Transversus abdominis plane blocks are widely used, but the association between the cutaneous sensory block area and the analgesic effect is still debated. We aimed to determine the relationship between the cutaneous sensory block area, the surgical incision's location, and the block's analgesic efficacy.

A sensitivity analysis of data from a multicentre, patient-, clinician-, investigator-blinded, placebo- and active-controlled, 3-arm randomised clinical trial. Patients undergoing minimally invasive colon surgery were included from four hospitals across Denmark between January 2021 and February 2024. In this sensitivity analysis, we used our previously collected data of the cutaneous sensory block area to examine the efficacy of two different approaches to the transversus abdominis plane block, as compared to each other and placebo based on incision location. The primary outcome was total morphine dose equivalents administered in the first 24 h after minimally invasive surgery in patients receiving either a Pfannenstiel or a supraumbilical transverse incision.

We found that the subcostal dual laparoscopic-assisted transversus abdominis plane block was superior to both the ultrasound-guided posterior transversus abdominis plane block and placebo in patients with a Pfannenstiel incision with an absolute difference of - 8.9 mg (95% CI, - 16.5 to - 1.3 mg; p = 0.02) and - 10.3 mg (95% CI, - 17.0 to - 3.6 mg; p < 0.01) morphine dose equivalents, respectively. No difference was found for the supraumbilical transverse incision. Patient-reported outcome measures favoured the laparoscopic-assisted block, with an absolute difference of 13 (95% CI, 1.7-24.3; p = 0.025) in the Quality of Recovery-15 score compared to placebo.

The effect of the transversus abdominis plane block seems to be independent of the distribution of the cutaneous sensory block area of the approach. The laparoscopic-assisted subcostal transversus abdominis plane block reduced postoperative pain with a high QoR-15 score.

The oncologic impact of D3 lymph node dissection (LND) for colon cancer (CC) has been reported to be favorable. However, D3 LND is potentially more invasive than non-D3 LND, and whether it is beneficial for elderly patients with CC remains unclear. This study aimed to evaluate the perioperative safety and short- and long-term oncologic outcomes of D3 LND in elderly patients with CC.

Subjects were 442 elderly patients aged ≥ 70 years who underwent curative surgery for pathologic stage (pStage) I-III CC between 2011 and 2022. Background clinical factors and short- and long-term outcomes were compared between patients who received D3 LND (D3 group; n = 363) and those who received non-D3 LND (non-D3 group; n = 79).

The D3 group had a significantly higher number of retrieved lymph nodes (median 20 vs. 12, p < 0.001) and a lower rate of postoperative complications (18% vs. 32%, p = 0.040) than the non-D3 group. In the overall cohort, overall survival (OS) did not differ between the two groups. Among pStage III patients, however, OS was significantly better (69.8% vs. 34.1%, p = 0.028), and RFS tended to be better (60.7% vs. 42.6%, p = 0.075) in the D3 group than in the non-D3 group. Multivariable analysis revealed that D3 LND was independently associated with better OS (HR 0.477; 95% CI 0.245-0.931, p = 0.030) and tended to be associated with better RFS (HR 0.588; 95% CI 0.329-1.051, p = 0.073).

D3 LND is safe and effective in improving the prognosis of elderly patients with pStage II/III CC.

Right hemicolectomy (RHC) is an important treatment for colorectal cancer. The superior mesenteric artery and superior mesenteric vein are known for their significant vascular variations. This study evaluated the short-term outcomes of integrating Mixed Reality (MR) technology into RHC for the treatment of colorectal cancer. Patients who underwent RHC for clinical stage II or III colon cancer between January 2015 and August 2024 were included. Patients were divided into two groups: the MR (+) group (n = 47), in which MR was used, and the MR (-) group (n = 145), in which MR was not used. MR using SYNAPSE VINCENT, Holoeyes MD, and HoloLens2 was utilized for detailed 3D visualization of the vascular anatomy preoperatively and intraoperatively. Forty-four patients per group were matched via propensity score matching and surgical outcomes were compared. In both groups, approximately 70% of the surgeries were performed by the training surgeon. Compared with the MR (-) group, intraoperative blood loss and hospital stay were decreased, and the number of lymph nodes harvested around the middle colic artery/vein were increased without prolonging the operative time in the MR (+) group. MR in RHC offers surgical precision, safety, enhanced patient recovery, and educational value.

Lymphadenectomy for rectal cancer is clearly defined by total mesorectal excision (TME). The analogous surgical strategy for the colon, the complete mesocolic excision (CME), follows the same principles of dissection in embryologically predefined planes.

This narrative review initially identified key issues related to lymphadenectomy of rectal and colon cancer. The subsequent search was based on PubMed and focused on meta-analyses. The endpoints for rectal cancer were the benefit of high tie versus low tie and the indications for lateral pelvic lymphadenectomy. For colon cancer the evidence for CME, for the longitudinal extent of resection, for the dissection of infrapyloric and gastroepiploic lymph nodes, for the number of lymph nodes and for the sentinel lymph node technique were used as endpoints.

