A systematic review, meta-analysis and GRADE assessment of the evidence on complete mesocolic excision for right-sided colon cancer with SAGES and ESCP participation

Alexander A Tzanis^{1

2}, Francesco Maria Carrano^{3

4}, Konstantinos Perivoliotis⁵, Sunjay S Kumar⁶, Christos Christogiannis^{7

8}, Dimitris Mavridis^{3

7}, Bright Huo^{3

9}, Nicole Bouvy¹⁰, Niki Christou¹¹, Suzanne Dore¹², Audrius Dulskas¹³, Christos Kontovounisios¹⁴, Tim Lubbers¹⁰, Francesco Palazzo⁶, Philip Quirke¹⁵, Dimitra Repana¹⁶, Monica Terlizzo¹⁷, Bethany J Slater¹⁸, Ivan D Florez^{19

20

21}, Monica Ortenzi²², Tan Arulampalam²³, Stavros A Antoniou^{3

24}

Affiliations

¹ 1st Department of Obstetrics and Gynaecology, Alexandra University Hospital, National and Kapodistrian University of Athens, Athens, Greece. alexandros.tzanis@gmail.com.
² Guidelines Committee, European Association for Endoscopic Surgery, Eindhoven, Netherlands. alexandros.tzanis@gmail.com.
³ Guidelines Committee, European Association for Endoscopic Surgery, Eindhoven, Netherlands.
⁴ Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St Andrea Hospital, Sapienza University, Rome, Italy.
⁵ Department of Surgery, General Hospital of Volos, Volos, Greece.
⁶ Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
⁷ Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece.
⁸ Developmental EPI (Evidence Synthesis, Prediction, Implementation) Lab, Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.
⁹ Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Canada.
¹⁰ Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.
¹¹ Department of Visceral Surgery, University Hospital of Limoges, Limoges, France.
¹² Patient Representative, Rayne, Essex, UK.
¹³ National Cancer Center, Affiliate of Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania.
¹⁴ 2nd Surgical Department, Evangelismos General Hospital, Athens, Greece.
¹⁵ Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK.
¹⁶ Department of Medical Oncology, St George's University Hospitals, London, UK.
¹⁷ Department of Pathology, The Royal Marsden NHS Foundation Trust, London, UK.
¹⁸ Department of Surgery, University of Chicago Medicine, Chicago, IL, USA.
¹⁹ Department of Pediatrics, University of Antioquia, Medellin, Colombia.
²⁰ Pediatric Intensive Care Unit, Clínica Las Américas-AUNA, Medellin, Colombia.
²¹ School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada.
²² Department of General and Emergency Surgery, Polytechnic University of Marche, Ancona, Italy.
²³ School of Medicine, Anglia Ruskin University, Chelmsford, UK.
²⁴ Department of Surgery, Papageorgiou General Hospital, Thessaloniki, Greece.

PMID: 40325243
DOI: 10.1007/s00464-025-11749-7

Meta-Analysis

A systematic review, meta-analysis and GRADE assessment of the evidence on complete mesocolic excision for right-sided colon cancer with SAGES and ESCP participation

Alexander A Tzanis et al. Surg Endosc. 2025 Jun.

. 2025 Jun;39(6):3466-3473.

doi: 10.1007/s00464-025-11749-7. Epub 2025 May 5.

Authors

Affiliations

¹ 1st Department of Obstetrics and Gynaecology, Alexandra University Hospital, National and Kapodistrian University of Athens, Athens, Greece. alexandros.tzanis@gmail.com.
² Guidelines Committee, European Association for Endoscopic Surgery, Eindhoven, Netherlands. alexandros.tzanis@gmail.com.
³ Guidelines Committee, European Association for Endoscopic Surgery, Eindhoven, Netherlands.
⁴ Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St Andrea Hospital, Sapienza University, Rome, Italy.
⁵ Department of Surgery, General Hospital of Volos, Volos, Greece.
⁶ Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
⁷ Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece.
⁸ Developmental EPI (Evidence Synthesis, Prediction, Implementation) Lab, Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.
⁹ Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Canada.
¹⁰ Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.
¹¹ Department of Visceral Surgery, University Hospital of Limoges, Limoges, France.
¹² Patient Representative, Rayne, Essex, UK.
¹³ National Cancer Center, Affiliate of Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania.
¹⁴ 2nd Surgical Department, Evangelismos General Hospital, Athens, Greece.
¹⁵ Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK.
¹⁶ Department of Medical Oncology, St George's University Hospitals, London, UK.
¹⁷ Department of Pathology, The Royal Marsden NHS Foundation Trust, London, UK.
¹⁸ Department of Surgery, University of Chicago Medicine, Chicago, IL, USA.
¹⁹ Department of Pediatrics, University of Antioquia, Medellin, Colombia.
²⁰ Pediatric Intensive Care Unit, Clínica Las Américas-AUNA, Medellin, Colombia.
²¹ School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada.
²² Department of General and Emergency Surgery, Polytechnic University of Marche, Ancona, Italy.
²³ School of Medicine, Anglia Ruskin University, Chelmsford, UK.
²⁴ Department of Surgery, Papageorgiou General Hospital, Thessaloniki, Greece.

