Original article doi:10.1111/codi.

13159

Long-term results following an anatomically based surgical

technique for resection of colon cancer: a comparison with
results from complete mesocolic excision
L. Bokey*†, P. H. Chapuis‡§, C. Chan¶**, P. Stewart‡, M. J. F. X. Rickard‡, A. Keshava‡§ and
O. F. Dent*†‡§
*Department of Surgery, Liverpool Hospital, Sydney, New South Wales, Australia, †School of Medicine, University of Western Sydney, Sydney, New
South Wales, Australia, ‡Department of Colorectal Surgery, Concord Hospital, Sydney, New South Wales, Australia, §Discipline of Surgery, Sydney
Medical School, The University of Sydney, Sydney, New South Wales, Australia, ¶Division of Anatomical Pathology, Concord Hospital, Sydney, New
South Wales, Australia and **Discipline of Pathology, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia

Received 28 April 2015; accepted 5 September 2015; Accepted Article online 17 October 2015

Abstract

Aim Complete mesocolic excision (CME) has been
advocated as likely to improve the long-term oncologi-
cal outcome of colon cancer resection, although there is
a paucity of long-term results in the literature. The aim
of this study was to supplement our previously pub-
lished results on colon cancer resection based on a stan-
dardized technique of precise dissection along
anatomical planes with high vascular ligation and to
compare our long-term results with those of recent
European studies of CME.
Method Data were drawn from a prospective hospital
registry of consecutive resections for colon cancer
between 1996 and 2007, including follow-up to the
end of 2012. The principal outcomes from potentially
curative resections were 5-year Kaplan–Meier rates of
local recurrence, systemic recurrence, overall survival
and cancer-specific survival. Secondary outcomes for all
resections were postoperative complications, number of
lymph nodes retrieved and R0 status.
Results For 779 potentially curative resections the local
recurrence rate was 2.1% (95% CI 1.3–3.4), the sys-
temic recurrence rate was 10.2% (95% CI 8.1–12.7),
the 5-year overall survival rate was 76.2% (95% CI
73.0–79.0) and the cancer-specific survival rate was
89.8% (95% CI 87.3–91.9). For all 905 resections, rates
of 14 surgical complications were low and not dissimilar
to those in a comparable study. The median lymph
node count was 15 (range 0–113). R0 status was
confirmed in 883/905 patients (97.6%; 95% CI 96.4–
98.5).
Conclusion For colon cancer, meticulous dissection
along anatomical planes together with high vascular
ligation results in few complications, a high R0 rate,
low recurrence and high survival.
Keywords Complete mesocolic excision, recurrence,
survival
What does this paper add to the literature?
The literature on CME contains very little information
on long-term recurrence or survival, either overall or
within tumour stages. This study of 779 potentially
curative resections between 1996 and 2007 presents
observed recurrence and overall and cancer-specific sur-
vival rates, both in total and separately for tumour
stages.

patients up to 1995 [1]. This technique, which we did

Introduction
In 2003 we described a standardized technique for dis-
section of colonic cancer which had been adopted in
our unit in 1980 and subsequently carried out in 657
Correspondence to: Professor Owen F. Dent, Department of Surgery,
University of Western Sydney, Liverpool Hospital, Sydney, New South Wales,
Australia.
E-mail: owen.dent@netspeed.com.au
not claim to be novel, was based on precise dissection
along anatomical planes with high vascular ligation,
resulting in removal of the tumour and its lymphovas-
cular drainage within an intact layer of fusion fascia. In
2009 Hohenberger et al. described patients treated in a
similar fashion between 1979 and 2002, naming their
technique ‘complete mesocolic excision’ (CME) [2].
The aim of the surgical technique in both series was to