An oncological benefit of the high tie cannot be derived from the current data. Lateral pelvic lymphadenectomy should only be selectively performed after chemoradiotherapy (CRT) in cases of remaining lymph nodes with suspected metastases. In most studies CME proved to be oncologically superior, especially in stage III. The longitudinal extent of resection should be at least 10 cm in both directions if the principles of CME are observed. Infrapyloric and gastroepiploic lymph node involvement is to be expected in 0.7-22% of cases, depending on patient selection, which justifies dissection, particularly in carcinomas of both flexure and the transverse colon. The minimum number of lymph nodes to be removed cannot be clearly derived from the available studies. Precisely performed CME and an optimal pathological work-up are important. The sentinel lymph node technique cannot currently be used as a criterion for limiting the extent of resection.

Both TME and CME are reliable standards for the lymphadenectomy in colorectal carcinomas. A lymphadenectomy that goes beyond this is reserved for selected cases and is partly the subject of currently ongoing studies.

The present study aimed to investigate factors influencing postsurgical gastroparesis syndrome (PGS) in patients with right-sided colon cancer. In total, 260 patients who underwent complete mesocolic excision for right-sided colon cancer were included in the present analysis. Among the included patients, 69 underwent open radical right-sided colon resection, 175 underwent laparoscopic radical right-sided colon resection and 16 underwent robot-assisted radical right-sided colon resection. The occurrence of PGS was observed, and both the χ2 test and multivariate regression analysis were conducted to identify influencing factors. Among the 260 patients, 32 experienced PGS, with an incidence rate of 12.3%. Univariate analysis demonstrated that age, perioperative blood glucose levels, self-rated anxiety scale scores and surgical approach were significantly associated with PGS (P<0.05), whereas sex, surgical duration, diabetes and perioperative albumin levels were not significant factors (P>0.05). Multivariate logistic regression analysis showed that age >70 years, perioperative blood glucose ≥11.1 mmol/l, a self-rating anxiety scale score ≥50 and radical extended right-sided colon resection were risk factors for PGS occurrence. In conclusion, the occurrence of PGS in patients with right-sided colon cancer was revealed to be associated with age, perioperative blood glucose levels, self-rated anxiety scale scores and surgical approach.

Complete mesocolic excision (CME) for colon cancer has been associated with improved oncological outcomes but requires a detailed understanding of complex mesenteric vasculature. Three-dimensional (3D) reconstructed models derived from patient imaging could enhance preoperative anatomical comprehension, enabling safer, precision CME.

In this two-phase, blinded, crossover study, four expert CME surgeons evaluated mesenteric vascular anatomy on CT scans and 3D models. In phase 1, surgeons assessed 66 cases, while 20 were re-evaluated in phase 2. The primary outcome measure was inter-rater reliability by Fleiss's kappa. Secondary outcomes were intra-rater reliability by Cohen's kappa and anatomical accuracy rates measured as a percentage of correct responses on a standardised questionnaire.

In phase 1, inter-rater agreement was higher for 3D models (average kappa 0.6, moderate agreement) than for CT scans (average kappa 0.1, poor agreement). Ileocolic vein drainage and ileocolic artery trajectory showed the highest kappa values with 3D imaging (0.85 and 0.93, respectively). Accuracy was also superior with 3D across all surgeons (mean 89.7% correct) versus CT (mean 79.1% correct, P < 0.001). In phase 2, intra-rater reliability remained higher for 3D (average Cohen's kappa 0.61) than CT scans (Cohen's kappa 0.27).

3D mesenteric models significantly improve inter- and intra-rater reliability among CME experts over traditional CT scans while markedly enhancing anatomical comprehension accuracy about critical right-sided colonic vasculature. 3D planning could facilitate CME by enabling superior preoperative visualisation of these vessels.

Gastroparesis following complete mesocolic excision (CME) can precipitate a cascade of severe complications, which may significantly hinder postoperative recovery and diminish the patient's quality of life. In the present study, four advanced machine learning algorithms-Extreme Gradient Boosting (XGBoost), Random Forest (RF), Support Vector Machine (SVM), and k-nearest neighbor (KNN)-were employed to develop predictive models. The clinical data of critically ill patients transferred to the intensive care unit (ICU) post-CME were meticulously analyzed to identify key risk factors associated with the development of gastroparesis.

We gathered 34 feature variables from a cohort of 1,097 colon cancer patients, including 87 individuals who developed gastroparesis post-surgery, across multiple hospitals, and applied a range of machine learning algorithms to construct the predictive model. To assess the model's generalization performance, we employed 10-fold cross-validation, while the receiver operating characteristic (ROC) curve was utilized to evaluate its discriminative capacity. Additionally, calibration curves, decision curve analysis (DCA), and external validation were integrated to provide a comprehensive evaluation of the model's clinical applicability and utility.

Among the four predictive models, the XGBoost algorithm demonstrated superior performance. As indicated by the ROC curve, XGBoost achieved an area under the curve (AUC) of 0.939 in the training set and 0.876 in the validation set, reflecting exceptional predictive accuracy. Notably, in the k-fold cross-validation, the XGBoost model exhibited robust consistency across all folds, underscoring its stability. The calibration curve further revealed a favorable concordance between the predicted probabilities and the actual outcomes of the XGBoost model. Additionally, the DCA highlighted that patients receiving intervention under the XGBoost model experienced significantly greater clinical benefit.

The onset of postoperative gastroparesis in colon cancer patients remains an elusive challenge to entirely prevent. However, the prediction model developed in this study offers valuable assistance to clinicians in identifying key high-risk factors for gastroparesis, thereby enhancing the quality of life and survival outcomes for these patients.