PMID: 40325243
DOI: 10.1007/s00464-025-11749-7

Abstract

Background: Complete mesocolic excision (CME) is a surgical approach for right-sided colon cancer, involving the resection of the primary tumour along with an intact mesocolon, central vascular ligation, and exposure of the superior mesenteric vein. It has been postulated to improve oncologic outcomes such as disease-free survival and reduce local recurrence compared to standard right colectomy. However, the clinical benefits are still debated.

Objective: This systematic review and meta-analysis, sponsored by the European Association for Endoscopic Surgery, aims to compare the oncologic outcomes of CME with standard right colectomy for right-sided colon cancer, with the ultimate objective to inform clinical practice recommendations.

Methods: We followed the PRISMA 2020 reporting standards. A comprehensive literature search was conducted to identify relevant studies published from 2008 onwards, focusing on randomised trials and matched cohort studies comparing CME with standard right hemicolectomy. The GRADE methodology was used to assess the certainty of evidence, and minimal important differences were calculated to inform clinical relevance.

Results: Thirteen studies, amongst which three randomised trials, were included. No difference was found between CME and standard colectomy in terms of 30-day mortality, major peri-operative morbidity, or major blood loss. However, patients who underwent CME showed improved overall survival (HR = 0.67, 95%CI [0.48 - 0.93], low certainty of evidence) and disease-free survival (HR = 0.78, 95% CI [0.63 - 0.96], low certainty of evidence) compared to those who underwent standard colectomy, though certainty of the evidence was low due to the high risk of bias in the observational studies.

Conclusion: Complete mesocolic excision may offer survival benefits over standard right colectomy for right-sided colon cancer. However, the evidence remains of low certainty, mainly due to the predominance of observational data with significant risk of bias. Future high-quality randomized trials are needed to confirm these findings and standardize surgical techniques to reduce heterogeneity and improve clinical outcomes.

Keywords: CME; Colon cancer; Complete mesocolic excision; EAES; Guidelines.

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Conflict of interest statement

Declarations. Disclosures: The authors declare no direct conflicts of interest related to this work. Indirect conflicts of external advisors were documented and managed as per Guidelines International Network Standards. Detailed conflict of interest statements of all contributors can be found online: https://osf.io/nfkwe/?view_only=f5e504b08325402e98f1480877795f53 . Alexander A. Tzanis, Francesco Maria Carrano, Konstantinos Perivoliotis, Sunjay Kumar, Christos Christogiannis, Dimitris Mavridis, Bright Huo, Nicole Bouvy, Niki Christou, Suzanne Dore, Audrius Dulskas, Christos Kontovounisios, Tim Lubbers, Francesco Palazzo, Philip Quirke, Dimitra Repana, Monica Terlizzo, Bethany Slater, Ivan D. Florez, Monica Ortenzi, Tan Arulampalam and Stavros A. Antoniou declare no direct conflicts of interest related to this work. Indirect conflicts of external advisors were documented and managed as per Guidelines International Network Standards. Detailed conflict of interest statements of all contributors can be found in the online appendix [40]. Ethical approval: Not applicable. Informed consent: Not applicable.

References

1. Tejedor P, Francis N, Jayne D, Hohenberger W, Khan J (2022) Consensus statements on complete mesocolic excision for right-sided colon cancer-technical steps and training implications. Surg Endosc 36(8):5595–5601. https://doi.org/10.1007/S00464-021-08395-0 - DOI - PubMed - PMC
1. Wang C, Gao Z, Shen Z et al (2022) Five-year prognosis of complete mesocolic excision in patients with colon cancer: a prospective, nonrandomized, double-blind controlled trial. J Am Coll Surg 235(4):666–676. https://doi.org/10.1097/XCS.0000000000000282 - DOI - PubMed
1. Kong JC, Prabhakaran S, Choy KT, Larach JT, Heriot A, Warrier SK (2021) Oncological reasons for performing a complete mesocolic excision: a systematic review and meta-analysis. ANZ J Surg 91(1–2):124–131. https://doi.org/10.1111/ANS.16518 - DOI - PubMed
1. Sica GS, Vinci D, Siragusa L et al (2023) Definition and reporting of lymphadenectomy and complete mesocolic excision for radical right colectomy: a systematic review. Surg Endosc 37(2):846–861. https://doi.org/10.1007/S00464-022-09548-5 - DOI - PubMed
1. Antoniou SA, Carrano FM, Tzanis AA et al (2025) Complete mesocolic excision for right-sided colon cancer: EAES rapid guideline – with SAGES and ESCP participation. Surg Endosc. 10(4):425

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A systematic review, meta-analysis and GRADE assessment of the evidence on complete mesocolic excision for right-sided colon cancer with SAGES and ESCP participation

Affiliations

A systematic review, meta-analysis and GRADE assessment of the evidence on complete mesocolic excision for right-sided colon cancer with SAGES and ESCP participation

Authors

Affiliations

Abstract

Conflict of interest statement

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources