Retrospective Cohort Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Mar 15, 2019; 11(3): 208-226
Published online Mar 15, 2019. doi: 10.4251/wjgo.v11.i3.208
Post-operative computed tomography scan – reliable tool for quality assessment of complete mesocolic excision
Cristian Livadaru, Stefan Morarasu, Tudor Cristian Frunza, Florina A Ghitun, Elena Florina Paiu-Spiridon, Florina Sava, Cristina Terinte, Dan Ferariu, Sorinel Lunca, Gabriel Mihail Dimofte
Cristian Livadaru, Florina A Ghitun, ”Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
Stefan Morarasu, Tudor Cristian Frunza, Sorinel Lunca, Gabriel Mihail Dimofte, 2nd Clinic of Surgical Oncology, Regional Oncology Institute, “Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
Elena Florina Paiu-Spiridon, Florina Sava, Department of Radiology, Regional Oncology Institute, “Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
Cristina Terinte, Dan Ferariu, Department of Pathology, Regional Oncology Institute, “Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
Author contributions: Dimofte GM and Livadaru C conceived the original idea, elaborated the study design and generated the manuscript up to its final form; Livadaru C, Ghitun FA, Morarasu S, Frunza TC, Paiu-Spiridon EF, Sava F, Terinte C, Ferariu D and Lunca S, each provided significant input in documentation, bibliography research, acquisition of data and statistical analysis; Livadaru C, Paiu-Spiridon EF and Sava F performed the radiological measurements and data interpretation; Dimofte GM, Morarasu S, Frunza TC and Lunca S performed the surgeries; Terinte C and Ferariu F performed the pathological examination; Livadaru C and Ghitun FA wrote the initial manuscript, with Morarasu S, Frunza TC, Paiu-Spiridon EF, Sava F, Terinte C, Ferariu D, Lunca S and Dimofte GM providing essential intellectual content and thorough comments; Livadaru C, Morarasu S, Frunza TC, Ghitun FA, Paiu-Spiridon EF, Sava F, Terinte C, Ferariu D, Lunca S and Dimofte GM provided the final critical review and approval of the manuscript.
Institutional review board statement: The Regional Oncology Institute’s Institutional Review Board approved this study (No. 16321/20.08.2018).
STROBE statement: The authors have read the STROBE Statement – checklist of items, and the manuscript was prepared and revised according to the STROBE Statement – checklist of items.
Conflict-of-interest statement: The authors declare no conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Stefan Morarasu, MD, Surgeon, 2nd Clinic of Surgical Oncology, Regional Oncology Institute, “Grigore T Popa” University of Medicine and Pharmacy, 2-4 General Henri Mathias Berthelot St., Iasi 700115, Romania. stefan.morarasu@hse.ie
Telephone: +35-385-8760635
Received: October 2, 2018
Peer-review started: October 2, 2018
First decision: November 15, 2018
Revised: December 6, 2018
Accepted: January 9, 2019
Article in press: January 10, 2019
Published online: March 15, 2019
Abstract
BACKGROUND

Quality control in colon cancer surgery is an ongoing debate ever since standardization proved to be highly efficient in improving survival in rectal cancer. Complete mesocolic excision (CME) is widely acclaimed as the new gold-standard in colon cancer resections, thus it is imperative to establish quality criteria of CME in order to make it easily understood and verified by surgeons worldwide. One simple and reproducible tool could be the measurement of arterial stumps postoperatively and a straightforward way to test its reliability is to test it in a comparative study between CME and non-CME surgery.

AIM

To validate arterial stump measurement as a surgical quality tool by comparing CME with conventional radical colectomies.

METHODS

This was a retrospective study, carried out on a prospective database. We collected data from two groups of patients, divided according to standard CME with D2 central vascular ligation (group A) and non-standardized surgery (group B). The two groups were compared with regard to the arterial stump length after right- and left-sided colectomies for colon cancer. The actual stump lengths of the ileocolic artery (ICA) and inferior mesenteric artery (IMA) were compared with their theoretical best D2 position of predicted ligation levels (D2PLLs) for calculating the potential for improvement. Measurements on follow-up computed tomography scans were carried out by three observers. Pathological data were recorded (specimen length, lymph node yield) and correlated with stump length.

RESULTS

We analysed 58 colectomies. The stump lengths (mean ± SD) in group A were 16.97 ± 4.77 mm for ICA and 31.70 ± 15.71 mm for IMA, whereas group B had 49.93 ± 20.29 mm for ICA and 67.24 ± 28.71 mm for IMA. Shorter lengths were obtained in group A, by a mean difference of 35.66 mm (χ2 = 27.38, P < 0.001), which was significant for all types of colectomies. Except for a 5.85 ± 4.71 mm difference for right colectomies, all the ligations from group A significantly reached their potential height (0.26 ± 12.18 mm from D2PLL; χ2 = 0.005, P = 0.944). Apart from three left colectomies, group B failed to reach D2PLL, by a mean difference of 32.14 ± 26.15 mm (χ2 = 21.77, P < 0.001). The calculated improvement potentials were significantly shorter in group A than in group B, by a mean of 31.88 mm (χ2= 22.13, P < 0.001). The large spread of results in group B showed that there is significant variability (P = 0.004) when compared to standard surgery. Significant correlations were found between stump length, specimen length and number of lymph nodes (P = 0.018 and P = 0.008 respectively). No statistical difference was found between observers’ measurements (P = 0.866).

CONCLUSION

Arterial stump monitoring is a significant step in defining surgical quality, as longer stumps contain residual mesocolic tissue and correlate with major prognostic factors.

Keywords: Complete mesocolic excision, Central vascular ligation, Colon surgery, Arterial stump measurement, Computed tomography

Core tip: This is the first study to assess arterial stump measurement as a tool for comparative analysis between complete mesocolic excision and non-standardized colonic surgery. We demonstrated its benefit as a tool for evaluating surgical quality, mainly due to its correlation with a major prognostic factor. It is a simple and reproducible measurement on routine computed tomography scans without metallic markers. We showed that the central vascular ligation can be performed without extensive D3 lymphatic dissection.