A SICE (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie) observational prospective multicenter study on lymphadenectomy during right hemicolectomy: Should anatomical variability of the right colic artery influence the surgical strategy?-CoDIG 2 database (ColonDx Italian Group)

Abstract

Colon cancer is a worldwide common disease in both gender. Surgery is the best option for the treatment of advanced colon cancer without distant metasisis, 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 lymphonodes (203,213,223), but in 2009 Hoenberger et al. introduced the concept of complete mesocolic excision (CME) in which surgical dissection should follow the embryological planes in order to remove mesentery entirely. This way to prevent leakege of cancer cells and collect more lymphonodes. However, it is not possibile to verify that CME has improved onclogical survival, so our tudy shows how lymphadenectomy is currently performed in major italian centers against an unclear indication on the type of lymphadenectomy that should be performed during right hemicolectomy (RH). CoDIG2 is observational multicenter national study that involves 76 italian general surgery ward highly specialized in colorectal surgery. Each centers was asked not to modify their traditional surgical and clinical practice. Exclusion criteria were: aged < 18 years old, emergency surgery, laparotomic RH, ASA > IV and pregnant women. The aim of study was comparing the risk of postoperative complicationd during RH related to lymphadenectomy performed and the differences between CoDIG 1 study coducted 4 years ago. 788 patients was enrolled. The most used surgical technique was laparoscopic (82.1%) with intracorporeal (73.4%) side-to-side (98.7%) isoperistaltic (96.0%) anastomosis. Comparison between CoDIG1 and CoDIG2 shows a stable trend in surgical technique and complications, with the exception of the robotic approach which has been increasing in recent years (7.7% vs 12.3%). About lymphadenectomy the integrity of mesocolic sail has been in 88.3% of cases and the average lymph nodes harvest was 23, more frequently collected along colic vessels. Instead, sampling of lymph nodes at the origin of the colic vessels was more difficult and associated with more complications, even if the robotic surgery was most used. This analysis show a promising trend regarding how lymphadenectomy is performed in Italy to achieve the oncological outcomes in the RH, even if the technique to achieve a higher lymph nodes count has not been standardized yet.

Keywords: CoDIG2; D3 lymphadenectomy; Japanese classification; Laparoscopy; Right colectomy; Right colic artery; Right colon cancer lymphadenectomy.