676 Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 18, 676–683
L. Bokey et al.
perform a bloodless extrafascial dissection with minimal
handling of the tumour and to remove the entire speci-
men as an ‘intact package’ without disrupting the
embryological tissue planes, thus minimizing the poten-
tial for surgical transection of the tumour. These tech-
niques also entailed ligation of the lymphovascular
bundle at the origins of the relevant principal named
vessels. A recent review of the outcome from several
CME series showed that although short-term results
were widely reported, data on long-term survival and
recurrence were available for only three of the eight
studies considered [3].
In our 2003 paper we compared our results during
the period from 1980 to 1995 with those from the per-
iod 1971 to 1979 before the technique was adopted in
our hospital, showing a statistically significant and inde-
pendent improvement in both overall and cancer-speci-
fic survival in the latter period [1]. The aims of the
present study were to report recurrence and survival
results from our continuing use of this technique over
the subsequent period from 1996 to 2007 and to com-
pare our findings with other studies giving long-term
results from CME. The primary end-points were recur-
rence, overall survival and cancer-specific survival. Sec-
ondary outcomes were complications, lymph node yield
and the absence or presence of tumour in any line of
resection (R status).
Method
Prospectively recorded data were drawn from a registry
of consecutive colorectal cancer resections which was
initiated in 1971 at Concord Hospital, a public tertiary
referral hospital in Sydney, Australia. The data set con-
tained detailed information on clinical aspects, operative
technique, pathology, adjuvant therapy and follow-up
[4,5] and had the approval of the Sydney Local Health
District Ethics Committee. All operations followed the
standardized procedure and were performed by mem-
bers the Concord Hospital colorectal surgical unit,
either at that hospital or at a single private hospital with
which they were affiliated. Resections between 1996
and 2007 inclusive for invasive adenocarcinoma in
which the distal margin of the tumour was more than
18 cm from the anal verge were selected for analysis.
There were two further phases of selection. First,
patients were excluded from analysis of lymph node
count and R0 resection rate if they had a resection as
an urgent operation, inflammatory bowel disease, ade-
nomatous polyposis coli, a previous resection for
colorectal cancer or a synchronous colorectal adenocar-
cinoma. Secondly, for analysis of recurrence and survival
after potentially curative operations, patients were fur-
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 18, 676–683
Long-term results of complete mesocolic excision
ther excluded if they had known unresected distant
metastases at the initial operation or histologically
demonstrated tumour in any line of resection, which is
the conventional definition of curative resection in stud-
ies of this type [2]. All patients who had not died were
followed for at least 5 years. Patients who had received
postoperative chemotherapy were excluded from our
previous report [1] but are included here for compara-
bility with other recent studies. Pathological examina-
tion of the resected specimen followed a standard
protocol as described previously [5–7]. Tumours were
staged according to the Australian Clinico-Pathological
Staging (ACPS) system for colorectal cancer [8]. The
four main stages of this system (A, B, C, D) are directly
equivalent to the main stages (I, II, III, IV) of the
American Joint Committee on Cancer/International
Union against Cancer (AJCC/UICC) pTNM system
but, importantly, ACPS differs in that all lesions with
histologically confirmed tumour in any line of resection
are coded as stage D (noncurative). There were no
missing data on any variable.
Outcome measures
The outcome measures for the first phase of analysis
were fourteen postoperative surgical complications,
seven medical complications, early reoperation, death
within 30 days of resection, lymph node count and R0
status. In the second phase the outcome measures were
local recurrence (clinically or radiologically suspected or
biopsy-proven tumour in the peritoneal cavity or pelvis
with or without newly diagnosed distant metastasis),
systemic recurrence (newly diagnosed distant metastasis
with or without local recurrence), overall survival and
colorectal cancer-specific survival.
Description of the operation
Our standardized operative technique was described in
our 2003 paper [1]. Dissection is performed along
extrafascial and avascular anatomical planes with high
vascular ligation. The technique is essentially the same
for open and laparoscopic surgery. Originally we did not
claim that this technique was novel and we believe that it
is currently widely practised by many surgeons [9].
Follow-up and assessment of recurrence and survival
Patients were seen at least every 6 months for the first
2 years after resection and then followed up yearly for
recurrence until death or 31 December 2012. Surveil-
lance included clinical examination, CT scan and serial
measurements of carcinoembryonic antigen. Colono-
677
Long-term results of complete mesocolic excision L. Bokey et al.

