arccs presentation

1. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Division of General and
Hepatobiliary Surgery
University Hospital of Verona
Laparoscopic resection
for T4 tumours
Corrado Pedrazzani, MD

2. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
I have no personal or financial interests to declare.
I have no financial support from an industry source at the current presentation.
Laparoscopic resection for T4 tumours
Asian Robotic Camp for Colorectal Surgeons
COI Disclosure
Name of Author： Corrado Pedrazzani

3. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
Asian Robotic Camp for Colorectal Surgeons
SELF Disclosure
Name of Author： Corrado Pedrazzani
• MIS has transformed CR surgery
• SURGICAL TECHNIQUE matters
• TUMOR STAGE matters
• CANCER BIOLOGY matters

4. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
Laparoscopic
surgery
•Less surgical trauma
•Less pain
•Less complications
•Shorter length of stay
•Improved recovery
ERAS
pathways
MIS & ERAS have transformed CR surgery

5. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
Pre-
Operative
OR
Hospital
stay
Early
Recovery
MIS & ERAS have transformed CR surgery

6. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
Pre-
Operative
OR
Hospital
stay
Early
Chemo
MIS & ERAS have transformed CR surgery

7. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
Pre-
Operative
OR
Hospital
stay
Early
Chemo
MIS & ERAS have transformed CR surgery
SURGICAL TECHNIQUE matters!

8. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
pT4 Colon Cancer & Laparoscopy

9. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
pT4 Colon Cancer & Laparoscopy
Guidelines
“…the role of laparoscopic surgery
in patients with T4 remains
controversial.”
“Laparoscopy is generally not
indicated in case of locally
advanced tumours.”
“Careful consideration must be
given as to whether operate
laparoscopically on patients with
T4 disease.”
Veldkamp et al., Surg Endosc 2004
SAGES, Surg Endosc 2013
NCCN Guidelines 2021
Kitano et al., Lancet Gastroenterol Hep 2017
“When the goal is curative resection,
intraoperative discovery of a T4 lesion
often requires conversion, unless the
surgeon is able to effectively resect
the lesion en bloc.”

10. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
pT4 Colon Cancer
pT4a: visceral serosa
10-15%
pT4b: adjacent structures
4-8%

11. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
Preoperative diagnosis of Serosal Invasion
Zhou et al. World J Surg Oncol 20121
Period: Jan 2018 – Jul 2020
Patients: 261
Correct Staging
T3cd: 45%
T4a: 66%
T3cd + T4a: 70%

12. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
• TUMOR STAGE
• CANCER BIOLOGY
RISK OF PERITONEAL METS!!

13. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
Lap Vs. Open Surgery
Zhou et al. World J Surg Oncol 20121
Meta-analysis
Period: 1995– 2012
No. of studies: 5 out of 2876
Patients: 1268
Conversion rate: 18.6% (95% CI 9 – 28%)

14. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
Lap Vs. Open Surgery
Zhou et al. World J Surg Oncol 20121
Retrospective cohort study with PSM
Period: 1997 – 2017
Patients: 272 pT4a cases
Laparoscopy: 126 cases

15. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
n = 63
Open Laparoscopy
Conversion / 11.1%
Anastomotic leak 4.8% 4.8%
Post-op ileus 7.9% 6.3%
Wound infection 4.8% 1.6%
Clavien-Dindo III-IV 9.5% 7.9%
Mortality -- --
LOS, days (95% CI) 10 (7-15) 7 (6-10)
Laparoscopic surgery
n = 204
Assessed for eligibility
n = 283 Inclusion criteria:
- Jan 2014 – Dec 2018
- Elective Surgery
- R0-R1 resection
- F-up > 24 months
Open surgery
n = 72
Case matching for
age, gender, center, BMI, ASA, pT4a/pT4b
n = 63

16. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
Lap Vs. Open Surgery: Long-term outcomes
Zhou et al. World J Surg Oncol 20121
Disease-free survival
Disease-specific survival

17. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
Lap Vs. Open Surgery: Long-term outcomes
Zhou et al. World J Surg Oncol 20121
Isolated Peritoneal Recurrence
Overall Peritoneal Recurrence

18. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
Zhou et al. World J Surg Oncol 20121
Period: Jan 2018 – Jul 2020
Patients: 261
Correct Staging
cT4b: 60%
Preoperative diagnosis of Adj. Organ Invasion

19. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Lap Vs. Open Surgery

20. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
Importance of Circumferential Resection Margins
Lancet Oncol 2008
Philip Quirke

21. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
pT4b Colon Cancer & Laparoscopy

22. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
pT4b Colon Cancer & Laparoscopy
Retrospective cohort study
Period: 2005 – 2014
Patients: 48 Lap cases
Conversion: 13%
Mortality: 0%
CRM+: 4.2%

23. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Lap Vs. Open Surgery

24. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Lap Vs. Open Surgery

25. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Lap Vs. Open Surgery

26. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
n = 167
pT4a pT4b
Conversion 3% 8.1%
Anastomotic leak 2.4% 2.7%
Infective compl. 3% 2.7%
Clavien-Dindo III-IV 4.2% 8.1%
Mortality -- --
Laparoscopic surgery
n = 204
Assessed for eligibility
n = 283
Open surgery
n = 72
Urgent surgery
N = 7
n = 37

27. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Laparoscopic resection for T4 tumours
pT4b Vs. pT4a Tumors
Mode of Recurrence
0
10
20
30
40
50
60
Systemic Peritoneal Locoregional Multiple
pT4a pT4b

28. V E R O N A U N I V E R S I T Y
Laparoscopic Right CME Hemicolectomy with D3 lymphadenectomy
Thanks for listening
Corrado Pedrazzani, MD
Associate Professor
Unit of Minimally Invasive Gastrointestinal Surgery
University Hospital ’G.B. Rossi’
Verona University
Tel: +39 045 8126719
Fax: +39 045 8027426
E-mail: corrado.pedrazzani@univr.it