally pt3c,d; any N; M0 R 1 1/344 (0.3 %) R2 0 Rx 0 all 1/344 (0.3 %) Chirurgische Universitätsklinik Erlangen;

59 Colon Cancer R1,2 Resections Locally M0 R 1 4/1375 (0.3 %) R2 2/1375 (0.15 %) Rx 5/1375 (0.4 %) all 11/1375 (0.85 %) Chirurgische Universitätsklinik Erlangen;

60 Colon Cancer Locoregional Recurrence Recurrence (5 years) UICC Stage I 0,9 % II 2,7 % III 9,6 % IV 2,8 % Chir. Univ. Klinik Erlangen , n = 474, R0

61 Is the benefit of adjuvant chemotherapy in colon cancer presently overestimated? L. Pahlman, W. Hohenberger, K. Matzel K. Sugihara, P. Quirke, B. Glimelius

62 CME for Colon Cancer Surgery Work in Progress Anatomical studies - unification of nomenclature - venous variations - teaching plane principle Implementation of CME - open and laporoscopically Randomized trial adjuvant chemoth. - based on true CME

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