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Extent of surgery in cancer of the colon: is more better?

Wouter Willaert (UGent) and Wim Ceelen (UGent)
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Abstract
Since the introduction of total mesorectal excision as the standard approach in mid and low rectal cancer, the incidence of local recurrence has sharply declined. Similar attention to surgical technique in colon cancer (CC) has resulted in the concept of complete mesocolic excision (CME), which consists of complete removal of the intact mesentery and high ligation of the vascular supply at its origin. Although renewed attention to meticulous surgical technique certainly has its merits, routine implementation of CME is currently unfounded. Firstly, in contrast to rectal cancer, local recurrence originating from an incompletely removed mesentery is rare in CC and usually a manifestation of systemic disease. Secondly, although CME may increase nodal counts and therefore staging accuracy, this is unlikely to affect survival since the observed relationship between nodal counts and outcome in CC is most probably not causal but confounded by a range of clinical variables. Thirdly, several lines of evidence suggest that metastasis to locoregional nodes occurs early and is a stochastic rather than a stepwise phenomenon in CC, in essence reflecting the tumor-host-metastasis relationship. Unsurprisingly, therefore, comparative studies in CC as well as in other digestive cancers have failed to demonstrate any survival benefit associated with extensive, additional or extra-mesenteric lymphadenectomy. Finally, routine implementation of CME may cause patient harm by longer operating times, major vascular damage and autonomic nerve injury. Therefore, data from randomized trials reporting relevant endpoints are required before CME can be recommended as a standard approach in CC surgery.
Keywords
Adenocarcinoma, Colon, Surgery, Cancer, Mesocolic excision, Lymph node count, COMPLETE MESOCOLIC EXCISION, CENTRAL VASCULAR LIGATION, INFERIOR MESENTERIC-ARTERY, TOTAL MESORECTAL EXCISION, LYMPH-NODE METASTASIS, COLORECTAL-CANCER, CURATIVE RESECTION, TUMOR-CELLS, LOCAL RECURRENCE, STAGE-III

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Citation

Please use this url to cite or link to this publication:

MLA
Willaert, Wouter, and Wim Ceelen. “Extent of Surgery in Cancer of the Colon: Is More Better?” WORLD JOURNAL OF GASTROENTEROLOGY 21.1 (2015): 132–138. Print.
APA
Willaert, W., & Ceelen, W. (2015). Extent of surgery in cancer of the colon: is more better? WORLD JOURNAL OF GASTROENTEROLOGY, 21(1), 132–138.
Chicago author-date
Willaert, Wouter, and Wim Ceelen. 2015. “Extent of Surgery in Cancer of the Colon: Is More Better?” World Journal of Gastroenterology 21 (1): 132–138.
Chicago author-date (all authors)
Willaert, Wouter, and Wim Ceelen. 2015. “Extent of Surgery in Cancer of the Colon: Is More Better?” World Journal of Gastroenterology 21 (1): 132–138.
Vancouver
1.
Willaert W, Ceelen W. Extent of surgery in cancer of the colon: is more better? WORLD JOURNAL OF GASTROENTEROLOGY. 2015;21(1):132–8.
IEEE
[1]
W. Willaert and W. Ceelen, “Extent of surgery in cancer of the colon: is more better?,” WORLD JOURNAL OF GASTROENTEROLOGY, vol. 21, no. 1, pp. 132–138, 2015.
@article{5958283,
  abstract     = {Since the introduction of total mesorectal excision as the standard approach in mid and low rectal cancer, the incidence of local recurrence has sharply declined. Similar attention to surgical technique in colon cancer (CC) has resulted in the concept of complete mesocolic excision (CME), which consists of complete removal of the intact mesentery and high ligation of the vascular supply at its origin. Although renewed attention to meticulous surgical technique certainly has its merits, routine implementation of CME is currently unfounded. Firstly, in contrast to rectal cancer, local recurrence originating from an incompletely removed mesentery is rare in CC and usually a manifestation of systemic disease. Secondly, although CME may increase nodal counts and therefore staging accuracy, this is unlikely to affect survival since the observed relationship between nodal counts and outcome in CC is most probably not causal but confounded by a range of clinical variables. Thirdly, several lines of evidence suggest that metastasis to locoregional nodes occurs early and is a stochastic rather than a stepwise phenomenon in CC, in essence reflecting the tumor-host-metastasis relationship. Unsurprisingly, therefore, comparative studies in CC as well as in other digestive cancers have failed to demonstrate any survival benefit associated with extensive, additional or extra-mesenteric lymphadenectomy. Finally, routine implementation of CME may cause patient harm by longer operating times, major vascular damage and autonomic nerve injury. Therefore, data from randomized trials reporting relevant endpoints are required before CME can be recommended as a standard approach in CC surgery.},
  author       = {Willaert, Wouter and Ceelen, Wim},
  issn         = {1007-9327},
  journal      = {WORLD JOURNAL OF GASTROENTEROLOGY},
  keywords     = {Adenocarcinoma,Colon,Surgery,Cancer,Mesocolic excision,Lymph node count,COMPLETE MESOCOLIC EXCISION,CENTRAL VASCULAR LIGATION,INFERIOR MESENTERIC-ARTERY,TOTAL MESORECTAL EXCISION,LYMPH-NODE METASTASIS,COLORECTAL-CANCER,CURATIVE RESECTION,TUMOR-CELLS,LOCAL RECURRENCE,STAGE-III},
  language     = {eng},
  number       = {1},
  pages        = {132--138},
  title        = {Extent of surgery in cancer of the colon: is more better?},
  url          = {http://dx.doi.org/10.3748/wjg.v21.i1.132},
  volume       = {21},
  year         = {2015},
}

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