Evidence - Left hemicolectomy, open, curative

  1. Summary of the Literature

    Surgical Therapy of Colon Cancer

    The progress in the treatment of colon cancer over the past 30 years is due to an increasing individualization of therapy, the consistent implementation of surgical-oncological principles, more aggressive therapy regimens in the metastatic stage, and the use of minimally invasive surgical techniques. Standardized treatment concepts in multimodal tumor therapy have led, among other things, to an increase in the average five-year survival rate from 65% to over 85% and a reduction in the locoregional recurrence rate from an average of over 13% to under 2% in non-metastatic colon cancer in UICC stages II and III. [10]. In the metastatic stage, five-year survival rates of over 40% are now achieved in 20% of patients [19].

    Surgical-Oncological Principles

    Of crucial importance for the prognosis is the en-bloc resection of the tumor-bearing colon segment with systematic locoregional lymphadenectomy. The systematic lymphadenectomy with a high yield of potentially metastatic lymph nodes is the basis for a standardized classification of lymph node status, the resulting therapy recommendation, and the prognosis of the patient.

    The lymphogenic metastasis of colon cancer occurs centrally via the paracolic lymph nodes, which are affected in 70% of node-positive patients, as well as via the intermediate lymph nodes to the lymph nodes along the main artery. The longitudinal drainage to the sides of the tumor occurs via the paracolic lymph nodes with a lateral spread of a maximum of 10 cm [25, 26]. The extent of resection is thus oriented to the supply area of the radially resected main arteries and should also be at least 10 cm on both sides of the tumor. As the last lymph node station, the main lymph nodes are located centrally at the origin of the corresponding main vessels from the major vessels.

    Due to the increasing standardization of en-bloc resection with systematic lymphadenectomy, an improvement in the overall prognosis in the curative situation has been achieved over the past 20 years, also against the background of established chemotherapy [16]. Retrospective studies have demonstrated a correlation between the number of lymph nodes examined and the stage-independent prognosis [8, 13].

    The concept of the sentinel lymph node has not established itself as a staging instrument in colon surgery outside of studies [3, 4]. Although the study situation is inconsistent, the current S3 guideline "Colorectal Cancer" recommends the extirpation and histological processing of at least 12 lymph nodes as a quality criterion [21].

    In addition to systematic lymphadenectomy, the concept of Complete Mesocolic Excision (CME) also aims to maximize the reduction of the number of local recurrences by increasing the radicality and quality of the resection. The technique was published by Hohenberger et al. in 2009 and is based on three pillars [16, 24]:

    1. Preparation along the embryonic layers, whereby the two mesocolic fascial layers of the resection area are preserved and possible tumor cell dissemination is to be avoided.
    2. The strict close-to-origin resection of the respective main vessels allows for maximum lymph node yield and maximum local radicality towards the center.
    3. An adequate length of the resectate ensures maximum paracolic lymphadenectomy.

    Data from Denmark, Sweden, and Germany show that the CME technique is associated with better disease-free survival in patients with colon cancer in UICC stages I – III than conventional colon resection [5, 6, 18].

    Minimally Invasive Surgery

    Mono- and multicenter RCTs (KOLOR, COST, CLASSIC-Trail) found no differences between laparoscopic and open techniques in colon cancer surgery in terms of surgical-oncological quality indicators (R-status, number of lymph nodes) and long-term results (tumor recurrences, survival) with appropriate expertise of the surgeon [7, 11, 14]. As an advantage of minimally invasive surgery, a relatively low perioperative morbidity with unchanged overall morbidity and mortality was shown in the short-term course [23]. According to the current S3 guideline "Colorectal Cancer," laparoscopic resection of colon cancer can therefore be performed in suitable cases with appropriate experience of the surgeon [21]. There is currently no data basis for the application of NOTES in colon cancer.

