Standardized Surgery for Colonic Cancer - Complete Mesocolic Excision (CMF)

Kein Folientitel

Friedrich-Alexander-UniversittErlangen-Nrnberg

Standardized Surgery forColonic Cancer Complete Mesocolic Excision (CME)

Chirurgische Universittsklinik Erlangen Werner Hohenberger

Universittsklinikum Erlangen

Standardised Surgery for Colonic Cancer: Complete mesocolic excision (CME) and central ligation Technical notes and outcome

Colorectal Dis 2009, 11: 354-365 Hohenberger W. ,Matzel K.E. , Merkel S. , Papadopoulos T. , Weber K.


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Web of Science: 239 referencesGoogle Scholar: 573 referencesColorectal Disease: most frequently referenced paper 2011/2012

Colorectal Dis 2009, 11: 354-365Standardization of Colon Cancer

July 2016


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Editioral

Colonic surgery for cancer: a new paradigmWhile these advances were being made in rectal cancer (Bill Heald, Phil Quirke)Surgery for colonic cancer has been left untouched.

Najib Haboubi, Colorectal Disease 2003, 11; 333-334, 2009


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Colon and Rectal CancerOverall SurvivalGermany 2000-2002

Konvent der leitenden Krankenhauschirurgie,Colon Cancer n = 18291 Rectal Cancer n = 10329median follow up 40 months

Universittsklinikum ErlangenProctology has long been considered a part of general surgery in Britain and Ireland, however there is a long tradition of proctology as a separate discipline in continental Europe and in North America. Proctologists dealt with anal fistulae, perianal sepsis, haemorrhoids, fissure and perianal skin conditions.all conditions that tend to evoke a similar reaction among true visceral surgeonsSeite N

Survival of cancer patients in Europe, 19952002 The EUROCARE 4 study

Colon Cancer

relative 5 years survival 38.7 % - 59.1 %

Eur. J Cancer 2009, 931-91


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Colorectal Cancer Resections Tayside1997-2007 (n= 1992)

Significant Hazard ratiosT4 vs T1 2.05 (p =0.041)N1 vs N0 2.47 (p=0.000)N2 vs N0 5.19 (p=0.000)Rectum vs R colon 0.57 (p=0.001)L colon vs R colon 0.68 (p=0.019)Screening 0.48 (p=0.003)

courtesy Prof. R J C Steele / Dundee


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Colon Cancer Lomgterm Oncologic OutcomeChallenging Cases

Stage IIIT 4 tumorsEmergencies

Universittsklinikum ErlangenColon Cancer SurgeryOutcome DifferencesDisease-free Survival (5 years)

Stage III/pN1

Ren J-Q et al. 35.2 % Chin J Cancer 2012 Shimada Y. et al. 90.4 %

Europ J Cancer 2014


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Colon CancerSurvival Stage III5-years survival

Middle Franconia (n=1513) 54 %

German Study Group (n=9329) 59 % right c. 58 % left c.

Erlangen 79,5 % (1995 2005, n=204)

Japan (n=2808) 81,9 %

USA (high volume centers) 44,0 %


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Colon Cancer SurgeryPlanes and Package


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Cancer of the Ascending ColonOptimized Lymph-Node Dissection


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Surgery for Colon CancerComplete Mesocolic Excicion (CME)What the term includesPreservation of the mesocolic plane by sharp dissection off the parietal plane (turning embryology back)

Regional and central lymphnode dissection with central tie of supplying arteries


Visceral plane (mesentery)kidneyaortaspleenliverstomach

Somatic (parietal)plane


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lymphatic vesselserosal liningserosal liningMesenteryMicroscopic anatomyarteryveinColon anatomy: embryology, lymphatic drainage, mesocolonlymphe node

Similarity to mesorectum...