Surgery remains the most effective treatment for colon cancer. However, there are still controversies regarding the tumor treatment effect, prognosis, and perioperative impact of complete mesocolic excision (CME) surgery in colon carcinoma resection.

This study aims to compare laparoscopic complete mesocolic excision (LCME) and traditional open D2 radical surgery in colon carcinoma resection through a retrospective analysis using 1:1 propensity score matching (PSM).

98 cases undergoing LCME or open D2 colon carcinoma resection at our hospital from January 2014 to November 2021 were retrospectively collected. After excluding cases and 1:1 matching using PSM based on baseline clinical data, 86 patients were assigned in research queue. 43 patients were in each group. Two groups were compared for general clinical baseline indicators. Surgical results and postoperative adverse events of patients were also compared. Disease-free survival (DFS) rate and overall survival (OS) rate was analyzed.

After 1:1 PSM matching, there was no statistically significant differences in baseline data between the LCME group and D2 group (P> 0.05). LCME was characterized by longer total duration of surgery (P< 0.001), less intraoperative bleeding volume (P< 0.001), more postoperative drainage fluid volume (P< 0.001), greater number of lymph nodes retrieved (P= 0.014). No statistically differences was observed regarding intraoperative blood transfusion, hospital stay, Clavien-Dindo complicating disease classification (all P> 0.05), 1 and 3-year DFS rate (P= 0.84) and OS rate (P⩾ 0.1).

LCME had a longer duration of surgery but less intraoperative bleeding volume and more postoperative drainage fluid volume and retrieved lymph nodes compared to D2 radical surgery. LCME surgery is comparable to D2 surgery in terms of postoperative prognosis, but LCME surgery shows a positive trend in the overall survival curve.

Laparoscopic complete mesocolic excision (CME) with D3 lymphadenectomy for right colon cancer is gaining acceptance. However, this procedure has not yet been standardized like total mesorectal excision. Ergonomics is very important in this surgery (e.g. patient positioning, port placement) and identification of vascular anatomy is a critical step. The aim of this work is to present ten procedural steps that are simple and reproducible.

The French position is adopted. The surgeon stands between the patient's legs. Four ports are placed: a camera port 2.5 cm to the left of the umbilicus; two working ports-a 12 mm right-hand port 5-7 cm below the umbilicus in the midline and a 5 mm left-hand port 2.5 cm medial and at the level of anterior superior iliac spine-and an assistant port at the level of the umbilicus at the pararectal line. This is most comfortable position in the 'caudal to cranial approach' for CME dissection. The right-hand instrument always dissects parallel to the superior mesenteric artery (SMA) axis so there is less chance of injury to major vascular structures. When clipping the ileocolic, right colic and gastrocolic trunk (GCT) branches, the instrument is always perpendicular to these structures, giving ease of clipping and division. An intentional attempt is made to dissect all tributaries of the GCT. This avoids inadvertent injury and bleeding. Identifying the SMA/superior mesenteric vein (SMV) axis and ileocolic pedicle is the most crucial step. We use surface landmarks for this-the ligamentum teres and SMA/SMV are both midline structures. Giving traction on the transverse mesocolon just below the ligamentum makes the pulsatile SMA visible irrespective of the patient's body mass index. Giving traction at the ileocaecal junction mesentery makes the ileocolic pedicle prominent. These two landmarks for identification of the vascular anatomy make this technique unique and reproducible. CME dissection is done caudal to cranial and lateral to medial. Supracolic and lateral mobilization of the colon is simple. While starting dissection in the right paracolic gutter the already dissected CME plane make this step easier. Anastomosis can be made intracorporeal or extracorporeal.

Ergonomics and landmarks for identification of the vascular anatomy make this technique simple and reproducible.

Colon cancer is the third most common malignancy in Colombia, only exceeded by prostate and breast cancers. It is the second most common cancer among females and the third most common among males. The epidemiology of this disease has changed in Colombia, and its peak incidence has now surpassed that of gastric cancer.

We aimed to determine the association between hospital surgical volume and mortality in patients with colon cancer undergoing surgical resection in Colombia.

This was a national retrospective cohort study based on administrative data and included adult patients undergoing surgical resection for colon cancer who were enrolled in Colombia's contributory health system between 2012 and 2017. We defined exposure as the hospital's surgical volume where the colon cancer surgery was performed. We classified the patients as exposed to a high surgical volume (above the 90th percentile of the provider distribution) and a low surgical volume (under the 90th percentile). The main outcomes were 30-day and 1-year mortality. Multivariate Poisson regressions were used to identify the association between exposure and mortality rates.

The study included 4,647 patients, of which 4,188 underwent surgery at hospitals with a colectomy volume lower than 33 per year and 459 underwent surgery at institutions with volumes equal to or higher than 33 per year. In the multivariate analysis, after adjusting for observable variables, a lower risk of 30-day mortality was found in patients who underwent surgery at high surgical volume institutions (relative risk - RR 0.57, 95% confidence interval - 95%CI 0.033-0.97). No differences were found in the one-year mortality.

The high surgical volume of a hospital is associated with a 30-day mortality in colon cancer, as described in other studies, but the 1-year mortality did not show this association. Prospective studies are required to establish a causal relationship.

