Podcast
Questions and Answers
Which of the following statements is TRUE with regards to D3 lymphadenectomy for right colon cancer?
Which of the following statements is TRUE with regards to D3 lymphadenectomy for right colon cancer?
- D3 lymphadenectomy is associated with similar oncological outcomes as D2 lymphadenectomy
- D3 lymphadenectomy is associated with improved oncological outcomes, without any increased in anastomotic leak rates or operative mortality. (correct)
- Laparoscopic D3 retrieval is associated with lower or similar risk of hemorrhage as open technique.
- D3 lymphadenectomy is associated with increased lymph node harvest, without any impact on recurrence survival rates, but with an increase in the rate of anastomotic leak rates and operative mortality.
In the context of right colon cancer, which of the following is a risk specific to performing D3 lymphadenectomy laparoscopically, compared to open technique?
In the context of right colon cancer, which of the following is a risk specific to performing D3 lymphadenectomy laparoscopically, compared to open technique?
- Higher risk of distant metastatic recurrence
- Higher risk of anastomotic leaks
- Increased operative mortality
- Increased risk of major hemorrhage (correct)
What are the recommended margins for right colon cancer resection in centers advocating Complete Mesocolic Excision (CME) with D3 dissection?
What are the recommended margins for right colon cancer resection in centers advocating Complete Mesocolic Excision (CME) with D3 dissection?
- 5 cm proximal margin, and 10 cm distal margin.
- 10 cm proximal margin, and 5 cm distal margin
- 10 cm on both proximal and distal margins (correct)
- 5 cm on both proximal and distal margins
Which of the following approaches for mobilizing the right colon for right hemicolectomy is more commonly used in laparoscopic surgery, compared to the open technique?
Which of the following approaches for mobilizing the right colon for right hemicolectomy is more commonly used in laparoscopic surgery, compared to the open technique?
Which of the following is the principal goal of oncological colon surgery?
Which of the following is the principal goal of oncological colon surgery?
Which statement regarding the 'No touch technique' for colon cancer surgery is TRUE?
Which statement regarding the 'No touch technique' for colon cancer surgery is TRUE?
In the context of colon cancer surgery, how does stapled anastomosis compare to handsewn anastomosis?
In the context of colon cancer surgery, how does stapled anastomosis compare to handsewn anastomosis?
During a right hemicolectomy, which of the following vascular pedicles must be ligated?
During a right hemicolectomy, which of the following vascular pedicles must be ligated?
In the context of colon cancer, which of the following is classified as D1 lymph nodes?
In the context of colon cancer, which of the following is classified as D1 lymph nodes?
What percentage of positive lymph nodes is located around the head of the pancreas for colon cancers at the hepatic flexure?
What percentage of positive lymph nodes is located around the head of the pancreas for colon cancers at the hepatic flexure?
Which of the following is the most appropriate sequence of surgical technique during oncological colon surgery?
Which of the following is the most appropriate sequence of surgical technique during oncological colon surgery?
In which of the following situations does the complete mesocolic excision technique for colon cancer have the most impact on the oncological outcome?
In which of the following situations does the complete mesocolic excision technique for colon cancer have the most impact on the oncological outcome?
Which of the following outcomes is associated with intact mesocolic fascia in the surgical specimen from colon cancer surgery?
Which of the following outcomes is associated with intact mesocolic fascia in the surgical specimen from colon cancer surgery?
Which of the following colon resections has the highest risk of anastomotic leak?
Which of the following colon resections has the highest risk of anastomotic leak?
Which of the following is NOT an advantage of laparoscopic colon resection as compared to the open technique?
Which of the following is NOT an advantage of laparoscopic colon resection as compared to the open technique?
In colon cancer patients with no metastases, and undergoing colon cancer surgery, preoperative mood and wellbeing predict postoperative survival.
In colon cancer patients with no metastases, and undergoing colon cancer surgery, preoperative mood and wellbeing predict postoperative survival.
After how many weeks post colon resection does starting adjuvant therapy result in decreased survival?
After how many weeks post colon resection does starting adjuvant therapy result in decreased survival?
As per the MOSAIC trial for the adjuvant therapy for colon cancer, what is the advantage of FOLFOX compared to infusional 5FU/LV?
As per the MOSAIC trial for the adjuvant therapy for colon cancer, what is the advantage of FOLFOX compared to infusional 5FU/LV?
What is the half-life of bevacizumab?
What is the half-life of bevacizumab?
Flashcards
Oncological colon resection
Oncological colon resection
Surgical procedure aiming to completely remove the tumor and its surrounding lymph nodes.
Complete Mesocolic Excision (CME)
Complete Mesocolic Excision (CME)
A technique for oncological colon resection that involves removing the entire mesentery, the fatty tissue that holds the colon in place.
Central Vascular Ligation (CVL)
Central Vascular Ligation (CVL)
A technique where the blood vessels supplying the colon are tied high up, reducing the risk of cancer spreading.