    Multimodal Tumor Therapy

    Numerous studies demonstrate the importance of drug tumor therapy in non-metastatic colon cancer. An adjuvant chemotherapy in UICC stage III is associated with a significant improvement in prognosis of about 20% overall survival [22]. In stage II, patients with risk factors (T4 tumor, tumor perforation, emergency interventions, number of examined/extirpated lymph nodes < 12) have a significantly worse prognosis than patients in the same stage without risk factors and should therefore receive adjuvant chemotherapy [21]. The role of neoadjuvant chemotherapy in the treatment of locally advanced colon cancers has been investigated in recent years. A randomized study from the UK showed that combined neoadjuvant/adjuvant chemotherapy (oxaliplatin, folinic acid, and 5-FU) vs. adjuvant chemotherapy alone in locally advanced colon cancers resulted in a lower rate of R1 resections and significant downstaging. Tumor progression during ongoing neoadjuvant chemotherapy was not observed [2, 12]. Studies have shown that computed tomography is suitable for identifying locally advanced colon cancers in terms of the T-category and thus selecting for neoadjuvant chemotherapy or preoperatively assessing the response to chemotherapy [1, 20]. Oncological long-term results are still pending.

    Liver and Lung Metastases

    In the metastatic situation, the five-year survival rate is below 10%. Through drug tumor therapy (combination of dual therapy and antibodies) and more aggressive indication for metastasis resection, the prognosis for about 20% of metastatic patients improves significantly with a five-year survival rate of up to 50% [15]. Using various chemotherapy protocols, response rates of up to 60% and an R0 resection rate of up to 15% are achieved [9].

    Peritoneal Carcinomatosis

    If peritoneal carcinomatosis is already present in colon cancer, the indication for cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC) can be reviewed. The use of this combination therapy has shown a significant survival advantage in terms of an extension of median survival from 12.6 to 22.3 months [27]. The Peritoneal Cancer Index (PCI) is used to determine the extent of peritoneal carcinomatosis. If the PCI value is below 20 in patients without additional extra-abdominal metastases, operative cytoreduction with HIPEC can be performed in specialized centers, provided an R0 resection is possible [21].

    Perioperative Concept

    The ERAS concept ("enhanced recovery after surgery") of multimodal postoperative rehabilitation in gastrointestinal surgery is implemented in most clinics in this country in a partially modified form. The aim of the concept is to quickly manage the pathophysiological changes triggered by the surgical intervention, such as fatigue, bowel atony, and insulin resistance. The concept includes, among other things, the early removal of gastric tubes and intra-abdominal drains, early oral nutrition, stimulation of bowel motility, sufficient analgesia (epi-/peridural), and early mobilization. Numerous studies have shown that the ERAS concept can achieve a significant reduction in length of stay with a significantly lower complication rate [17].

  2. Currently ongoing studies on this topic

  3. Literature on this topic

    1: Arredondo J, González I, Baixauli J, Martínez P, Rodríguez J, Pastor C, Ribelles MJ, Sola JJ, Hernández-Lizoain JL. Tumor response assessment in locally advanced colon cancer after neoadjuvant chemotherapy. J Gastrointest Oncol. 2014 Apr;5(2):104-11.

    2: Arredondo J, Pastor C, Baixauli J, Rodríguez J, González I, Vigil C, Chopitea A, Hernández-Lizoáin JL. Preliminary outcome of a treatment strategy based on perioperative chemotherapy and surgery in patients with locally advanced colon cancer. Colorectal Dis. 2013 May;15(5):552-7.

    3: Bembenek A. Current clinical status of sentinel lymph nodes in colon and proximal rectal cancer. Colorectal Dis. 2011 Nov;13 Suppl 7:63-6.

