best techniques for colorectal surgeries for colon cancer and rectal cancer,

best techniques for colorectal surgeries

1. JOURNAL CLUB 24/05/2024 PRESENTER – DR MAYANK MODERATOR – DR ANIL DAHIYA

2. What is the best surgical procedure of transverse colon cancer? An evidence map and minireview Source: World Journal of Gastrointestinal Oncology Chen Li, Quan Wang, Ke-Wei Jiang, Department of Gastrointestinal Surgery, Peking University, People's Hospital, Beijing 100044, China

3. Abstract Colorectal cancers comprise a large percentage of tumors worldwide, and transverse colon cancer (TCC) is defined as tumors located between hepatic and splenic flexures. In this study, the current situation of transverse/extended colectomy, robotic/ laparoscopic/open surgery and complete mesocolic excision (CME)concept in TCC operations is discussed. According to published studies, laparoscopic or robotic transverse colectomy based on the CME concept was the appropriate surgical procedure for TCC patients.

4. Introduction On a global scale, colorectal cancer is the second most common cancer in females and ranks third among males. Transverse colon cancer (TCC) is defined as tumors located between hepatic and splenic flexure, and is relatively rare, accounting for 10% of all colon cancers. From an embryological standpoint, the proximal two-thirds of the transverse colon are derived from the midgut and the distal one-third is derived from the hindgut, and they are supplied by the middle and left colic artery, respectively. From an anatomical point of view, the transverse colon is in close proximity to upper abdominal vital structures, and is not fixed to the retroperitoneal structures. Due to the anatomy and embryology complexity, it is a challenging and daunting mission to mobilize and resect the transverse colon.

5. Symptoms and signs of TCC are not specific. Abdominal discomfort, which is difficult to locate might be the first complaint and is generally found in an advanced stage. According to published studies, the 5-year survival rate was 28%-50%, which is poorer than that of other colorectal tumors as lymph node metastasis will occur in TCC patients at both the superior and inferior mesenteric arterial branches, especially the splenic flexure cancers. Patients were included if: (1) The patients’ tumors strictly followed the definition of TCC (colon cancer located between hepatic and splenic flexure); and (2) Detailed surgical information. And patients were excluded if the study used informal surgical terms, which were hard to be classified.

6. SURGICAL PROCEDURE En-bloc resection of the tumor is the radical therapy of TCC as it is for other colorectal cancers. Because of a low incidence and excluded by RCTs, there is no consensus on the standard transverse colic operation, and the surgical approach for this tumor is frequently based on the surgeon’s preference. The common surgical procedures are extended left or right colectomy and transverse colectomy, by laparoscopy or conventional open resection

7. Extended colectomy Extended right hemicolectomy was applicable for tumors located less than distal 10 cm of the hepatic flexure, and lymph node dissection, and included ligation of the ileocolic, right colic and middle colic arteries. Correspondingly, extended left hemicolectomy was applied for tumors located less than 10 cm of the splenic flexure proximally, for which lymph node dissection included ligation of the left and middle colic arteries. The number of harvested lymph nodes, typically at least 15, is regarded as a crucial indicator of surgical quality and prognosis. Previous studies suggested that extended colectomy, which involves removing more lymph nodes, could lead to better outcomes for patients with advanced transverse colic carcinoma (TCC). However, localizing TCC during surgery is challenging due to its attachment to the omentum and fixed flexures, making intraoperative colonoscopy impractical. As a solution, preoperative tattooing of all four quadrants has been recommended unless the tumor is sufficiently large to be easily located.

8. Transverse colectomy Transverse colectomy has historically been utilized for tumors situated between the hepatic and splenic flexure, with lymph node dissection, including ligation of middle colic arteries. Research indicates that the length of resection does not significantly impact postoperative outcomes, with emphasis placed on appropriate central vessel ligation and ensuring a minimum distance of 5 cm from each margin. Studies suggest that a resection length of less than 20 cm may result in inadequate lymph node retrieval and unnecessary chemotherapy. Laparoscopic transverse colectomy presents surgical difficulties, particularly regarding lymphadenectomy of the middle colon artery. larger cohort studies have shown similar disease-free and overall survival rates between transverse colectomy and extended resection groups.

9. Laparoscopic, robotic, and open resection Laparoscopic colorectal surgery initially found application in benign conditions like inflammatory bowel disease but has progressively expanded to colorectal cancer over the last few decades. It's widely accepted due to its superior short-term outcomes and reduced surgical trauma. In the context of transverse colon cancer (TCC), laparoscopic resection, whether extended or transverse colectomy, is increasingly significant. Retrospective studies suggest that laparoscopic transverse colon resection yields better short-term outcomes and comparable oncological outcomes to open surgery, without significantly higher complication rates or poorer long-term prognoses. Some studies incorrectly suggest that laparoscopic surgery leads to fewer harvested lymph nodes due to inadequate review of colorectal cancer literature.

10. In robotic surgery, left and right colon resections are more common than transverse colectomy. However, robotic surgery has gained acceptance in transverse surgery, showing similar lymph node harvest, clearer surgical vision, lower conversion rates, and better short-term outcomes compared to laparoscopic surgery. Surgeons require longer learning curves for laparoscopic and robotic surgeries compared to open resection. Patient selection is crucial for maximizing safety and oncological outcomes. Robotic surgery generally has a shorter learning curve compared to traditional laparoscopy.

11. Complete mesocolic excision Hohenberger et al. introduced the concept of complete mesocolic excision (CME) in radical colic resection, akin to total mesorectal excision in rectal cancer surgery. CME involves en -bloc resection of the entire enveloped mesocolon, leading to higher lymphadenectomy, fewer local recurrences, and improved long-term oncological and clinical outcomes compared to non-CME resection. Storli and Eide conducted the initial studies comparing open and laparoscopic CME in transverse colon cancer (TCC) patients, finding no significant differences between the two methods. While previous research demonstrated the feasibility of laparoscopic CME for TCC, evidence remained limited. Only three published studies have explored the safety and feasibility of robotic transverse colectomy, with two focusing on non-CME and only one on CME.

12. LIMITATION This study faces several limitations. Firstly, due to the scarcity of data on transverse colon cancer (TCC) patients, including detailed oncological features, surgical quality, and long-term outcomes, it was challenging to reach definitive conclusions. Secondly, transverse colectomy is less commonly performed compared to extended right/left colectomy, which limits the available evidence. Thirdly, while the conclusions provide insight into the current status of TCC patients, they do not offer robust evidence for establishing standard treatment protocols.

13. CONCLUSION Advancements in surgical technology are reshaping the approach to transverse colon cancer (TCC) resection. Transverse colectomy challenges the traditional extended colectomy, demonstrating similar oncological and prognostic outcomes. Laparoscopic and robotic surgery are increasingly pivotal in both transverse and extended colectomy procedures. The concept of complete mesocolic excision (CME) may enhance radical resection of TCC and ensure an adequate number of harvested lymph nodes. Based on current evidence, laparoscopic or robotic transverse colectomy following the CME concept appears appropriate for most TCC patients. However, large-scale, multicenter , prospective randomized controlled trials (RCTs) are essential to standardize surgical approaches for TCC. Additionally, perioperative management, resection range based on tumor stages and transverse colic length, anastomosis methods, and long-term outcomes warrant further investigation and discussion.

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