Gastroparesis is a major complication following complete mesocolic excision (CME) and significantly impacts patient outcomes. This study aimed to create a machine learning model to pinpoint key risk factors before, during, and after surgery, effectively predicting the risk of gastroparesis after CME.

The study involved 1146 patients with colon cancer, out of which 95 developed gastroparesis. Data were collected on 34 variables, including demographics, chronic conditions, pre-surgery test results, types of surgery, and intraoperative details. Four machine learning techniques were employed: extreme gradient boosting (XGBoost), random forest (RF), support vector machine (SVM), and k-nearest neighbor (KNN). The evaluation involved k-fold cross-validation, receiver operating characteristic (ROC) analysis, calibration curves, decision curve analysis (DCA), and external validation.

XGBoost excelled in its performance for predictive models. ROC analysis showed high accuracy for XGBoost, with area under the curve (AUC) scores of 0.976 for the training set and 0.906 for the validation set. K-fold cross-validation confirmed the model's stability, and calibration curves indicated high predictive accuracy. Additionally, DCA highlighted XGBoost's superior patient benefits for intervention treatments. An AUC of 0.77 in external validation demonstrated XGBoost's strong generalization ability.

The XGBoost-fueled predictive model for post-surgery colon cancer patients proved highly effective. It underlined gastroparesis as a significant post-operative issue, associated with advanced age, prolonged surgeries, extensive intraoperative blood loss, surgical techniques, low serum protein levels, anemia, diabetes, and hypothyroidism.

The incidence and mortality of colorectal cancer (CRC) in China are increasing in recent years. The clarified pathogenesis and detectable precancerous lesions of CRC make it possible to prevent, screen, and diagnose CRC at an early stage. With the development of endoscopic and surgical techniques, the choice of treatment for early CRC is also worth further discussion, and accordingly, a standard follow-up program after treatment needs to be established.

This clinical practice guideline (CPG) was developed following the recommended process of the World Health Organization, adopting Grading of Recommendations Assessment, Development and Evaluation (GRADE) in assessing evidence quality, and using the Evidence to Decision framework to formulate clinical recommendations, thereby minimizing bias and increasing transparency of the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guides to ensure the guideline's completeness and transparency.

This CPG comprises 46 recommendations concerning prevention, screening, diagnosis, treatment, and surveillance of CRC. In these recommendations, we have indicated protective and risk factors for CRC and made recommendations for chemoprevention. We proposed a suitable screening program for CRC based on the Chinese context. We also provided normative statements for the diagnosis, treatment, and surveillance of CRC based on existing clinical evidence and guidelines.

The 46 recommendations in this CPG are formed with consideration for stakeholders' values and preferences, feasibility, and acceptability. Recommendations are generalizable to resource-limited settings with similar CRC epidemiology pattern as China.

Complete mesocolic excision (CME) with D3 lymphadenectomy for colon cancer has been shown to improve overall as well as disease-free survival compared to conventional right hemicolectomy. Performing a laparoscopic CME/D3 right hemicolectomy with intracorporeal anastomosis (ICA) can be technically demanding even for experienced operators. Here, we present a systematic, standardized approach to the surgery.

Quality assurance in surgery has been one of the most important topics of debate among colorectal surgeons in the past decade. It has produced new surgical standards that led in part to the impressive oncological outcomes we see in many units today. Total mesorectal excision, complete mesocolic excision (CME), and the Japanese D3 lymphadenectomy are now benchmark techniques embraced by many surgeons and widely recommended by surgical societies. However, there are still ongoing discrepancies in outcomes largely based on surgeon performance. This is one of the main reasons why many countries have shifted colorectal cancer surgery only to high volume centers. Defining markers of surgical quality is thus a perquisite to ensure that standards and oncological outcomes are met at an institutional level. With the evolution of CME surgery, various quality markers have been described, mostly based on measurements on the surgical specimen and lymph node yield, while others have proposed radiological markers (i.e. arterial stumps) measured on postoperative scans as part of the routine cancer follow-up. There is no ideal marker; however, taken together and assembled into a new score or set of criteria may become a future point of reference for reporting outcomes of colorectal cancer surgery in research studies and defining subspecialization requirements both at an individual and hospital level.

Debate exists concerning the impact of complete mesocolic excision (CME) on long-term oncological outcomes. The aim of this review was to condense the updated literature and assess the effect of CME on long-term survival after right colectomy for cancer.

PubMed, MEDLINE, Scopus, and Web of Science were searched through July 2023. The included studies evaluated the effect of CME on survival. The primary outcome was long-term overall survival. Restricted mean survival time difference (RMSTD), hazard ratio (HR), and 95% confidence intervals (CI) were used as pooled effect size measures. GRADE methodology was used to summarize the certainty of evidence.

Ten studies (3665 patients) were included. Overall, 1443 (39.4%) underwent CME. The RMSTD analysis shows that at 60-month follow-up, stage I-III CME patients lived 2.5 months (95% CI 1.1-4.1) more on average compared with noCME patients. Similarly, stage III patients that underwent CME lived longer compared to noCME patients at 55-month follow-up (6.1 months; 95% CI 3.4-8.5). The time-dependent HRs analysis for CME vs. noCME (stage I-III disease) shows a higher mortality hazard in patients with noCME at 6 months (HR 0.46, 95% CI 0.29-0.71), 12 months (HR 0.57, 95% CI 0.43-0.73), and 24 months (HR 0.73, 95% CI 0.57-0.92) up to 27 months.

