CME and CVL For colon cancer:

Why and how I do It?

Dr dr Adeodatus Yuda Handaya SpB KBD

FK UGM-RSUP DR Sardjito Yogyakarta
2019
 CRC
• New cases 2018, an estimated
95,270(NCCN)
• Surgery primary treatment
• Chemotherapy commonly adjuvant setting.
• The 5-year overall survival 
– Localized ( 91%,)
– regional ( 72%)
– metastatic colon cancer (13%).
 Curative resection (R0) CRC Non Obtructing

–removal of the tumor colonic segment with

adequate proximal and distal margins,
–central ligation and division of the
supplying vessels
–removal of the attached mesocolon (CME)

(LOE III, SOR A) (ROVC: 98%)

Colon cancer surgical management guidelines Annals of Gastroenterology (2016) 29, 3-17
 Surgery Resection R0 vs R2
• R0 : removal all regional to the resected
bowel segment and lymph nodes.
• R2: A resection incomplete  if involved
lymph nodes are not removed.
 UICC recommendations
• at least 12 lymph nodes.
• <12 in number,
stagingnot optimal
and safe.
• The accuracy of staging
parallels the number
of removed lymph
nodes
Colorectal Lnn Group
M-CRC-Lnn
 CME-CVL

• First described Prof Werner Hohenberger

University of Erlangen, Germany 2009
• Feasoning lymphatic spread CRC follows
lymphatic vessels along the arteries and veins
in the mesentery
• Concept and Philosophy Total Mesorectal
Excision (TME) Heald et al . 1989
 Concept of CME
mesocolic plane (Toldt’s line) Sharp disection
• complete removal mesocolon and all draining
lymph nodes
• intact visceral fascia layer (mesofacial and
retrofacial)

Siani LM et al. The frontier of “meso-resectional” surgery. World J Gastrointest Surg 2016 February 27; 8(2): 106-114. DOI:
10.4240/wjgs.v8.i2.106
 Concept CVL)
• central tie and division of the supplying
arteries and veins
• large resected portion of the mesocolon,
Ensuring a containing many lymph nodes
F E Moro ́ n and J Szklaruk Learning the nodal stations in the abdomen The British Journal of Radiology, October 2007
 CONTROVERSIES REGARDING CME

• The CME West in 2008

– CME is a more extensive
– Originally CME open procedure

• D3 lymphadenectomy Japanese, Chinese,

Korean and Taiwanese
– D3 lymphadenectomy dissection of the
paracolic, intermediate and central lymph nodes,
– equivalent to CME
Dimitriou N, Griniatsos J. Complete mesocolic excision: Techniques and outcomes. World J Gastrointest Oncol 2015; 7(12): 383-388 Available from: URL:
http://www.wjgnet. com/1948-5204/full/v7/i12/383.htm DOI: http://dx.doi. org/10.4251/wjgo.v7.i12.383
 D3-resection
• Japanese literature colon resection for
malignancies with dissection of lymph nodes
near the SMA or SMV”
 D3 vs CVL

D3 right hemicolectomy accordingly to 2010 JSCCR guidelines (red lines) vs

complete mesocolic excision with central vascular ligation Hohenberger’s rules
(blue lines).
Siani LM et al. The frontier of “meso-resectional” surgery. World J Gastrointest Surg 2016 February 27;
8(2): 106-114. DOI: 10.4240/wjgs.v8.i2.106
 significance of the number of removed
lymph nodes Why ?
• There are two additional reasons emphasizing the :
1. increased number of removed lymph nodes is
associated with improved survival
2. ratio of the metastatic to total number of removed
nodes is inversely related to recurrence and overall
survival [34]
3. increased absolute number of negative retrieved nodes
is associated with better oncological outcomes even in
stage III disease.
The latter two stand true only when the number of
examined nodes is >12 [30,35-39].
 CME with CVL Procedure
• Three essential components :
(1) CME mesofascial or retrofascial plane to
mobilize mesocolon as an intact package;
(2) CVL with high tie to maximize the vertical
lymph node dissection (central spread);
(3) adequate length of bowel remove pericolic
lymphnodes, maximizing the longitudinal
lymphnode harvesting (longitudinal spread).

