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Abstract

Introduction

This retrospective study compares the outcomes of right hemicolectomy (RHC) and extended right hemicolectomy (ERHC) in patients with hepatic flexure and proximal transverse colon tumors.

Methods

Data from 85 patients who underwent surgery for colonic adenocarcinoma between January 2015 and December 2023 were analyzed retrospectively. Patients who had hepatic flexure and proximal transverse colon tumors were included in the analysis. Patients were divided into two groups: RHC and ERHC. The primary endpoints were overall survival (OS) and disease-free survival (DFS), with secondary outcomes including postoperative complications and pathological data.

Results

The RHC group comprised 46 patients, while the EHRC group had 39 patients. The study found no significant difference in 5-year OS (77% RHC vs 69% ERHC, P = 0.135) or 5-year DFS (87% RHC vs 81% ERHC, P = 0.388) between the two groups. Although the ERHC group had a higher number of harvested lymph nodes (27 vs 22, P = 0.022), this did not correlate with improved survival outcomes. Tumor localization was identified as a significant factor influencing OS, with hepatic flexure tumors showing better survival compared to proximal transverse colon tumors. No significant differences were observed between the groups regarding postoperative complications.

Conclusion

Our study suggests that while ERHC leads to a higher lymph node yield, it does not significantly improve survival outcomes compared to RHC in patients with hepatic flexure and proximal transverse colon tumors. Further research is needed to optimize surgical strategies and improve patient outcomes.

Keywords

colorectal cancer right hemicolectomy extended right hemicolectomy long-term outcomes

Introduction

Worldwide, Colorectal Cancer is the second leading cause of newly diagnosed cancer cases and the third leading cause of cancer-related deaths annually.¹ The treatment for colon cancer is surgical resection. Depth of invasion and lymph node status are the two most important prognostic factors and determine the stage of the disease. While the 5-year survival rate is over 90% in stage I, this rate drops to approximately 60% in stage III.^2,3

Other important prognostic parameters are the histological type of the tumor and definitive oncological resection, which involves surgical removal of the tumor along with its feeding blood vessels and lymphatics.^4,5 If there is an invasion of adherent structures during this oncological resection, en bloc removal of these structures along with the primary tumor is required. The 2000 National Cancer Institute guidelines recommend a distance of 5 cm from the proximal and distal margins as sufficient for surgery to reduce the rate of anastomotic recurrence in colon cancer surgery.^6,7 This distance also ensures adequate lymph node excision, so that the recommended minimum number of lymph nodes to be examined for accurate staging is 12.⁸ Moreover, Complete Mesocolic Excision (CME), which was described by Hohenberger in 2009, is the standard dissection technique for colon cancer resection.⁹ Therefore, the recommended surgery in case of malignancy in the hepatic flexure or proximal transverse colon is to ligate the entire middle colic artery from its origin and perform an extended right hemicolectomy. On the contrary, El-Hussuna et al. have a study showing that extended resection not only does not have a survival benefit but is also associated with higher postoperative complication rates.¹⁰

In our study, we aimed to compare the results of the right hemicolectomy or extended right hemicolectomy procedure performed on patients with Hepatic Flexure and Proximal Transverse colon tumors operated on in our clinic. Moreover, the objective of this study was to determine whether ligation of the middle colic artery at its root is necessary for right flexure tumors and proximal transverse colon tumors.

Material-Method

Patient Selection

The data of all patients who underwent surgery for colorectal cancer at the Hospital’s General Surgery Clinic between January 2015 and December 2023 were analyzed retrospectively. Patients who underwent surgery for colonic adenocarcinoma for Hepatic Flexura and Proximal Transverse Colon Tumors were included in the study. Patients with pathological results other than colonic adenocarcinoma or those under 18 years old were excluded from the study. Patients with colorectal cancer located other than the Hepatic Flexure and Proximal Transverse Colon were excluded from the study. Emergency operations were excluded considering their significant impact on short-term and long-term outcomes, as well as the selection of operating strategy. To obtain more homogeneous groups, patients with tumors located in the cecum and ascending colon were also excluded from the study. The cases were divided into two groups according to the vascular ligation: Right Hemicolectomy (RHC), central ligation of the ileocolic artery, and ligation of the right colic artery, or if present, central ligation of the ileocolic artery and ligation of the right branch of the middle colic artery with CME (Figure 1). Extended Right Hemicolectomy (ERHC), central ligation of the ileocolic artery, and central ligation of the middle colic artery with CME.

Figure 1.