    4: Bembenek AE, Rosenberg R, Wagler E, Gretschel S, Sendler A, Siewert JR, Nährig J, Witzigmann H, Hauss J, Knorr C, Dimmler A, Gröne J, Buhr HJ, Haier J, Herbst H, Tepel J, Siphos B, Kleespies A, Koenigsrainer A, Stoecklein NH, Horstmann O, Grützmann R, Imdahl A, Svoboda D, Wittekind C, Schneider W, Wernecke KD, Schlag PM. Sentinel lymph node biopsy in colon cancer: a prospective multicenter trial. Ann Surg. 2007 Jun;245(6):858-63.

    5: Bernhoff R, Martling A, Sjövall A, Granath F, Hohenberger W, Holm T. Improved survival after an educational project on colon cancer management in the county of Stockholm–a population based cohort study. Eur J Surg Oncol. 2015 Nov;41(11):1479-84.

    6: Bertelsen CA, Neuenschwander AU, Jansen JE, Wilhelmsen M, Kirkegaard-Klitbo A, Tenma JR, Bols B, Ingeholm P, Rasmussen LA, Jepsen LV, Iversen ER, Kristensen B, Gögenur I; Danish Colorectal Cancer Group.. Disease-free survival after complete mesocolic excision compared with conventional colon cancer surgery: a retrospective, population-based study. Lancet Oncol. 2015 Feb;16(2):161-8.

    7: Colon Cancer Laparoscopic or Open Resection Study Group., Buunen M, Veldkamp R, Hop WC, Kuhry E, Jeekel J, Haglind E, Pahlman L, Cuesta MA, Msika S, Morino M, Lacy A, Bonjer HJ. Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol. 2009 Jan;10(1):44-52.

    8: Chen SL, Bilchik AJ. More extensive nodal dissection improves survival for stages I to III of colon cancer: a population-based study. Ann Surg. 2006 Oct;244(4):602-10.

    9: Falcone A, Ricci S, Brunetti I, Pfanner E, Allegrini G, Barbara C, Crinó L, Benedetti G, Evangelista W, Fanchini L, Cortesi E, Picone V, Vitello S, Chiara S, Granetto C, Porcile G, Fioretto L, Orlandini C, Andreuccetti M, Masi G; Gruppo Oncologico Nord Ovest.. Phase III trial of infusional fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFOXIRI) compared with infusional fluorouracil, leucovorin, and irinotecan (FOLFIRI) as first-line treatment for metastatic colorectal cancer: the Gruppo Oncologico Nord Ovest. J Clin Oncol. 2007 May 1;25(13):1670-6.

    10: Fischer J, Hellmich G, Jackisch T, Puffer E, Zimmer J, Bleyl D, Kittner T, Witzigmann H, Stelzner S. Outcome for stage II and III rectal and colon cancer equally good after treatment improvement over three decades. Int J Colorectal Dis. 2015 Jun;30(6):797-806.

    11: Fleshman J, Sargent DJ, Green E, Anvari M, Stryker SJ, Beart RW Jr, Hellinger M, Flanagan R Jr, Peters W, Nelson H; Clinical Outcomes of Surgical Therapy Study Group.. Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg. 2007 Oct;246(4):655-62; discussion 662-4.

    12: Foxtrot Collaborative Group. Feasibility of preoperative chemotherapy for locally advanced, operable colon cancer: the pilot phase of a randomised controlled trial. Lancet Oncol. 2012 Nov;13(11):1152-60.

    13: George S, Primrose J, Talbot R, Smith J, Mullee M, Bailey D, du Boulay C, Jordan H; Wessex Colorectal Cancer Audit Working Group.. Will Rogers revisited: prospective observational study of survival of 3592 patients with colorectal cancer according to number of nodes examined by pathologists. Br J Cancer. 2006 Oct 9;95(7):841-7.

    14: Green BL, Marshall HC, Collinson F, Quirke P, Guillou P, Jayne DG, Brown JM. Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer. Br J Surg. 2013 Jan;100(1):75-82.

    15: Heinrich S, Lang H. Neoadjuvant chemotherapy or primary surgery for colorectal liver metastases. Pro primary surgery. Chirurg. 2014 Jan;85(1):17-23.

