Hemikolektomie rechts OFFEN was sonst?
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1 Hemikolektomie rechts OFFEN was sonst? Hermann Kessler, M.D. Ph.D., FACS Department of Colorectal Surgery Digestive Disease Institute Cleveland Clinic, Cleveland, Ohio
2 Rectal Cancer Moynihan 1908: We have not yet sufficiently realized that the surgery of malignant disease is not the surgery of organs; it is the anatomy of the lymphatic system Suggestion of high tie Cirocchi R et al, Surg Oncol 2012;21:e
3 Ann Surg 1909; 50:
4 1982, Data from England Local recurrence of rectal cancer Common in 20-35% Cause unknown but obsession with distal margin and distal spread 90% mortality Long unpleasant death
5 Bill Heald & Phil Quirke
6 The Circumferential Resection Margin Quirke et al 1986
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8 The rectal cancer story
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10 V. Schmieden 1940
11 Colon Cancer Survival No touch vs. Conventional Turnbull Conventional all patients* 81,6% Dukes C* 67,3% observed all patients 68,85% 52,13% Dukes C* 57,84% 28,06% * age adjusted Rupert B.Turnbull 1967 and 1970
12 R. Turnbull 1967
13 R.Turnbull 1967
14 Surgery of Right Sided Colon Cancer in 2010
15 Colon Cancer Central Tie right branch of middle colic artery dissected, ready to clamp right colic artery ilecolic artery superior mesenteric artery
16 SGCRC Colon Carcinoma Locoregional Recurrences All patients 4-24% Stage I 0-9% Stage II 1-18% Stage III 9-38%
17 Colon Carcinoma 5-Year Survival Rates SGCRC* All Departments ERCRC all best surgeon UICC-Stage I 96.6% % 95.5% 100% UICC-Stage II 89.5% % 90.4% 96.7% UICC-Stage III 61.6% % 72.2% 80.4% R0, all stages 80.9% % 86.6% 93.6% * tumor related tumor related, no adjuvant therapy
18 Colon Carcinoma Observed Survival Rates All patients UICC stage III Middle Franconia 50,0 % 52,0 % German Study Group 52,7 % Colorectal Cancer Dept. of Surgery, Univ. of Erlangen 58,7 % 84,9 % SEERS pt1 N1 73,0 % pt3 N1 54,9 % pt3 N2 38,1 % USA very high volume * 49,6 % 44,0 % Sugihara/Tokyo 77,2 % Kube et al 2009 * Schrag et al 2010
19 Colon Cancer Cancer related 5-Year Survival Related to Periods : 90,2% : 87,2% : 84,6% : 83,6% : 82,1% Stages I-III, R0, Erlangen Registry
20 Colon Cancer Cancer related 5-Years Survival Related to Periods Stage III, R0, Erlanger Register : 81,8% : 73,7% : 74,0% : 69,0% : 62,0 %
21 Colon Cancer Paracolic Lymph Node Involvement
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24 060303Hohenberger
25 Lymph node involvement < pt category Hida J et al, Cancer (2),
26 Data from Tokyo
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28 Courtesy Prof. Solveig Anderson/Oslo
29 Colorectal Cancer Specimen Retrieval Grading of Quality Rectal planes Colonic planes Muscularis propria Intramesorectal Mesorectal Muscularis propria Intramesocolic Mesocolic Phil Quirke, Nich. West / Leeds
30 Colorectal Cancer Specimen Retrieval Grading of Quality Rectal planes Colonic planes Muscularis propria Intramesorectal Mesorectal Muscularis propria Intramesocolic Mesocolic Mesocolic plus high ties defined by measurement Phil Quirke, Nich. West / Leeds
31 Surgery for Colon Cancer Complete Mesocolic Excicion (CME) Preservation of the mesocolic plane by sharp dissection off the parietal plane (turning embryology back) Regional and central lymph node dissection with high tie of suppling vessels
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37 Colonic cancer planes of surgery Muscularis propria Intramesocolic Mesocolic plane plane plane Major defects in mesocolon Into mesocolon but not Smooth serosal/mesocolic and down onto down onto the mesentery only very muscularis propria muscularis propria minor defects Muscularis propria plane Intramesorectal plane Mesorectal plane
38 Survival probability Colon Cancer Complete Mesocolic Excision (CME) Quality of Specimen Retrieval Survival stage III cases (n=161) p= Multivariate HR = 0.45 ( ), p= Years Muscularis propria plane Intramesocolic plane Mesocolic plane
39 Universitätsklinikum Erlangen
40 Universitätsklinikum Erlangen
41 Universitätsklinikum Erlangen
42 Universitätsklinikum Erlangen
43 Universitätsklinikum Erlangen
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45 Plane of colon cancer resections Leeds and Clasicc Plane LGI Clasicc Mesocolic and high tie 0 (0%) 0 (0)% Mesocolic 127 (32%) 41 (25%) Intramesocolic 177 (44%) 86 (53%) Muscularis propria 95 (24%) 35 (22%) Total 399 (100%) 162 (100%) Overall interobserver agreement LGI seriers 85 5%. Phil Quirke and Nick West / Leeds
46 Expert Laparoscopic surgery 69 consecutive laparoscopic CME with CVL cases 3 converted to open surgery 58 invasive cancers Undertook: Tissue morphometry Plane of surgery Lymph node yields Data compared to open gold standard
47 Open vs. laparoscopic Erlangen St. Marks Difference P value Right-sided tumours Tumour to HVT (mm) Length of large bowel (mm) Area of mesentery (mm 2 ) , , Mesocolic plane rate (%) Lymph node yield < Left-sided tumours Tumour to HVT (mm) Length of large bowel (mm) Area of mesentery (mm 2 ) , , , Mesocolic plane rate (%) Lymph node yield <0.0001
48 Japan (open vs. laparoscopic) Open Lap Difference P value Right-sided tumours Tumour to HVT (mm) Length of large bowel (mm) Area of mesentery (mm 2 ) , , Mesocolic plane rate (%) Lymph node yield Left-sided tumours Tumour to HVT (mm) Length of large bowel (mm) Area of mesentery (mm 2 ) , , , < Mesocolic plane rate (%) Lymph node yield
49 Hillerød (open vs. laparoscopic) Open Lap Difference P value Right-sided tumours Tumour to HVT (mm) Length of large bowel (mm) Area of mesentery (mm 2 ) , , , Mesocolic plane rate (%) Lymph node yield Left-sided tumours Tumour to HVT (mm) Length of large bowel (mm) Area of mesentery (mm 2 ) , , , Mesocolic plane rate (%) Lymph node yield
50 Zusammenfassung Variationsbreite der offenen Chirurgie Evidenz der Bedeutung der Dissektionsebene Muscularis propria Intramesokolisch Mesokolon erhalten Komplette Mesokolonexzision als Package Keine Evidenz, daß Laparoskopie unterlegen Qualitätskontrolle durch Pathologie essentiell
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