Complete Mesocolic Excision (CME) is a surgical technique for colon cancer based on Total Mesorectal Excision principles for rectal cancer. CME involves sharp dissection along embryonic planes between the visceral and parietal fascia to remove the colon and intact mesocolon lymphovascular package. Central ligation of supplying vessels also aims to maximize lymph node harvest. A study of over 1,300 colon cancer patients who underwent CME found improved 5-year cancer survival rates and reduced local recurrence compared to previous techniques, correlated with higher lymph node counts. CME principles include producing an intact specimen and maximizing lymph node dissection for improved oncologic outcomes.

1. Complete Mesocolic Excision –
CME

2. Complete Mesocolic Excision –
CME
Principle
• Based upon TME (Total Mesorectal Excision)
principle Prof. RJ Heald
– Surgical technique rectal cancer
– “The holy plane” of rectal cancer
– Sharp dissection between the visceral
fascia (mesorectum) and parietal fascia
(Waldeyer - Denonvilliers)
– Specimen with lymphovascular entity of
rectum and mesorectum
– Initial rectal tumorspread confined
(lymphatic spread)

3. Complete Mesocolic excision -
CME
Principle
• TME principle
• Less local pelvic
recurrences 3%
• Improved rate curative
resections
• Improved survival and
tumor-free survival

4. Complete Mesocolic Excision -
CME
Principle
• TME principle

5. Complete Mesocolic Excision -
CME
Article

6. Complete Mesocolic Excision
Colonic cancer
• Embryological planes between visceral and
parietal (retroperitoneal) fascia present
around colon
• Sharp dissection visceral plane from
retroperitoneal
• Intact surgical specimen of colon and
mesocolon including possible initial lymphatic
spread
• Lymphatic spread follows colonic arteries in
mesocolon – high tie central origin – maximal
harvest regional lymph nodes
• Improved oncological outcome ?

7. Complete Mesocolic Excision -
CME
Method
• Separation visceral plane from the parietal one
– Right colon
– Mobilization of duodenum with pancreatic head
– Mesenteric root up to SMA/SMV – optimal exposure

8. Complete Mesocolic Excision -
CME
Method
• Separation visceral plane from the parietal one
– Right colon

9. Complete Mesocolic Excision -
CME
Method
• Separation visceral plane from the
parietal one
– Left colon
– Mobilisation splenic flexure,
mesocolon descending colon,
sigmoid
– Dissected off retroperitoneal
plane including prerenal fat,
ureter, vesicular/ovarian vessels

10. Complete Mesocolic Excision -
CME
Method
• Separation visceral plane from the
parietal one
– Transverse colon
– Detachment greater omentum
– Division two layers transverse
mesocolon at lower edge
pancreas

11. Complete Mesocolic Excision -
CME
Method
• Lymph spread first pericolic
• Subsequently towards central arteries
• Lymph node dissection
– Hepatic flexure 5 % head
pancreas, 4 % epiploic arcade
– Transverse colon epiploic
arcade
– Splenic flexure inferior edge
pancreatic tail
– Sigmoid sigmoidal arteries

12. Complete Mesocolic Excision -
CME
Method
• Lymph node dissection

13. Complete Mesocolic Excision -
CME
Method
• Central ligation supplying vessels
• Right colon

14. Complete Mesocolic Excision -
CME
Method
• Central ligation supplying vessels
• Right colon
• Ileocolic / right colic vessels
• Central origin SMA / SMV
• Preservation autonomic plexus
• Incision mesenterial plane covering SMV
• Right colic vein => superior gastroepiploic
vein divided
• Lymph nodes pancreatic head
• Caecum / ascending colon
• Above vessels + right branches middle colic
vessels

15. Complete Mesocolic Excision -
CME
Method
• Superior gastroepiploic vein

16. Complete Mesocolic Excision -
CME
Method
• Central ligation supplying vessels
• Transverse colon
• Central ligation middle colic artery /
vein
• Central tie right gastroepiploic artery
• Hepatic flexure transsection close
splenic flexure
• Splenic flexure transsection close
sigmoid
• Descending colon
• Central tie left ascending colonic
artery
• Preservation root IMA – dissection
lymph nodes origin