Operative Picture of Complete Mesocolic Excision

Demographic data, including age and gender; body mass index (BMI); the presence of comorbid disease; American Society of Anesthesiologists (ASA) score; postoperative hospital stay; pre-operative CEA and CA19-9 levels; tumor localization; operation type; postoperative complications, and pathological outcomes were noted. TNM classification of the tumor and pathological results were assessed according to the AJCC (American Joint Committee on Cancer) cancer staging manual, 8th edition.¹¹ Complications were assessed according to the Clavian-Dindo classification.¹²

The reporting of this study conforms to STROBE guidelines.¹³

The study was approved by the Marmara University Scientific Research Ethics Committee on 05.11.2024, with approval number “09.2024.891”. During the study, all procedures were carried out in accordance with the ethical rules and principles of the Declaration of Helsinki. Because of the retrospective design of the study, patients’ informed consent is not required.

Statistical Analysis

The statistical analysis was conducted using SPSS version 24.0 (SPSS Inc, IBM, in Chicago, US). The data were reported in terms of the mean ± standard deviation (SD), median, and interquartile range (IQR). The proportions or frequencies between the two groups were compared using Fisher’s exact test or the χ2 test. Differences in continuous variables were assessed using the Student’s t test for parametric values and the Mann-Whitney U test for non-parametric values. The survival curves were assessed using the Kaplan-Meier method and compared using the log-rank test. A Cox proportional hazard model was used to perform multivariate analysis in order to identify prognostic variables.

Results

Between January 2015 and December 2023, 573 right hemicolectomies were performed. Of them, 121 patients who underwent emergency surgeries were excluded. A total number of 318 patients who had caecum and descendant colon tumors were also excluded. Two patients had pathology results consistent with metastatic ovarian carcinoma. Patients who underwent surgery due to benign pathologies were excluded. Patients with synchronous metastasis were also excluded. Finally, 85 patients were eligible for the study (Figure 2). The patients were divided into two groups: RHC and EHRC. While RHC was performed in 46 patients, ERHC was performed in the remaining 39 patients. The basic characteristics of these groups are summarized in Table 1. No statistical difference was observed between groups regarding age, sex, BMI, Pre-Operative CEA, and CA 19-9 levels. However, it was observed that there was a statistically significant difference between the groups in terms of ASA score and comorbid diseases (P: 0.032 and P: 0.018, respectively).

Figure 2.

Patient Flowchart

Table 1.

Basic Characteristics Between Right Hemicolectomy (RHC) and Extended Right Hemicolectomy (ERHC) Groups. BMI: Body Mass Index ASA: American Society of Anesthesiologists CEA: Carcino Embryonic Antigen CA: Cancer Antigen IQR: InterQuartile Range

N: 85	RHC (N: 46)	ERHC (N:39)	P
Age (Mean)(±SD)	61.4 (±13.4)	65.1 (±12.1)	0.169
Gender (%)
Male	25 (54%)	19 (49%)	0.605
Female	21 (46%)	20 (51%)	0.605
BMI(kg/m2) (mean±SD)	27.5 (±5.4)	26.5 (±4.4)	0.852
ASA score
ASA 1	17 (37%)	7 (18%)	0.032
ASA 2	24 (52%)	20 (51%)
ASA 3	5 (11%)	12 (31%)
Comorbid diseases
Presence	24 (58%)	30 (76%)	0.018
Absence	22 (42%)	9 (24%)	0.018
Pre-operative CEA [median (IQR)]	2.5 (6.6)	3 (3.2)	0.939
Pre-operative CA 19-9 [median (IQR)]	10.2 (16)	9.7 (13)	0.385

Bolded values significant at p < 0.05.

Comparisons were made between the groups in terms of tumor localization, anastomosis type, hospital stay, postoperative complications, and pathological data (Table 2). Tumor localizations and anastomosis types differed significantly (P < 0.001 and P < 0.015, respectively). In the comparison of pathological data, there was no statistical difference between the groups in stage T, stage N, AJCC stage, lymphovascular invasion, perineural invasion, surgical margins, Micro Satellite Instability (MSI) status, and tumor-positive lymph node data. While the average number of harvested lymph nodes in the RHC group was 22, it was 27 in the ERHC group, and this difference was statistically significant (P: 0.022).

Table 2.