(Hohenberger et al., Colorectal Disease 11:354–365, 2009; West et al., J Clin Oncol
28:272–278, 2009)
 Based on the fact
• pericolic lymph nodes does not extend the 8
cm proximal and distal to the tumor baring
bowel segment
• bowel resection margins should be at least 10
cm
unless this is restricted by the exact location of
the tumor or/and type of colectomy
 Recomedation
• curative resection (R0) of the non-obstructing
colonic cancer involves :
– removal of the tumor baring colonic segment with
adequate proximal and distal margins, central
ligation and division of the supplying vessels and
removal of the attached mesocolon (CME).
– The exact length of bowel removed, vessels ligated
and divided and mesocolon removed depends on
the exact location of the tumor
(LOE III, SOR A) (ROVC: 98%)
 CVL
• proximal ligation and division of the vascular
stems supplying the specimen to be resected
(central vascular ligation, CVL) -->ensures
CME and the highest possible retrieved
number of lymph nodes [26,27].
 CVL and Tumor Situated
• cecum and ascending colon,
– CVL involves the ileocolic vessels and the right
branches of the middle colic vessels
• right side of the transverse colon,
– CVL involves the ileocolic and the middle colic
vessels
Cecum : CVL involves the ileocolic vessels and the right branches of the
middle colic vessels
 CVL and Tumor Situated
• middle and left transverse colon and the upper
descending colon
– CVL involves the middle colic vessels, and the ascending
branches of the left colic vessels
• descending colon to the rectosigmoid
– division of the inferior mesenteric artery at 1 cm distal to
its origin from the aorta and the inferior mesenteric vein
just below the lower border of the pancreas.
 CME

• Mesofascial between the Toldt’s fascia and the overlaying mesocolon

• Retrofascial between the Toldt’s fascia and the underlying
retroperitoneum.
Siani LM et al . The frontier of “meso-resectional” surgery
 CME + CVL in right colonic cancer
• Galizia et al (Italy), 2014
– 45 consecutive cases with open CME compared with 58 historical
controls using conventional operative techniques, mean FU 60 months
• Results
– Better lymph node harvest : 20 vs 15 (P<0.01)
– No loco-regional recurrences : 0 vs 12 (P=0.03)
– Higher disease specific survival : 93% vs 75%
– Longer operative time: 178 min vs 130min (P<0.01)
– More blood loss: 280ml vs 200ml (P<0.01)
– conventional operation associated with poor outcome: HR 1.34
(P<0.01) (Multivariate analysis):
 mortality and complication rates
CME-CVL
• Acceptable : Even though CME  more extensive
procedure
• Comparable: morbidity and mortality:
– In a systematic review,
• 30-d mortality 19.4%
• re-operative intervention 3.2%
• vascular complications 1.1%
• mean blood loss was 150 mL
• unusual complications: such as chyle leakage ,
duodenal injury
Dimitriou N, Griniatsos J. Complete mesocolic excision: Techniques and outcomes. World J Gastrointest Oncol 2015; 7(12): 383-388 Available from: URL:
http://www.wjgnet. com/1948-5204/full/v7/i12/383.htm DOI: http://dx.doi. org/10.4251/wjgo.v7.i12.383
 Outcome
• A retrospective, population-based study in
(Denmark) (stage I-III) colon cancer,
– 4-year DFS
• CME (85.8%; 95% CI, 81.4–90.1) VS Conventional
(75.9%, 95% CI, 72.2–79.7).
significant difference (P = .001)
• A systematic review 4 of 9 prospective studies
– improved lymph node harvest and survival
– reported improved specimen quality
 Laparoscopic vs open CME + CVL

• Systematic review by Miskovic D. et al (2016)

– 1 randomized and 7 case control trials from Korea, Japan and
Norway
– Total 1377 lap vs 1265 open CME colectomies
– Median FU range 48-60 months
• Results
– No statistically significant differences 
• 30 day mortality, anastomotic leakage, postoperative ileus,
wound infection, LOS, LN yield, local recurrence & survival
– Laparoscopic CME only significant in longer
operative time and less blood loss
 Controversies

• Routine performance of extended

lymphadenectomy is not recommended. Grade
of Recommendation: Strong recommendation
based on moderate-quality evidence, 1B.
 Recomedation
• macroscopic quality specimen integrity of
peritoneal and fascial- mesothelial surfaces
– classified as mesocolic, intramesocolic and
intramuscularis
(LOE III, SOR B) (ROVC: 99%)

Annals of Gastroenterology (2016) 29, 3-17

 Recomedation
• adequate staging at least 12 lymph nodes
should be found
– (LOE II, SOR A) (ROVC: 97%)
• Removal of the highest possible number of
lymph nodes is encouraged, as it is
associated with better oncological outcomes in
both stage II and III disease
– (LOE III, SOR B) (ROVC: 97%)

Annals of Gastroenterology (2016) 29, 3-17

 Conclusion
• if involved lymph nodes are not removed.
Resection is incomplete
• CMV-CVL Acceptable/safe procedure with
significan Better lymph node harvest and
loco-regional recurrences
Terimakasih