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. 2020 Jul;24(7):757-760.
doi: 10.1007/s10151-020-02197-7. Epub 2020 Apr 2.

Resectional surgery for malignant disease of abdominal digestive organs is not surgery of the organ itself, but also that of the mesenteric organ

J Bunni  1 , J C Coffey  2 , M F Kalady  3
Affiliations

Resectional surgery for malignant disease of abdominal digestive organs is not surgery of the organ itself, but also that of the mesenteric organ

J Bunni et al. Tech Coloproctol. 2020 Jul.

Abstract

Despite large strides in molecular oncology, surgery remains the bedrock in the management of visceral cancer. The primacy of surgery cannot be understated and a mesenteric (i.e. ontogenetic) approach is particularly beneficial to patients. Heald greatly advanced the management of rectal cancer with his description of the anatomical foundation of total mesorectal excision (TME), dramatically improving outcomes worldwide with this mesenteric-based approach. Moreover, complete mesocolic excision (CME) based on similar principles is becoming popular. Introduced by Hohenberger, CME resembles TME insofar as it emphasises strictly anatomical dissection along embryological planes to detach an intact (i.e. "complete") mesentery with peritoneal envelope. CME also incorporates "central" vascular ligation (CVL) which broadly correlates with the "D3 lymphadenectomy" of Eastern literature. As many surgeons already practise anatomical and mesenteric-based surgery, it is unclear how the putative benefits of CME (including CVL) arise. Herein, we argue that these may relate to a more extensive resection of the mesentery, and thus mesenteric tumour deposits within the connective tissue lattice of the mesentery, and not necessarily the lymphadenectomy alone. We believe the connective tissue interface between the bowel wall and mesentery provides an alternative mode of spread of pathogenic elements. Whilst this remains a suggestion only, it would explain the histological independence of tumour deposits and why a greater mesenterectomy could be associated with benefits in survival. If this argument holds, it follows that resectional surgery for digestive organ malignancy is not surgery of the organ itself (or lymphatics only), but also that of the contiguous mesentery.

Keywords: Central vascular ligation (CVL); Colorectal cancer; Complete mesocolic excision (CME); D3 lymphadenectomy; Embryology; Mesentery; Ontogenetics.

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Conflict of interest statement

The authors declare that they have no conflict of interest.

References

    1. Sullivan R, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol. 2015;16(11):1193–1224. doi: 10.1016/S1470-2045(15)00223-5. - DOI - PubMed
    1. Bunni J. The primacy of embryological, ontogenetic and specimen orientated (mesenteric) surgery as the most important tool in treating visceral (colorectal) cancer. Mesentery Peritoneum. 2017;1:3. doi: 10.21037/map.2017.12.01. - DOI
    1. Hirono S, et al. Mesenteric approach during pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. Ann Gastroenterol Surg. 2017;1(3):208–218. doi: 10.1002/ags3.12013. - DOI - PMC - PubMed
    1. Heald RJ. The 'Holy Plane' of rectal surgery. J R Soc Med. 1988;81(9):503–508. doi: 10.1177/014107688808100904. - DOI - PMC - PubMed
    1. Culligan K, Remzi FH, Soop M, Coffey JC. Review of nomenclature in colonic surgery—proposal of a standardised nomenclature based on mesocolic anatomy. Surgeon. 2013;11(1):1–5. doi: 10.1016/j.surge.2012.01.006. - DOI - PubMed