Complete Mesocolic Excision (CME) in Right-Sided Colon Cancer - An Interview with Dr Patricia Tejedor
Dr Patricia Tejedor is a Colorectal Consultant Surgeon at University Hospital ‘Gregorio Marañón’ in Madrid, Spain. She was a Colorectal & Robotic Surgery Fellow in Portsmouth, United Kingdom 2018-2020, and a Colorectal & Robotic Surgery ESCP Fellow in Santander, Spain in 2021. She received EBSQ Coloproctology in 2022, and Pelvic Floor Master in 2021. She has also been a member of the ESCP Research Committee since 2020.
In this interview, Dr Tejedor speaks to Miguel Cunha about Complete Mesocolic Excision in right-sided colon cancer.
Miguel Cunha (MC): Before we start, thank you for agreeing to participate in this interview! It is a pleasure to interview you about such a special topic.
Dr Patricia Tejedor (Dr PT): It is a real pleasure. Thank you!
MC: You are an active researcher on Complete Mesocolic Excision (CME) for Right colon cancer. Can you please explain to us what CME is and what are the specificities of this technique?
Dr PT: The concept of CME includes three agreed key components: First, a standardized dissection along the embryological mesocolic plane, with the aim to achieve an intact mesocolon. Second, central vascular ligation; and third, the exposure of the superior mesenteric vein (SMV)
The technique can be performed by a subileal approach, SMV first, or supracolic approach, depending on the surgeon's preference and familiarity with each technique.
MC: The recently published Consensus from the CME Project Working Group is an important landmark paper. Congratulations on this fantastic paper! Your working group highlights the surgical approach and its learning curve. Is there evidence regarding the best surgical approach to performing this technique? Also, how many surgeries does one need to be considered an expert on CME?
Dr PT: The first phase of this project was organized during the CME meeting held in Portsmouth (UK) in 2019, where international experts in CME discussed the definition of CME, its indications, the technical steps, and the learning curve required to perform this intervention. Regarding the surgical approach, there is no evidence supporting robotic or laparoscopic surgery over the open approach, so it should be left to the surgeon's preference and training.
There is no minimum number of procedures required to be considered an expert in CME. However, it is important to follow a training pathway before performing such a complex procedure, beginning with previous laparoscopic experience and completing training courses and/or fellowships.
MC: Let’s discuss surgical complications and surgical outcomes. What are the most common short and long-term complications from CME? Concerning surgical and oncological outcomes, what would CME add to the standard right colectomy without CME?
Dr PT: Short- and long-term postoperative complications after CME are similar to those after a right colectomy, with some studies reporting a slightly higher incidence of postoperative ileus. However, there are some technique-related specific complications, such as delayed gastric emptying. Contrary to common belief, the rate of vascular injury is as low as approximately 1%. Although results from randomized controlled trials are not yet available, experts in the field have already demonstrated the oncological benefits of this technique for stage III disease. There is around a 10-15% increase in survival and lower rates of local recurrence compared to non-CME surgery.
MC: Do you think that CME should be applied to every patient with right/transverse colon cancer? If not, how can we select the appropriate patients?
Dr PT: CME is recommended for all patients diagnosed with locally advanced right-sided colon cancer (T3/T4, N+ve) based on preoperative CT scans. However, the main limitation is the difficulty in identifying these patients. We believe that achieving accurate tumour staging is one of the key aspects of CME surgery, as imaging methods may overstage some patients.
MC: That brings us to the end of this interview! Thank you for sharing your insight and expertise with us.
As for a final question: As a researcher and colorectal surgeon rising star, what do you think is required to implement this technique in a surgical department safely?
Dr PT: I believe it is essential to follow the same principles for every new technique implemented in a surgical department. Ideally, a team of two surgeons with previous experience in laparoscopic or robotic surgery and a background in CME should be designated to set up the procedure. They should also have the opportunity to receive training in hands-on courses and/or fellowships. Moreover, having a proctorship for the first few cases is even more important until they feel confident with the technique.
MC: Thank you so much for sharing your knowledge with us.