Universittsklinikum Erlangen19

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CourtesyProf. Solveig Anderson/Oslo


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Universittsklinikum ErlangenMRC CLASICC trial

Courtesy of Phil Quirke


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Lymph nodedissection


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right branch of middle colic artery dissected, ready to clampright colic arteryilecolic arterysuperior mesenteric arteryColon CancerCentral Tie



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060303Hohenberger


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Colon CancerComplete Mesocolic Excision (CME) number of lymphnodes / pos.conventionalcentral segment Eiholm a. Ovesen 2010

Excess of lymph node harvest

110 / 05 / 0 26 / 06 / 0 328 / 23 / 2 412 / 02 / 0 510 / 12 / 0 620 / 12 / 0 711 / 02 / 0 812 / 17 / 0 914 / 06 / 01025 / 09 / 0 11 7 / 0 6 / 1

patients


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Colon Cancer SurgeryPostoperative complicationsBenchmark Report German Cancer Society 2014

Reoperations 0 - 25.9 % 9.4 %Anastomotic leaks 0 - 21.7 % 4.4 %Mortality 0 - 10.5 % 2.7 %

12.457 cases

Variation Median


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Surgery for Colon CancerComplete Mesocolic Excicion (CME)Postoperative Complicationspostop. morbidity 133/633 (21.0 %)anastomotic leak 11/610 (1.8 %) reoperations 25/633 (3.9)in hospital mortality 21/633 (3.3 %)

Chirurg, Univ.-Klinik Erlangen, 2005-2011emergencies included

Universittsklinikum ErlangenColon CancerLocoregional RecurrenceLiteratureRecurrence Moertel 1991 (Stage III) 20 % Read 2002 4 % Sjvall 2006 11.5 % Renehan 2002 15.5 % Elferink 2012 6.4 % Hatano 2013 (Stage II) 1.5 % Krarup 2014 13.3 %

Universittsklinikum ErlangenProctology has long been considered a part of general surgery in Britain and Ireland, however there is a long tradition of proctology as a separate discipline in continental Europe and in North America. Proctologists dealt with anal fistulae, perianal sepsis, haemorrhoids, fissure and perianal skin conditions.all conditions that tend to evoke a similar reaction among true visceral surgeonsSeite N

Colon CancerLocal recurrence by Periods

1978 - 1984 6.7 %1985 - 1994 5.0 %1995 2002 3.3 %2003 2009 2.1 %Surg. Department Univ. Erlangen


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Surgery for Colon CancerComplete Mesocolic Excicion (CME)Cancer related SurvivalStage I 100 % II 91.3 % (88.5 93.9) III 79.5 % (73.8-85.2

Chirurg, Univ.-Klinik Erlangen, 1995-2005, R0

Universittsklinikum ErlangenColon Cancer Stge IIICancer-related Survival (5 years)

Period

1978 1884 61.7 % 1985 1994 69.7 % 1995 2002 75.4 % 2003 2009 80.9 %

Surgical Department Univ. Erlangen


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Colon Cancer SurgeryQuality of Specimens

N. West et al, JCO 2012


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The surgeon an importantprognostic factor


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Colorectal Cancer Outcome Differences

SurgeonVolumelowerSphincterLRSurvivalthird < 6cmpres.

A18030,0%86,1%12,385,2

B13228,6%79,5% 7,186,9

C 4310,9%69,0%20,977,2

D 6211,4%78,0% 9,985,7

all others12119,1%78,1% 8,781,4

Chir. Univ. - Klinik ErlangenR0, Stage I-III, solitary cancer


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Colon CancerCancer related SurvivalSurg. Department Univ. Hosp. Erlangenpostop. mortality excluded, 1995-2005, stage I-IIIoooooo

Universittsklinikum ErlangenThat is NOT new. I was doing that for so much time

We know that surgical selfishness is probably the biggest thing in this universe, so there were many opposers with the argument that we already do that for so many years and he has the nerve to call it new???55Seite N

Standardized Surgery for Colonic Cancer - Complete Mesocolic Excision (CMF)

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