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World J Gastroenterol. Jan 7, 2015; 21(1): 132-138
Published online Jan 7, 2015. doi: 10.3748/wjg.v21.i1.132
Extent of surgery in cancer of the colon: Is more better?
Wouter Willaert, Wim Ceelen
Wouter Willaert, Wim Ceelen, Department of Surgery, Ghent University Hospital, B-9000 Ghent, Belgium
Author contributions: Willaert W performed the literature search and co-authored the paper; Ceelen W designed the topic, co-authored the paper and approved the final version.
Supported by The Fund for Scientific Research - Flanders (FWO) to Ceelen W (Senior Clinical Researcher)
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/
Correspondence to: Wim Ceelen, MD, PhD, Department of Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium. wim.ceelen@ugent.be
Telephone: +32-9-3326251 Fax: +32-9-3323891
Received: July 1, 2014
Peer-review started: July 2, 2014
First decision: August 6, 2014
Revised: August 14, 2014
Accepted: November 7, 2014
Article in press: November 11, 2014
Published online: January 7, 2015
Abstract

Since the introduction of total mesorectal excision as the standard approach in mid and low rectal cancer, the incidence of local recurrence has sharply declined. Similar attention to surgical technique in colon cancer (CC) has resulted in the concept of complete mesocolic excision (CME), which consists of complete removal of the intact mesentery and high ligation of the vascular supply at its origin. Although renewed attention to meticulous surgical technique certainly has its merits, routine implementation of CME is currently unfounded. Firstly, in contrast to rectal cancer, local recurrence originating from an incompletely removed mesentery is rare in CC and usually a manifestation of systemic disease. Secondly, although CME may increase nodal counts and therefore staging accuracy, this is unlikely to affect survival since the observed relationship between nodal counts and outcome in CC is most probably not causal but confounded by a range of clinical variables. Thirdly, several lines of evidence suggest that metastasis to locoregional nodes occurs early and is a stochastic rather than a stepwise phenomenon in CC, in essence reflecting the tumor-host-metastasis relationship. Unsurprisingly, therefore, comparative studies in CC as well as in other digestive cancers have failed to demonstrate any survival benefit associated with extensive, additional or extra-mesenteric lymphadenectomy. Finally, routine implementation of CME may cause patient harm by longer operating times, major vascular damage and autonomic nerve injury. Therefore, data from randomized trials reporting relevant endpoints are required before CME can be recommended as a standard approach in CC surgery.

Keywords: Colon, Adenocarcinoma, Surgery, Cancer, Mesocolic excision, Lymph node count

Core tip: The extent of surgery in cancer of the colon is a matter of debate. Proponents of complete mesocolic excision (CME) argue that more extensive en bloc removal of the lymph node harboring mesentery may improve recurrence free survival. Here, we critically review the relevant clinical data and colorectal cancer biology and conclude that at present, routine implementation of a more extensive resection such as CME is unjustified outside the setting of controlled clinical trials.