Table 1 Clinical and pathological characteristics of patients undergoing colonic resection.

Curative and noncurative Curative only

Feature Category (n = 905), n (%) (n = 779), n (%)

Sex Male 479 (53) 409 (52)

Female 426 (47) 370 (48)
Age (years) 20–74 558 (62) 469 (60)
≥ 75 347 (38) 310 (40)
Tumour site Caecum 147 (16) 127 (16)
Ascending colon 192 (21) 173 (22)
Hepatic flexure 43 (5) 39 (5)
Transverse colon 102 (11) 93 (12)
Splenic flexure 20 (2) 16 (2)
Descending colon 37 (4) 33 (4)
Sigmoid colon 364 (40) 298 (38)
Operative access Open 791 (87) 674 (87)
Laparoscopic 40 (4) 36 (5)
Laparoscopic assisted 74 (8) 69 (9)
Operation Right hemicolectomy 412 (46) 368 (47)
Transverse colectomy 8 (1) 7 (1)
Left hemicolectomy 55 (6) 44 (6)
Extended colectomy 63 (7) 54 (7)
Total colectomy 1 (0) 1 (0)
Proctocolectomy 4 (1) 4 (1)
High anterior resection 327 (36) 287 (33)
Hartmann’s operation 35 (4) 14 (2)
Maximum luminal dimension of tumour (cm) <5 508 (56) 458 (59)
≥5 397 (44) 321 (41)
Histological type Adenocarcinoma 791 (87) 680 (87)
Mucinous adenocarcinoma 108 (12) 95 (12)
Signet ring adenocarcinoma 6 (1) 4 (1)
Direct spread Submucosa 97 (11) 96 (12)
Muscularis propria 122 (14) 121 (16)
Beyond muscularis propria 538 (59) 461 (59)
Free serosal surface 148 (16) 101 (13)
Lymph node metastasis None 563 (62) 535 (69)
1–3 nodes 217 (24) 171 (22)
≥ 4 nodes 125 (14) 73 (9)
Apical node involved No 841 (93) 746 (96)
Yes 64 (7) 33 (4)
Tumour grade Low 47 (5) 47 (6)
Average 670 (74) 609 (78)
High 188 (21) 123 (16)
Venous invasion No 791 (87) 718 (92)
Yes 114 (13) 61 (8)
Adjacent organ infiltrated No 858 (95) 755 (97)
Yes 47 (5) 24 (3)
Australian clinicopathological stage A 184 (20) 184 (24)
B 351 (39) 351 (45)
C 244 (27) 244 (31)
D 126 (14) –
Postoperative radiotherapy No 896 (99) 776 (99)
Yes 6 (1) 0
Postoperative chemotherapy No 697 (77) 630 (81)
Yes 208 (23) 149 (19)

678 Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 18, 676–683
L. Bokey et al. Long-term results of complete mesocolic excision

