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“

Rupert B.Turnbull 1967 and 1970

* age adjusted

all patients* 81,6% Dukes C* 67,3%

observed all patients 68,85% 52,13% Dukes C* 57,84% 28,06%

Turnbull Conventional

R. Turnbull 1967

R.Turnbull 1967

Surgery of Right Sided Colon Cancer in 2010

right branch of middle colic artery

dissected, ready to clamp

right colic artery

ilecolic artery

superior mesenteric artery

Colon Cancer

„Central Tie“

Colon Carcinoma Locoregional Recurrences

All patients 4- 24%

Stage I 0 - 9%

Stage II 1- 18%

Stage III 9- 38%

SGCRC

Colon Carcinoma 5-Year Survival Rates

* tumor related

tumor related, no adjuvant therapy

All Departments

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%

all „best surgeon“

SGCRC* ERCRC°

Colon Carcinoma Observed Survival Rates

° Kube et al 2009

* Schrag et al 2010

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 %

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-Year 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

Cancer related 5-Years Survival

Related to Periods

Colon Cancer Paracolic Lymph Node Involvement

06

03

03

Ho

he

nb

erg

er

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

Colonic planes

Muscularis propria

Intramesocolic

Mesocolic

Rectal planes

Muscularis propria

Intramesorectal

Mesorectal

Phil Quirke, Nich. West / Leeds

Colorectal Cancer

Specimen Retrieval

Grading of Quality

Colonic planes

Muscularis propria

Intramesocolic

Mesocolic

‘Mesocolic plus high ties’ –

defined by measurement

Rectal planes

Muscularis propria

Intramesorectal

Mesorectal

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

Colon Cancer Complete Mesocolic Excision (CME)

Quality of Specimen Retrieval

Survival stage III cases (n=161)

0

0.2

0.4

0.6

0.8

1

0 1 2 3 4 5

Su

rviv

al

pro

ba

bil

ity

Years

Muscularis propria plane Intramesocolic plane Mesocolic plane

p=0.006

Multivariate HR = 0.45 (0.24-0.85), p=0.014

Universitätsklinikum Erlangen

Universitätsklinikum Erlangen

Universitätsklinikum Erlangen

Universitätsklinikum Erlangen

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 (mm2)

Mesocolic plane rate (%)

Lymph node yield

118

251

15,533

94

32

107

289

15,057

100

20

11

48

476

6

12

0.008

0.001

0.321

0.179

<0.0001

Left-sided

tumours

Tumour to HVT (mm)

Length of large bowel (mm)

Area of mesentery (mm2)

Mesocolic plane rate (%)

Lymph node yield

126

382

18,551

82

25

122

366

16,692

81

15

4

16

1,859

1

10

0.384

0.299

0.195

0.899

<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 (mm2)

Mesocolic plane rate (%)

Lymph node yield

100

168

7,620

76

24

121

131

7,964

82

24

21

37

344

6

0

0.019

0.223

0.700

0.681

0.797

Left-sided

tumours

Tumour to HVT (mm)

Length of large bowel (mm)

Area of mesentery (mm2)

Mesocolic plane rate (%)

Lymph node yield

122

154

8,413

73

16

136

106

6,700

85

19

14

48

1,713

12

3

0.013

<0.0001

0.016

0.257

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 (mm2)

Mesocolic plane rate (%)

Lymph node yield

106

353

15,567

69

29

103

303

14,459

71

29

3

50

1,108

2

0

0.724

0.655

0.689

0.922

0.505

Left-sided

tumours

Tumour to HVT (mm)

Length of large bowel (mm)

Area of mesentery (mm2)

Mesocolic plane rate (%)

Lymph node yield

83

461

13,548

70

32

117

264

12,508

88

25

37

197

1,040

18

7

0.031

0.034

0.172

0.418

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