    16: Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation–technical notes and outcome. Colorectal Dis. 2009 May;11(4):354-64; discussion 364-5.

    17: Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008 Aug;248(2):189-98.

    18: Merkel S, Weber K, Matzel KE, Agaimy A, Göhl J, Hohenberger W. Prognosis of patients with colonic carcinoma before, during and after implementation of complete mesocolic excision. Br J Surg. 2016 Aug;103(9):1220-9.

    19: Neumann UP, Seehofer D, Neuhaus P. The surgical treatment of hepatic metastases in colorectal carcinoma. Dtsch Arztebl Int. 2010 May;107(19):335-42.

    20: Norgaard A, Dam C, Jakobsen A, Plöen J, Lindebjerg J, Rafaelsen SR. Selection of colon cancer patients for neoadjuvant chemotherapy by preoperative CT scan. Scand J Gastroenterol. 2014 Feb;49(2):202-8.

    21: Pox C, Aretz S, Bischoff SC, Graeven U, Hass M, Heußner P, Hohenberger W, Holstege A, Hübner J, Kolligs F, Kreis M, Lux P, Ockenga J, Porschen R, Post S, Rahner N, Reinacher-Schick A, Riemann JF, Sauer R, Sieg A, Scheppach W, Schmitt W, Schmoll HJ, Schulmann K, Tannapfel A, Schmiegel W; Leitlinienprogramm Onkologie der AWMF.; Deutschen Krebsgesellschaft e.V.; Deutschen Krebshilfe e.V.. S3-guideline colorectal cancer version 1.0. Z Gastroenterol. 2013 Aug;51(8):753-854.

    22: Ragnhammar P, Hafström L, Nygren P, Glimelius B; SBU-group. Swedish Council of Technology Assessment in Health Care.. A systematic overview of chemotherapy effects in colorectal cancer. Acta Oncol. 2001;40(2-3):282-308.

    23: Schwenk W, Neudecker J, Raue W, Haase O, Müller JM. "Fast-track" rehabilitation after rectal cancer resection. Int J Colorectal Dis. 2006 Sep;21(6):547-53.

    24: Sondenaa K, Quirke P, Hohenberger W, Sugihara K, Kobayashi H, Kessler H, Brown G, Tudyka V, D’Hoore A, Kennedy RH, West NP, Kim SH, Heald R, Storli KE, Nesbakken A, Moran B. The rationale behind complete mesocolic excision (CME) and a central vascular ligation for colon cancer in open and laparoscopic surgery: proceedings of a consensus conference. Int J Colorectal Dis. 2014 Apr;29(4):419-28.

    25: Tan KY, Kawamura YJ, Mizokami K, Sasaki J, Tsujinaka S, Maeda T, Nobuki M, Konishi F. Distribution of the first metastatic lymph node in colon cancer and its clinical significance. Colorectal Dis. 2010 Jan;12(1):44-7.

    26: Toyota S, Ohta H, Anazawa S. Rationale for extent of lymph node dissection for right colon cancer. Dis Colon Rectum. 1995 Jul;38(7):705-11.

    27: Verwaal VJ, van Ruth S, de Bree E, van Sloothen GW, van Tinteren H, Boot H, Zoetmulder FA. Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol. 2003 Oct 15;21(20):3737-43.

Reviews

Huang S, Ye J, Gao X, Huang X, Huang J, Lu L, Lu C, Li Y, Luo M, Xie M, Lin Y, Liang R. Progress of

Activate now and continue learning straight away.

Single Access

Activation of this course for 3 days.

US$9.40  inclusive VAT

Most popular offer

webop - Savings Flex

Combine our learning modules flexibly and save up to 50%.

from US$7.27 / module

US$87.34/ yearly payment

price overview

general and visceral surgery

Unlock all courses in this module.

US$14.55 / month

US$174.70 / yearly payment

  • literature search

    Literature search on the pages of pubmed.