Table 2 Postoperative complications. remained alive at the close of the study. Cancer-specific
survival time was measured to the date of death due to
Complication No. (%) (n = 905)
colorectal cancer and censored as for overall survival or
at the date of death due to other cause.
Surgical complications
Any wound complication 69 (7.6)
Septicaemia 26 (2.9) Statistical analysis
Abdominal abscess 14 (1.5)
Pelvic abscess 2 (0.2) The chi-square test was used to assess the significance
Infected vascular access line 25 (2.8) of differences in proportions. The Mann–Whitney U-
Pelvic haematoma 2 (0.2) test was used to assess the significance of differences in
Postoperative ileus > 3 days 84 (9.3) the lymph node count between stages. The Kaplan–
Any urinary complication 59 (6.5) Meier method and log-rank test were used to assess dif-
Small bowel obstruction 27 (3.0) ferences in survival between stages. The level for two-
Bleeding necessitating reoperation 3 (0.3) tailed statistical significance was taken as P ≤ 0.05 with
Deep venous thrombosis 11 (1.2)
confidence intervals (CI) at the 95% level. Analyses were
Pulmonary embolus 24 (2.7)
performed with SPSS version 22 (IBM Australia Lim-
Anastomotic leak* 14/864 (1.6)
Medical complications
ited, Sydney, 2013) and StatXact 9 (Cytel Software
Respiratory complication 135 (14.9) Corporation, Massachusetts, USA, 2010).
Cardiac complication 111 (12.3)
Renal failure necessitating dialysis 3 (0.3)
Results
Cerebrovascular accident 3 (0.3)
Organic confusional state > 24 h 84 (9.3) After exclusions 905 patients remained; 779 of these
Acute drug withdrawal 7 (0.8) had a potentially curative operation and their survival
Multi system failure 10 (1.1) and recurrence rates were determined. Patient and
Number of complications tumour characteristics for these two groups are shown
None 578 (63.9)
in Table 1. Rates of postoperative surgical complications
1 177 (19.6)
in the entire set of 905 patients were generally very low
2 71 (7.8)
3 26 (2.9)
(Table 2) except for prolonged postoperative ileus
4 21 (2.3) (9.3%), any wound complication (7.6%) and any urinary
5 19 (2.1) complication (6.5%). Medical complication rates were
≥6 13 (1.4) low apart from respiratory (14.9%), cardiac (12.3%) and
Early reoperation 35 (3.9) confusion (9.3%).
Died within 30 days of resection 12 (1.3) The lymph node count ranged from 0 to 113 with a
median of 15. The stage-specific medians were 13, 16,
*For 864 patients who had a restorative operation.
16 and 15 for Stages A, B, C and D respectively [signif-
icant differences were A vs B (P < 0.001), A vs C
scopy was generally not repeated until 1 year after (P = 0.001), B vs D (P = 0.042)]. R0 status was con-
resection and thereafter at 3–5 years unless otherwise firmed in 883/905 patients (97.6%; 95% CI 96.4–
indicated. If, at annual follow-up, the patient was found 98.5%).
to have died, the date of death and whether or not For 779 potentially curative operations, at the close
death was attributed to colorectal cancer were ascer- of study in December 2012, 8 (1.0%) patients had died
tained principally from the patient’s surgeon, family before discharge from hospital, 334 (42.9%) had died
physician or hospital records or, in a small number of subsequently, 427 (54.8%) remained alive at their last
cases, from the national death registration system or a follow-up [median survival 113 (60–203) months] and
close relative of the patient. 10 (1.3%) had been lost to follow-up [median survival
The time to recurrence was measured from the date 57 (6–108) months]. By the close of the study 17
of resection to the date of diagnosis of recurrence and patients had experienced local recurrence (13 with local
was censored at last contact for patients who were lost recurrence alone and four with local and systemic recur-
to follow-up or who remained alive and free of recur- rence). There had been 76 patients with purely systemic
rence in December 2012. Overall survival time was recurrence. Total and stage-specific Kaplan–Meier recur-
measured from the date of resection to the date of rence rates are shown in Table 3. Stage-specific 5-year
death due to any cause with times censored at last con- overall survival rates are shown in Table 3 and Fig. 1.
tact for patients who were lost to follow-up or who Regarding cause of death, by the close of the study 94

Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 18, 676–683 679
Long-term results of complete mesocolic excision L. Bokey et al.

Table 3 Kaplan–Meier recurrence and survival rates in 779 patients who had a potentially curative operation.

No. of patients No. of events Percentage 5-year survival/recurrence (95% CI)

Local recurrence 779 17 2.1 (1.3–3.4)

A 184 1 0.6 (0.1–4.0)
B 351 6 1.5 (0.6–3.6)
C 244 10 4.1 (2.2–7.8)
Systemic recurrence 779 80 10.2 (8.1–12.7)
Stage A 184 1 0.6 (0.1–4.0)
Stage B 351 24 5.8 (3.7–9.0)
Stage C 244 55 24.6 (19.4–30.9)
Overall survival 779 342 76.2 (73.0–79.0)
Stage A 184 63 86.4 (80.5–90.6)
Stage B 351 150 77.6 (72.9–81.7)
Stage C 244 129 66.3 (60.0–71.9)
Cancer-specific survival 739* 94 89.8 (87.3–91.9)
Stage A 178 4 98.2 (94.4–99.4)
Stage B 333 26 95.3 (92.1–97.2)
Stage C 228 64 75.2 (68.7–80.5)

*Cause of death could not be ascertained for 40 patients.