D3 lymphadenectomy
D3 lymphadenectomy
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Medial-to-lateral approach
Medial-to-lateral approach
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Lateral-to-medial approach
Lateral-to-medial approach
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Cranial-to-caudal approach
Cranial-to-caudal approach
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No touch technique
No touch technique
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Anastomotic leak rate
Anastomotic leak rate
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Surgical volume
Surgical volume
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Chylous ascites
Chylous ascites
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D1 Lymph Nodes
D1 Lymph Nodes
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D2 Lymph Nodes
D2 Lymph Nodes
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D3 Lymph Nodes
D3 Lymph Nodes
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Complete Resection
Complete Resection
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Rationale for CME
Rationale for CME
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Total Mesorectal Excision (TME)
Total Mesorectal Excision (TME)
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Avoid Unnecessary Manipulation
Avoid Unnecessary Manipulation
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Anastomosis
Anastomosis
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Surgical Steps
Surgical Steps
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R0 Resection
R0 Resection
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Study Notes
Colon Cancer Surgery: Technical Aspects
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Thorough Peritoneal Cavity Exploration: Crucial for detecting metastatic disease before surgical dissection.
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Tumor Margin Requirements: 5 cm margin at proximal and distal ends for standard resections; 10 cm margin for CME (Complete Mesocolic Excision) + D3 dissection proponents.
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Goal of Resection: Complete tumor and lymph node removal. Accomplished by Complete Mesocolic Excision (CME), Central Vascular Ligation (CVL), and D3 lymphadenectomy.
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Colonic Mobilization Approaches:
- Medial-to-Lateral: Retract region, incise visceral peritoneum medial to blood vessel, dissect mesocolic plane, proceed laterally to paracolic gutter. Often used for minimally invasive procedures.
- Lateral-to-Medial: Retract region medially, incise peritoneum medial to Toldt's line, dissect into mesocolic plane, mobilize blood vessel for ligation. Faster mobilization, beneficial in emergencies.
- Cranial-to-Caudal: Retract greater omentum and transverse colon, sharply incise omento-colic attachment, proceed into avascular plane, mobilize colon medially and inferiorly to paracolic gutter.
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No-Touch Technique:
- Theoretical Rationale: Studies show malignant cell spread into the portal vein following manipulation.
- Practical Outcome: No correlation between "no-touch" technique application and worsened survival rates.
- Practical Advice: Avoid unnecessary manipulation of the primary tumor during surgery.
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Dissect, Ligate, Resect: Recommended sequence for surgical procedures.
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Anastomosis Techniques:
- Stapled vs. Handsewn: No difference in anastomotic leak rate; stapled anastomosis more associated with strictures; handsewn anastomosis results in longer operation time.
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Complete Mesocolic Excision (CME):
- Definition: Sharp dissection along avascular embryological planes separating the colon from retroperitoneal tissues. Pioneered by Dr. W. Hohenberger.
- Rationale: Reversed colorectal cancer survival trends. Intact mesocolic fascia suggests better outcomes (15% increased 5-year survival, 27% in Stage III).
- Outcomes: Reduced local recurrence (6.5% to 3.6%), improved 5-year overall survival (82% to 89%), most impactful in Stage III.
- Key Study from Hohenberger (2008): Prospective data from 1438 patients.
- Emergency procedures: 9.5%.
- Multi-visceral resections: ~ 12%, ~ 50% true tumor invasion.
- Open technique used.
- Mortality ~3%. Reoperation 4.7%. Anastomotic leak 2.6%.
- Median lymph nodes: 32. 28 lymph nodes as a cut-off for good prognosis (90% vs. 96% 5 year DSS).
- 85% 5-year survival for all stages (I-III).
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Central Vascular Ligation (CVL):
- Definition: Ligation of target vascular pedicle at most proximal site. Targets Arterial and venous structures.
- Rationale: Enhances mesenteric tissue and lymph node retrieval, lessening recurrence risk.
- Target Locations (for different colectomies): Right hemicolectomy, extended right, transverse colectomy; extended left, left colectomy, sigmoidectomy - detailed arterial targets given for each.
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D3 Lymphadenectomy:
- Definition: Regional lymph node dissection adjacent to major vascular trunks.
- Different Dissection Levels: D1 (pericolonic), D2 (along vessels), D3 (adjacent to vascular origins).
- Rationale: Majority of metastases are in small, non-enlarged (<5 mm) nodes. Number of retrieved nodes directly impacts local recurrence rate.
- Key Findings: D3 dissection (right colon) yields ~10% more positive lymph nodes.
- Border Specifications (right colon): Superior, medial, lateral, and caudal borders defined by targeted vessels.
- Outcomes (right colon): Better disease-free and overall survival; higher lymph node yields. No increase in complications. Benefits more evident in Stage III.
- COLD Trial: D2 vs. D3 in resectable colon cancer: D3 had significantly higher positive lymph node positivity.
Surgical Outcomes of Colectomy
- Anastomotic Leak Rates: Vary by colectomy type (right, others).
- Surgical Volume Correlation: Higher volume centers show lower mortality, complications, and reoperation.
- Preoperative Mood & Well-being: Influences postoperative survival in non-metastatic patients.
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