This study suggests that CME is associated with unclear OS benefit in stage I-III disease. Caution is recommended to avoid overestimation of the effect of CME in stage III disease since the marginal benefit of a more extended resection may have been influenced by tumor biology/molecular profile and multimodal adjuvant treatments.

Although complete mesocolic excision (CME) is supposed to be associated with a higher lymph node (LN) yield, decreased local recurrence, and survival improvement, its implementation currently is debated because the evidence level of these data is rather low and still not supported by randomized controlled trials.

This is a multicenter, randomized, superiority trial (NCT04871399). The 3-year disease-free survival (DFS) was the primary end point of the study. The secondary end points were safety (duration of operation, perioperative complications, hospital length of stay), oncologic outcomes (number of LNs retrieved, 3- and 5-year overall survival, 5-year DFS), and surgery quality (specimen length, area and integrity rate of mesentery, length of ileocolic and middle-colic vessels). The trial design required the LN yield to be higher in the CME group at interim analysis.

Interim data analysis is presented in this report. The study enrolled 258 patients in nine referral centers. The number of LNs retrieved was significantly higher after CME (25 vs. 20; p = 0.012). No differences were observed with respect to intra- or post-operative complications, postoperative mortality, or duration of surgery. The hospital stay was even shorter after CME (p = 0.039). Quality of surgery indicators were higher in the CME arm of the study. Survival data still were not available.

Interim data show that CME for right colon cancer in referral centers is safe and feasible and does not increase perioperative complications. The study documented with evidence that quality of surgery and LN yield are higher after CME, and this is essential for continuation of patient recruitment and implementation of an optimal comparison. Trial registration The trial was registered at ClinicalTrials.gov with the code NCT04871399 and with the acronym CoME-In trial.

According to Hohenberger's original description, complete mesocolic excision for colon cancer involves precise dissection of the avascular embryonic plane between the parietal retroperitoneum and visceral peritoneum of the mesocolon. This ensures mesocolic integrity, access to high ligation of the supplying vessels at their origin and an associated extended lymphadenectomy. Results from centres which have adopted this approach routinely have demonstrated that oncological outcomes can be improved by the rigorous implementation of established principles of cancer surgery. Meticulous anatomical dissection along embryonic planes is a well-established principle of precision cancer surgery used routinely by the specialist colorectal surgeon. Therefore, the real question concerns the need for true central vascular ligation and associated extended (D3) lymphadenectomy or otherwise, particularly along the superior mesenteric vessels when performing a right colectomy. Whether this approach results in improved overall or disease-free survival remains unclear and its role remains controversial particularly given the potential for significant morbidity associated with a more extensive central vascular dissection. Current literature is limited by considerable bias, as well as inconsistent and variable terminology, and the results of established randomized trials are awaited. As a result of the current state of equipoise, various national guidelines have disparate recommendations as to when complete mesocolic excision should be performed if at all. This article aims to review the rationale for and technical aspects of complete mesocolic excision, summarize available short and long term outcome data and address current controversies.

Colon cancer is a disease with a worldwide spread. Surgery is the best option for the treatment of advanced colon cancer, but some aspects are still debated, such as the extent of lymphadenectomy. In Japanese guidelines, the gold standard was D3 dissection to remove the central lymph nodes (203, 213, and 223), but in 2009, Hoenberger et al. introduced the concept of complete mesocolic excision, in which surgical dissection follows the embryological planes to remove the mesentery entirely to prevent leakage of cancer cells and collect more lymph nodes. Our study describes how lymphadenectomy is currently performed in major Italian centers with an unclear indication on the type of lymphadenectomy that should be performed during right hemicolectomy (RH).

CoDIG 2 is an observational multicenter national study that involves 76 Italian general surgery wards highly specialized in colorectal surgery. Each center was asked not to modify their usual surgical and clinical practices. The aim of the study was to assess the preference of Italian surgeons on the type of lymphadenectomy to perform during RH and the rise of any new trends or modifications in habits compared to the findings of the CoDIG 1 study conducted 4 years ago.

A total of 788 patients were enrolled. The most commonly used surgical technique was laparoscopic (82.1%) with intracorporeal (73.4%), side-to-side (98.7%), or isoperistaltic (96.0%) anastomosis. The lymph nodes at the origin of the vessels were harvested in an inferior number of cases (203, 213, and 223: 42.4%, 31.1%, and 20.3%, respectively). A comparison between CoDIG 1 and CoDIG 2 showed a stable trend in surgical techniques and complications, with an increase in the robotic approach (7.7% vs. 12.3%).

This analysis shows how lymphadenectomy is performed in Italy to achieve oncological outcomes in RH, although the technique to achieve a higher lymph node count has not yet been standardized. Trial registration (ClinicalTrials.gov) ID: NCT05943951.

This article discusses the management of isolated metastatic lymph nodes for colon and rectal cancer. There are traditionally significant differences in how certain regions of lymph nodes for colon and rectal cancer are managed in the East and West. This has led to the development of the lateral lymph node dissection for rectal cancer and extended lymphadenectomy techniques for colon cancer. This article will evaluate the literature on these techniques and what the surgical and oncological outcomes are at this time. In addition, colon and rectal cancers can occasionally have isolated distant lymph node metastases. These would traditionally be treated as systemic disease with chemotherapy. There is consideration though that these could be treated as similar to isolated liver or lung metastases which have been shown to be able to be treated surgically with good oncological results. The literature for these isolated distant lymph node metastases will be reviewed and treatment options available will be discussed.