Proportion surviving Proportion surviving

1.0 1.0 Stage A

0.9 0.9
Stage B
0.8 0.8
Stage A
0.7 0.7
0.6 Stage C
0.6
Stage B
0.5 0.5
0.4 Stage C 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0
0 12 24 36 48 60 72 84 96 108 120 0 12 24 36 48 60 72 84 96 108 120
Months Months
Number at risk Number at risk
Stage A 184 178 160 144 95 57 Stage A 178 173 157 141 94 57
Stage B 351 318 295 245 170 125 Stage B 333 303 284 238 164 122
Stage C 244 207 174 138 86 63 Stage C 228 194 163 131 83 60
Figure 1 Overall 5-year survival by stage in patients who had Figure 2 Colon cancer-specific 5-year survival rates in patients
a potentially curative operation. who had a potentially curative operation.

(12.1%) patients had died of colorectal cancer and 40
(5.1%) of unknown causes, the latter necessarily being
excluded from analysis of cancer-specific survival. Stage-
specific cancer-specific survival rates are shown in
Table 3 and Fig. 2. Notably, cancer-specific survival did
not differ significantly between Stage B patients who
did and did not receive postoperative chemotherapy
[5-year rates 94.4% and 95.3% (log-rank P = 0.873)] or
between the equivalent Stage C patients (80.4% and
67.9%, P = 0.107).
Discussion
Given the growing interest in CME over the past dec-
ade it is surprising that so few studies have reported
long-term recurrence or survival. Apart from our own

680 Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 18, 676–683
L. Bokey et al. Long-term results of complete mesocolic excision

Table 4 Results from reports of patients who had an anatomical dissection of the colon for cancer. All survival and recurrence rates
are Kaplan–Meier rates.

Bokey (2003) [1] West (2008) [10] Hohenberger (2009) [2] Bokey (2014)

Study period 1980–95 1997–30 June 2002 1978–2002 1996–2008

Exclusions Noninvasive Inadequate digital Noninvasive Noninvasive
Metachronous CRC images to grade Previous malignancy Nonadenocarcinoma
FAP, IBD plane of Synchronous malignancy Previous CRC
Resection at urgent mesocolic dissection FAP, IBD Synchronous CRC
operation retrospectively Neoadjuvant therapy FAP, IBD
Distant metastasis No other exclusions Stage IV Resection at urgent
No patient had For survival/recurrence operation
neoadjuvant analyses: tumour in Hartmann’s operation
therapy resection margin; No patient had
Adjuvant therapy postoperative death; neoadjuvant therapy.
Postoperative death no data on recurrence For survival/recurrence
For survival/recurrence analyses: distant
analyses: metastasis; tumour in
tumour in resection resection margin
margin.
Central vascular Yes Not specified Yes Yes
ligation
Adjuvant therapy* Excluded Included Included Included
R0 resection 867/914 (94.9%) – 1401/1438 (97.4%) 883/905 (97.6%)
(95% CI (95% CI 96.5–98.2%) (95% CI 96.4–98.5%)
93.3–96.2%)
Lymph node yield – Mean 14.7 (SD 7.4) Median 32 Median 15
(range 2–169) (range 0–113)
5-year overall survival: 63.7% (n = 657) 65% (n = 120)† – 76.2%
Stages A/I to C/III (95% CI 73.0–79.0%)
curative (n = 779)
5-year cancer-specific 76.6% (n = 618) – 85% (95%CI 83.0–87.0%) 89.8%
survival: Stages A/I to (n = 1329) (95% CI 87.3–91.9%)
C/III curative (n = 739
5-year local recurrence: – – 4.9% (95% CI 3.7–6.1%) 2.1% (95% CI 1.3–3.4%)
Stages A/I to C/III (n = 1329) (n = 779)
curative
5-year systemic recurrence: – – – 10.2%
Stages A/I to C/III (95% CI 8.1–12.7%)
curative (n = 779)

