Hemikolektomie rechts OFFEN was sonst?

Hemikolektomie rechts OFFEN was sonst? Hermann Kessler, M.D. Ph.D., FACS Department of Colorectal Surgery Digestive Disease Institute Cleveland Clinic, Cleveland, Ohio

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:e111-123

Ann Surg 1909; 50: 1077-90

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

Bill Heald & Phil Quirke

The Circumferential Resection Margin Quirke et al 1986

The rectal cancer story

V. Schmieden 1940

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

R. Turnbull 1967

R.Turnbull 1967

Surgery of Right Sided Colon Cancer in 2010

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

SGCRC Colon Carcinoma Locoregional Recurrences All patients 4-24% Stage I 0-9% Stage II 1-18% Stage III 9-38%

Colon Carcinoma 5-Year Survival Rates SGCRC* All Departments ERCRC all best surgeon UICC-Stage I 96.6% 92.8-100% 95.5% 100% UICC-Stage II 89.5% 85.4-93.8% 90.4% 96.7% UICC-Stage III 61.6% 54.4-69.7% 72.2% 80.4% R0, all stages 80.9% 77.3 84.6% 86.6% 93.6% * tumor related tumor related, no adjuvant therapy

Colon Carcinoma Observed Survival Rates All patients UICC stage III Middle Franconia 50,0 % 52,0 % 1998-2007 German Study Group 52,7 % Colorectal Cancer Dept. of Surgery, Univ. of Erlangen 58,7 % 84,9 % 1995-2002 SEERS pt1 N1 73,0 % 1992-2004 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

Colon Cancer Cancer related 5-Year Survival Related to Periods 2000-2004: 90,2% 1995-1999: 87,2% 1990-1994: 84,6% 1985-1989: 83,6% 1978-1984: 82,1% Stages I-III, R0, Erlangen Registry 1978-2004

Colon Cancer Cancer related 5-Years Survival Related to Periods Stage III, R0, Erlanger Register 1978-2004 2000-2004: 81,8% 1995-1999: 73,7% 1990-1994: 74,0% 1985-1989: 69,0% 1978-1984: 62,0 %

Colon Cancer Paracolic Lymph Node Involvement

060303Hohenberger

Lymph node involvement < pt category Hida J et al, Cancer 1997 80(2),188-192

Data from Tokyo

Courtesy Prof. Solveig Anderson/Oslo

Colorectal Cancer Specimen Retrieval Grading of Quality Rectal planes Colonic planes Muscularis propria Intramesorectal Mesorectal Muscularis propria Intramesocolic Mesocolic Phil Quirke, Nich. West / Leeds

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

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

Survival probability Colon Cancer Complete Mesocolic Excision (CME) Quality of Specimen Retrieval Survival stage III cases (n=161) 1 0.8 p=0.006 0.6 0.4 0.2 Multivariate HR = 0.45 (0.24-0.85), p=0.014 0 0 1 2 3 4 5 Years Muscularis propria plane Intramesocolic plane Mesocolic plane

Universitätsklinikum Erlangen

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

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

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 ) 118 251 15,533 107 289 15,057 11 48 476 0.008 0.001 0.321 Mesocolic plane rate (%) 94 100 6 0.179 Lymph node yield 32 20 12 <0.0001 Left-sided tumours Tumour to HVT (mm) Length of large bowel (mm) Area of mesentery (mm 2 ) 126 382 18,551 122 366 16,692 4 16 1,859 0.384 0.299 0.195 Mesocolic plane rate (%) 82 81 1 0.899 Lymph node yield 25 15 10 <0.0001

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 ) 100 168 7,620 121 131 7,964 21 37 344 0.019 0.223 0.700 Mesocolic plane rate (%) 76 82 6 0.681 Lymph node yield 24 24 0 0.797 Left-sided tumours Tumour to HVT (mm) Length of large bowel (mm) Area of mesentery (mm 2 ) 122 154 8,413 136 106 6,700 14 48 1,713 0.013 <0.0001 0.016 Mesocolic plane rate (%) 73 85 12 0.257 Lymph node yield 16 19 3 0.471

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 ) 106 353 15,567 103 303 14,459 3 50 1,108 0.724 0.655 0.689 Mesocolic plane rate (%) 69 71 2 0.922 Lymph node yield 29 29 0 0.505 Left-sided tumours Tumour to HVT (mm) Length of large bowel (mm) Area of mesentery (mm 2 ) 83 461 13,548 117 264 12,508 37 197 1,040 0.031 0.034 0.172 Mesocolic plane rate (%) 70 88 18 0.418 Lymph node yield 32 25 7 0.076

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