To evaluate surgical and oncological results of standard and extended lymph node dissection (D2 and D3) in patients with colon cancer.

We analyzed treatment outcomes in 74 patients with colon cancer stage T1-4aN0-2M0 who underwent right- and left-sided hemicolectomy, resection of sigmoid colon with standard and extended lymph node dissection (D2 and D3).

Surgical approach and level of D3 lymph node dissection did not increase intra- and postoperative morbidity. Laparoscopic interventions were followed by significantly lower intraoperative blood loss and earlier gas discharge. Metastatic lesion of apical lymph nodes was observed in 5 out of 36 patients who underwent D3 lymph node dissection (13.8%), and metastases in regional lymph nodes rN1-2 were found in all these patients. Overall 5-year survival was 86%. Disease-free and overall 5-year survival were similar after D2 and D3 lymph node dissection.

D3 lymph node dissection is safe for colon cancer. Metastatic lesions of apical lymph nodes during D3 lymph node dissection were detected only in patients with lesions of regional lymph nodes (rN1-2). Disease-free and overall 5-year survival were similar after D2 and D3 lymph node dissection.

The complete mesocolic excision competency assessment tool (CMECAT) is a novel tool designed to assess technical skills in minimally invasive complete mesocolic excision (CME) surgery. The aim of this study was to assess construct validity and reliability of CMECAT in a clinical context.

Colorectal surgeons were asked to submit video recorded laparoscopic CME resections for independent assessment of their technical abilities. The videos were grouped by surgeons' training level, and four established CME experts were recruited as CMECAT assessors. Extended reliability analysis (G-theory) was applied to describe assessor agreement.

A total of 19 videos and 72 assessments were included in the analysis. Overall, technical skills assessed by CMECAT improved with increased training level: the experts scored significantly better than the untrained surgeons (3.3 vs. 2.5 points; p < 0.01). On right-sided resections, significantly higher scores were reported with increased training level for all categories and sections, while for left-sided resections, the variance across groups was smaller and significantly higher scores were only reported for oncological safety describing items. Overall, assessor agreement was high (G-coefficient: 0.81).

This study confirms that CMECAT can be applied to video recorded CME cases for technical skill assessment. Further, it can reliably assess technical performance in right sided CME surgery, where construct validity has now been established. More videos are required to evaluate its validity on left colonic CME. In the future, we hope CMECAT can improve feedback during CME training, serve as a tool in certification processes and contribute to distinguishing CME from conventional surgery in future research.

Clinical experience shows complaints similar to LARS not only after rectal surgery, but even after other types of colorectal surgery. Our aim was to investigate the occurrence of LARS after several types of colorectal surgery and its impact on quality of life.

We included adult patients who underwent colorectal surgery at our centre from January 2016 until March 2019, regardless of indication. A questionnaire was sent evaluating LARS and quality of life.

The questionnaire was answered by 119 patients. We noticed highest LARS-score after rectum surgery (26.1), but also surprisingly higher LARS-score after right-sided colectomy (21.0) compared to left-sided colectomy (16.4). We report lowest quality of life after rectal surgery, but higher quality of life in left colectomy compared to right colectomy.

LARS-score did not significantly correlate with type of procedure; however, higher LARS-scores were noted after right-sided colectomy compared to left-sided colectomy with similar impact on quality of life. We suggest CORS (colorectal resection syndrome) as a more suiting conceptual name instead of LARS to describe functional bowel complaints after colorectal surgery.

Complete mesocolic excision (CME) or D3 lymphadenectomy led to survival benefits for locally advanced right colon cancer, but with vague definitions in anatomy and debated surgical hazard in clinic. Aiming to achieve a precise definition of it in anatomy, we proposed laparoscopic right hemicolectomy (D3 + CME) as a novel procedure for colon cancer. However, the surgical and oncological results of this procedure in clinic were uncertain.

We performed a cohort study involving prospective data collected from a single-center in China. Data from all patients who underwent right hemicolectomy between January 2014 and December 2018 were included. We compared the surgical and oncological outcomes between D3 + CME and conventional CME.

After implementation of exclusion criteria, a total of 442 patients were included. D3 + CME group performed better in lymph nodes harvested (25.0 [17.0, 33.8] vs. 18.0 [14.0, 25.0], P < 0.001) and the proportion of intraoperative blood loss ≥ 50 mL (31.7% vs. 51.8%, P < 0.001); no significant difference was observed in the complication rates between two groups. Kaplan-Meier analysis demonstrated that a better cumulative 5-year disease-free survival (91.3% vs. 82.2%, P = 0.026) and a better cumulative 5-year overall survival (95.2% vs. 86.1%, P = 0.012) were obtained in the D3 + CME group. Multivariate COX regression revealed that D3 + CME was an independent protective factor for disease-free survival (P = 0.026).

D3 + CME could improve surgical and oncological outcomes simultaneously for right colon cancer compared to conventional CME. Large-scale randomized controlled trials were further required to confirm this conclusion, if possible.