17. Complete Mesocolic Excision -
CME
Method
• Central ligation supplying vessels
• Middle descending colon / sigmoid
• Division root IMA / IMV
• Transsection distally upper 1/3 rectum
• Transsection proximally between left
transverse colon / distal descending
colon

18. Complete Mesocolic excision -
CME
Patients
• Prospective study
• University Hospital Erlangen, Germany
• 1438 patients between 1978 and 2002
• Inclusion criteria
– Solitary invasive (at least submucosa) colon
carcinoma (>16 cm from anal verge)
– No other history of previous or synchronous
malignancies
– No carcinoma because of FAP, UC or Crohn's
– No neo-adjuvant treatment; Stage I-III

19. Complete Mesocolic excision -
CME
Patients
• Exclusion criteria
– 109 patients (7,6 %)
– 37 patients no R0-resection (2,6 %)
– 42 patients surgical mortality (2,9 %)
– 30 patients tumour status unknown to
recurrence (2,1 %)
• 1329 patients analysed
• Median follow-up 103 months (1-335)
• WHO tumour classification / 6th
TNM classification

20. Complete Mesocolic excision -
CME
Patients
• Outcome assessment
– Cancer-related survival
• Death with locoregional or distant
metastases
– Rate locoregional recurrence
– Amount lymph node harvest
– Postoperative complications and mortality
• Comparison three time periods 1978-1984 /
1985-1994 / 1995-2002

21. Complete Mesocolic excision -
CME

22. Complete Mesocolic excision -
CME
Results
• 80,3 % uneventful post-op course
• 4,7 % re-operation (anastomotic
leak)
• Post-operative mortality 3,1 %
• Emergencies (9,5 %) higher rate
complications 34,4 % - 17 %
• Complication rate between
surgeons 11,7 % - 35,5 %

23. Complete Mesocolic excision -
CME
Results
• Lymph node harvest
• Median number 32 (2 – 169)
• Influence nodes on prognosis
• 682 N0 patients
• Median 29 (2-106)
• < 28 (n=314) 5 year survival 90,7 % (95% CI 87,4 - 94,0)
• > 28 (n=368) 5 year survival 96,3 % (95% CI 94,3 – 98,3),
P=0,018
• 383 Lymph node positive patients
• < 28 64,6 % (n=145, CI 56,6 – 72,6)
• > 28 71,7 % (n=238, CI 65,8 – 77,6) P=0,088

24. Complete Mesocolic excision -
CME
Results
• 5 year-rate of locoregional
recurrence 4,9 %
• Improvement recurrence rate
during 1978-1984 (6,5%) to 1995-
2002 (3,6%)
• Recurrence rate increased higher pT
or pN

25. Complete Mesocolic excision -
CME
Results

26. Complete Mesocolic excision -
CME
Results
• CME principle with production of an intact lymphovascular entity
(colon and mesocolon – dissection between visceral and parietal
fascia) and high central ligation of supplying vessels
• Improved 5-year cancer related survival (82,1% - 89,1%)
• Reduced local 5-year recurrence rate (6,5% - 3,1%)
• Prognostic factors
• Harvested lymph nodes
• pN, pT, extramural invasion, emergency presentation
• Institution

27. Complete Mesocolic excision -
CME
Discussion
• CME principle with production of an intact
lymphovascular entity (colon and mesocolon –
dissection between visceral and parietal fascia) and
high central ligation of supplying vessels
• Maximizing lymph node harvest (correlates
prognosis => improved survival)
• Intact fascial layer (prognostic relevance)
• Important provide integrity viseral mesocolic layer
along specimen - danger tumour dissemination
• Central vascular ligation maximizes node harvest

28. Complete Mesocolic excision -
CME
Discussion
• CME principle with production of an intact lymphovascular entity
(colon and mesocolon – dissection between visceral and parietal
fascia) and high central ligation of supplying vessels
• Right colon mobilisation mesenteric root and duodenum
with pancreatic head
• Right colonic flexure pancreatic head metastases
• Transverse colon and splenic flexure mobilisation
gastroepiploic arcade and dissection inferior edge pancreas

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