CRC, colorectal cancer; FAP, familial adenomatous polyposis coli; IBD, inflammatory bowel disease.
*Included in or excluded from survival and recurrence analyses.
†
Estimated for curative mesocolic plane dissection from their Fig. 6(B).

study in 2003 [1] we know of only two other similar
large consecutive patient series of mesocolic plane sur-
gery for colon cancer at all sites which give long-term
oncological results [2,10]. In one, there is no indication
of whether central vascular ligation was performed [10],
whereas in the other [2] it was, as in our practice. The
characteristics and findings of these studies are com-
pared with our 2003 report and the present study in
Table 4. There is also a report [11] which we have not
included in the comparisons because a large majority of
its patients had already been reported in Hohenberger
et al. [2] and because it focused specifically on the
impact of radical lymph node dissection. A recent
review of CME findings [3] reported survival results
from two other studies, neither of which we included
because one was restricted to right hemicolectomy
rather than including all colonic segments [12] while
the other was focused on the extent of lymph node dis-
section and did not indicate whether patients had
undergone mesocolic plane surgery [13].
One of the two previous reports of original findings
(apart from our own) contained information on surgical

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Long-term results of complete mesocolic excision L. Bokey et al.

Table 5 Postoperative surgical complications in the report by reported elsewhere. For potentially curative operations,
Hohenberger et al. [2] and in the present study. the 65% overall 5-year survival rate reported by West
et al. [10] was distinctly lower than our rate of 76.2%
Hohenberger Present study
(95% CI 73.0–79.0%), while Hohenberger et al. did
[2] (n = 1438), (n = 905), n
n (%) [% (95% CI)] not report this rate. The 5-year cancer-specific survival
rate reported by Hohenberger et al. [85% (95% CI
Wound infection 49 (3.4) 61 [6.7 (5.2–8.6)] 83.0–87.0%)] [2] was lower than in our patients [89.8%
Septicaemia 10 (0.7) 26 [2.9 (1.9–4.1)] (95% CI 87.3–91.9%)]. Our failure to find a difference
Haemorrhage 13 (0.9) 3 [0.3 (0.0–0.9)] in cancer-specific survival between patients who did and
Abscess 20 (1.4) 16 [1.8 (1.1–2.8)] did not receive adjuvant chemotherapy suggests that
Urinary complication 43 (3.0) 59 [6.5 (5.0–8.3)] such treatment did not influence the favourable out-
Anastomotic leakage* 38 (2.6) 14 [1.6 (0.9–2.5)] come we observed. Our recent survival rates were signif-
Ileus 11 (0.8) 84 [9.3 (7.5–11.3)] icantly higher than those we reported in 2003 [1].
Postoperative death 45 (3.1) 12 [1.3 (0.7–2.2)] In summary, all three studies show generally good
*Calculated over all operations, restorative and nonrestorative. results with few pronounced differences, but the litera-
ture is deficient in comparisons between long-term out-
complications. [2] The complication rates in that study come from anatomical and nonanatomical colonic
were generally low but only some indices were directly dissection. The only such report is our own original
comparable with our findings (Table 5). 2003 study in which the control group comprised 210
By comparing estimated rates in the other series with patients who had nonstandardized operations before
the confidence interval around rates in our series it 1980 and the intervention group of 657 subsequent
appeared that rates of haemorrhage and abscess forma- patients had standardized operations along anatomical
tion were equivalent. Our rates of wound infection, sep- planes. After adjustment for other prognostic variables
ticaemia, urinary complications and prolonged we found significantly longer overall survival [hazard
postoperative ileus were higher than theirs, whereas ratio (HR) 1.5, 95% CI 1.2–1.8] and cancer-specific
their rates of anastomotic leakage and postoperative survival (HR 1.7, 95% CI 1.3–2.2) in the latter group.
death were higher than ours. However, it is possible Admittedly this study may have suffered from the prob-
that some disparities were due to differences in defini- lem that historical controls do not account for other