There is a potential benefit on long-term outcomes following complete mesocolic excision (CME) for right-sided colon cancer when compared to conventional colectomy. This study aims to analyze the learning curve and short-term outcomes of laparoscopic CME with intracorporeal anastomosis (ICA) for right-sided colon cancer in the hands of experienced colorectal surgeons.

A two-center cohort study of consecutive patients undergoing right-sided colectomy from September 2021 to May 2022 at two tertiary colorectal centers in Denmark. Learning curves of surgical time were estimated using a cumulative sum analysis (CUSUM).

A total of 61 patients were included. According to the CUSUM analysis, 32 cases were needed to obtain a peak in operative time, resulting in a decrease in time consumption (group 1/learning phase: 217.2 min [SD 53.6] and group 2/plateau phase 191.6 min [SD 45.1], p = 0.05). There was a nonsignificant reduction in the rates of severe surgical complications (Clavien-Dindo > 3) (13% vs. 7%, p = 0.67) between the two groups, while the length of hospital stay remained constant (median 3.0 days, interquartile range, IQR [2.0; 4.0]).

The learning curve of laparoscopic CME with ICA for right-sided colon cancer demonstrated that 32 cases were needed to obtain a plateau phase expressed by operative time.

To investigate oncologic outcomes including overall survival and disease-free survival depending on the extent of lymphadenectomy (D3 versus D2) by comparing D3 and D2 lymphadenectomy in patients with clinical stage 2/3 right colon cancer.

Consecutive series of patients who underwent radical resection for right colon cancer at our three hospitals between January 2015 and June 2018 were retrospectively analyzed. Study cohorts were divided into two groups: D3 group and D2 group. Oncologic, pathologic, and perioperative outcomes of the two groups were compared.

A total of 295 patients (167 in the D2 group and 128 in the D3 group) were included in this study. Patients' characteristics showed no significant difference between the two groups. The median number of harvested lymph nodes was significantly higher in the D3 group than in the D2 group. The rate of complications was not significantly different between the two groups except for chyle leakage, which was more frequent in the D3 group. Five-year disease-free survival was 90.2% (95% CI: 84.8-95.9%) in the D3 group, which was significantly (p = 0.028) higher than that (80.5%, 95% CI: 74-87.5%) in the D2 group. There was no significant difference in overall survival between the two groups.

Our results indicate that D3 lymphadenectomy is associated with more favorable 5-year disease-free survival than D2 lymphadenectomy for patients with stage 2/3 right-sided colon cancer. D3 lymphadenectomy might improve oncologic outcomes in consideration of the recurrence rate.

Identification of positive lymph nodes in colon cancer can significantly impact treatment. Few studies have examined the role of lymph node size in staging and prognosis. This study evaluated the relationship between lymph node size and lymph node metastases in right-sided colon cancer.

Retrospective chart review was performed for patients undergoing colectomy for right-sided colon cancer from 2015 to 2020 across a single multi-hospital health system. Patients under age 18 or who did not have invasive adenocarcinoma upon pathological examination were excluded. Primary endpoints assessed lymph node size and lymph node metastases. 572 patients were stratified by lymph node size; lymph nodes ≥5 mm (n = 308) were characterized as enlarged.

All surgical specimens examined had adequate number of lymph nodes for staging. 33.9% of all specimens examined contained lymph node metastases. Patients with enlarged lymph nodes were significantly more likely to have lymph node metastases than those with normal-sized lymph nodes (p < 0.001). Enlarged lymph nodes were associated with advanced nodal staging.

Patients with enlarged nodes were significantly more likely to have lymph node metastases than those with normal-sized lymph nodes. Further research to analyze these enlarged lymph nodes on radiologic imaging is warranted to determine the role of radiographic assessment of lymph node size during pre-operative staging.

Complete mesocolic excision (CME), which involves the adequate resection of the tumor-bearing colonic segment with "en bloc" removal of its mesocolon along embryological fascial planes is associated with superior oncological outcomes. However, CME presents a higher complication rate compared to non-CME resections due to a higher risk of vascular injury. Hyperspectral imaging (HSI) is a contrast-free optical imaging technology, which facilitates the quantitative imaging of physiological tissue parameters and the visualization of anatomical structures. This study evaluates the accuracy of HSI combined with deep learning (DL) to differentiate the colon and its mesenteric tissue from retroperitoneal tissue. In an animal study including 20 pig models, intraoperative hyperspectral images of the sigmoid colon, sigmoid mesentery, and retroperitoneum were recorded. A convolutional neural network (CNN) was trained to distinguish the two tissue classes using HSI data, validated with a leave-one-out cross-validation process. The overall recognition sensitivity of the tissues to be preserved (retroperitoneum) and the tissues to be resected (colon and mesentery) was 79.0 ± 21.0% and 86.0 ± 16.0%, respectively. Automatic classification based on HSI and CNNs is a promising tool to automatically, non-invasively, and objectively differentiate the colon and its mesentery from retroperitoneal tissue.

Guidelines recommend regional lymphadenectomy with a lymph node yield (LNY) of at least 12 lymph nodes (LN) for adequate colon cancer (CC) staging. LNY ≥22LN may improve survival, especially in right-sided CC [Lee et al., Surg Oncol, 27(3), 2018]. This multicentric retrospective cohort study evaluated the impact of LNY and tumor laterality on CC staging and survival.