tions. unmeasured factors with the potential to influence the
Our lymph node count was determined in routine outcome (and that changed between the two periods).
histopathology practice rather than in a setting with a Although there are plausible reasons why CME should
special emphasis on lymph node recovery. Only routine theoretically achieve superior oncological results
staining was used and no fat-clearing techniques were [10,14], before being adopted generally the technique
employed. Our median node count of 15 was equiva- should be subjected to a randomized controlled trial to
lent to that of West et al. [10] (mean 14.7) but only demonstrate that it truly does yield improved long-term
half that of Hohenberger et al. [2] (median 32). The results that are not only statistically but also clinically
reason for the difference is not immediately apparent as significant. However, such a study would be technically
the dissection of lymph nodes described by Hohen- difficult and might be deemed unethical because dissec-
berger et al. appears very similar to our own, although tion along anatomical planes is now regarded as good
it may arise from a more intensive preparation of the and desirable surgery [9]. This notwithstanding, further
pathology specimen, not described in the report. Our well-designed, prospective studies are needed to confirm
R0 resection rate of 97.6% (95% CI 96.4–98.5%) was that the expected long-term benefits of anatomical colo-
identical to that of Hohenberger et al. [97.4% (95% CI nic dissection are not illusory.
96.5–98.2%)] [2], but Hohenberger et al. excluded Whereas West et al. had previously used the term
Stage IV patients whereas we did not. Our recent R0 ‘mesocolic plane surgery’ [10], Hohenberger et al.
resection rate was slightly higher than in our 2003 coined the term ‘complete mesocolic excision’ to
study. Although the difference was small it was never- encompass two aspects: (i) excision along anatomical
theless statistically significant. planes to avoid disruption of the fascial layer and (ii)
The 5-year local recurrence rate for potentially cura- high ligation at the origin of colonic arteries [2].
tive resection of 2.1% (95% CI 1.3–3.4%) in our Although this term has since been widely adopted we
patients was lower than that of Hohenberger et al. are concerned that it has led to confusion because of
[4.9% (95% CI 3.7–6.1%)] [2]. Our systemic recurrence the prominence of the word ‘complete’, which diverts
rate was 10.2% (95% CI 8.1–12.7%), but this was not attention from the key principle of dissection along

682 Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 18, 676–683
L. Bokey et al.
anatomical planes. ‘Complete’ implies a focus on the
extent and volume of the mesocolon resected rather
than on correct dissection along mesocolic anatomical
planes in order to deliver a specimen surrounded by an
intact mesocolic fascia. In this regard, the history of the
term ‘total mesorectal excision’ (TME) is instructive.
Initially TME was advocated for tumours at all levels in
the rectum [15]. By the mid 1980s, however, it was
realized that TME was neither necessary nor desirable
in the upper third of the rectum, at which time propo-
nents changed their policy so that TME was restricted
to tumours in the mid and lower third of the rectum
[16,17], a practice which was subsequently and confus-
ingly termed ‘selective total mesorectal excision’ [18],
then ‘partial mesorectal excision’ [19]. Despite this
change, in some centres the application of TME for
tumours at all levels persisted even up to the late 1990s
[20–22]. We feel that the term total mesorectal excision
contributed to this confusion and that similar confusion
may arise from the term complete mesocolic excision.
We believe that ‘anatomical dissection of the colon’
(ADC) would be a more appropriate term.
Acknowledgements
We thank Ronald C. Newland who examined and
reported on over 90% of the specimens and reviewed the
remainder before 2001, Gael Sinclair who maintained
the database and Jennifer White who was involved in the
follow-up of patients. Other surgeons responsible for
management of patients in the study were Stanley
Koorey, Peter Zelas and Christopher Young.
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