Patients with stage I-III CC that underwent surgery from 2012 to 2018 were grouped according to LNY: <22 and ≥ 22. Primary outcomes were LN positivity (N+ rate) and disease-free survival (DFS). Overall survival (OS) was the secondary outcome. Exploratory analyses were performed for laterality and stage.

We included 795 patients (417 < 22LN, 378 ≥ 22LN); 53% had left-sided CC and 29%/37%/38% had stage I/II/III tumors. There was no association between LNY ≥22LN and N+ rate after adjustment for grade, T stage, lymphovascular invasion (LVI) and perineural invasion; a trend for a higher N+ rate in left-sided CC was identified (interaction p = 0.033). With a median follow-up of 63.6 months for DFS and 73.2 months for OS, 254 patients (31.9%) relapsed and 207 (26.0%) died. In multivariate analysis adjusted for age, ASA score, laparoscopic approach, T/N stage, mucinous histology, LVI and adjuvant chemotherapy, LNY ≥22LN was significantly associated with both DFS (HR 0.75, p = 0.031) and OS (HR 0.71, p = 0.025). Restricted cubic spline analysis showed a more significant benefit for right-sided CC.

LNY ≥22LN was associated with longer DFS and OS in patients with operable CC, especially for right-sided CC.

The following article summarizes technical aspects of how to operate in the mesentery during complete mesocolic excision (CME). Increasingly, CME is being adopted and as such it is important to establish the anatomical basis of the techniques involved. This review thus serves to provide that foundation and explains the surgical techniques built on it.

Complete mesocolic excision (CME) of colon cancer is a resection performed along embryological planes to include the completely intact mesentery surrounding the tumour with a high central vascular ligation. The aim is to remove all lymph nodes draining the cancer. Proponents of the technique cite the significantly decreased local recurrence and improved 5-year survival rates associated with CME versus conventional colectomy. Although increasingly performed in many centres, it has not yet gained widespread acceptance as it is technically more challenging and can incur an increased bleeding risk. A man in his 80s underwent a conventional right hemicolectomy for a pT4aN2aM0 ascending colon cancer at another institution. This was followed by chemotherapy. He presented to our institution 2 years later with an isolated 3.7×3.2 cm mesenteric tumour adjacent to his anastomosis. There was no intraluminal recurrence. He then underwent a repeat extended right colectomy with CME. Pathology confirmed lymph node recurrence. His case demonstrates the importance of CME in reducing carcinoma recurrence risk.

Colon cancer treatment is on the way to evolution over several decades. The minimally invasive surgery has improved postoperative short-term outcomes. Adjuvant chemotherapy has prolonged the survival of advanced colon cancer patients. Hohenberger proposed the noble concept of complete mesocolic excision (CME) which consists of 3 components: plane surgery, sufficient longitudinal bowel resection, and central vascular ligation (CVL). Mesocolic plane surgery shares the same surgical principle of total mesorectal excision, which is maintaining the intact mesothelial envelope. However, there remain debates about the extent of bowel resection and the level of CVL for maximizing lymph node dissection. There is no solid clinical evidence for the oncological necessity and benefit of extended radical dissection in right hemicolectomy. CME with CVL based on open surgery has been adopted in laparoscopic surgery. So, it is also necessary to look at how the CME could be transformed and successfully implanted in the laparoscopic era. Recent rapid advances in surgical technology and cancer biology are preparing for fundamental changes in cancer surgery. In this study, we reviewed the history, oncological necessity, and compatibility of CME for the right hemicolectomy in the laparoscopic era and outline the new perspectives on the evolution of cancer surgery.

The aim was to describe changes in incidence and mortality from colorectal cancer (CRC) in England by analysing data available from the National Cancer Registration and Analysis Service (NCRAS, 2001-2017).

Data analysis was undertaken to interpret trends and patterns in age-standardized incidence and death rates from CRC, including sub-analyses by six age groups (0-24, 25-49, 50-59, 60-69, 70-79, 80+) and three sites of cancer-colonic, rectosigmoid and rectal.

Overall CRC incidence remained relatively stable-70.1 cases per 100 000 individuals (95% CI 69.3-71.0) in 2001 and 68.8 cases (95% CI 68.0-69.5) in 2017. Sub-analysis demonstrates a quarter fewer incidence of rectosigmoid cancer (-27%). This is counterbalanced by a 3% rise in colon cancers. The age-standardized incidence rate of CRC increased by 59% in the 25-49 age group. In the over 50s, CRC incidence remained stable, with reductions seen in rectosigmoid cancer (50-59 years, -19%; 60-69, -26%; 70-79, -39%; 80+, -27%). Overall, mortality improved (-18.7%), primarily as a result of the reduction in deaths from colon (-31.6%) and rectal cancers (-25.1%). Deaths from the small incident number of rectosigmoid cancers, however, demonstrated a significant increase overall (+166.7%). Grouped age-standardized death rate analyses showed increasing death rates in the under 50s (+28.3%) compared to declining rates in the over 50s (-15.8%).

There is a clear trend in increased incidence and mortality in individuals under 50 years old. There is also a trend to increased mortality from rectosigmoid cancer. These findings should have implications for national screening programme extension to under 50s and a call to arms for appropriate identification, staging and treatment of rectosigmoid cancers.