Pathological and Operational Outcomes Between Right Hemicolectomy (RHC) and Extended Right Hemicolectomy (ERHC) Groups

N: 85	RHC (N: 46)	ERHC (N:39)	P
Tumor localization			<0.001
Hepatic flexure	39 (85%)	20 (51%)
Transverse colon	7 (15%)	19 (49%)
Anastomosis			0.015
Hand-sawn	0	5 (13%)
Circular stapled	28 (61%)	26 (67%)
Linear stapled	18 (39%)	8 (20%)
Laparoscopic surgery	9 (20%)	7 (18%)	0.849
Hospital stay (days) [median (IQR)]	5 (1)	5 (2)	0.283
Complication	8 (17%)	7 (18%)	0.946
Hospital mortality	0	0
Stage T			0.634
T1	2 (4%)	1 (3%)
T2	5 (11%)	2 (5%)
T3	28 (61%)	23 (59%)
T4	11 (24%)	13 (33%)
Stage N			0.194
N0	32 (70%)	20 (51%)
N1	9 (20%)	11 (27%)
N2	5 (10%)	8 (22%)
Pathological stage			0.728
Stage I	4 (9%)	2 (5%)
Stage II	22 (48%)	20 (51%)
Stage III	20 (43%)	17 (44%)
Proximal surgical Margin(cm) [median (IQR)]	16 (8.5)	19 (13.2)	0.179
Distal surgical Margin(cm) [median (IQR)]	8 (5.8)	5.5 (4.8)	0.070
Tumor diameter (cm) [median (IQR)]	5 (3.5)	5 (2)	0.495
Lymphovascular invasion	26 (56%)	26 (67%)	0.339
Perineural invasion	19 (41%)	15 (38%)	0.790
Micro satellite Instability(MSI)			0.546
MSI low	34 (74%)	31 (79%)
MSI High	12 (26%)	8 (21%)
Harvested lymph nodes [median (IQR)]	22 (14)	27 (19)	0.022
Tumor positive lymph Nodes(mean±SD)	1.58 (±2.9)	1.5 (±2.7)	0.898

Bolded values significant at p < 0.05.

Overall Survival Analysis Between RHC and ERHC

Five-year Overall Survival (OS) was 77 % in RHC patients, while it was 69 % in ERHC patients (P = 0.135) (Figure 3). In the univariate OS analyses, the only significant parameter was observed to be tumor localization (Table 3). Since no difference was found in other parameters such as gender, age, pathological parameters, and comorbid diseases, it could not be applied in multivariate analysis.

Figure 3.

Overall Survival in Patients Who Underwent Right Hemicolectomy and Extended Right Hemicolectomy

Table 3.

Univariate and Multivariate Overall Survival Analysis for Colon Cancer

N:85	Univariate			Multivariate
N:85	HR	95% CI	P	HR	95% CI	P
Gender	1.606	0.719-3.584	0.248
Age	1.030	0.996-1.065	0.080
Comorbid diseases	1.880	0.750-4.714	0.178
Operation type	1.809	0.820-3.992	0.142
Tumor localization	2.384	1.087-5.226	0.030
Complication	1.235	0.458-3.332	0.677
Stage T (T1-T2 vs T3-T4)	0.691	0.237-2.017	0.499
Stage N (N0 vs N+)	1.824	0.829-4.014	0.135
Tumor diameter	0.997	0.853-1.167	0.993
Lymphovascular invasion	2.085	0.831-5.232	0.118
Perineural invasion	1.223	0.552-2.685	0.616
MSI low/High	0.799	0.299-2.131	0.653

Bolded values significant at p < 0.05.

Disease-free Survival Between RHC and ERHC

Five-year Disease-Free Survival (DFS) was 87 % in RHC patients, while it was 81 % in ERHC patients (P = 0.388) (Figure 4). Tumor Localization and Perineural Invasion were found to be related to DFS according to univariate and multivariate survival analysis with a 95% confidence interval (Table 4). The other parameters found not to be related to DFS were gender, age, comorbid disease, operation type, complication, Stage T, Stage N, Tumor Diameter, Lymphovascular invasion, and MSI status.

Figure 4.

Disease-Free Survival in Patients Who Underwent Right Hemicolectomy and Extended Right Hemicolectomy

Table 4.

Univariate and Multivariate Disease-free Survival Analysis for Colon Cancer

N:85	Univariate			Multivariate
N:85	HR	95% CI	P	HR	95% CI	P
Gender	2.118	0.721-6.217	0.172
Age	1.013	0.973-1.054	0.527
Comorbid diseases	0.869	0.309-2.442	0.789
Tumor localization	2.627	0.949-7.270	0.037	3.318	1.172-9.392	0.024
Operation type	1.564	0.567-4.317	0.388
Complication	0.742	0.166-3.319	0.696
Stage T (T1-T2 vs T3-T4)	0.806	0.182-3.573	0.776
Stage N (N0 vs N+)	1.525	0.551-4.218	0.416
Tumor diameter	0.959	0.776-1.185	0.696
Lymphovascular invasion	1.315	0.449-3.850	0.617
Perineural invasion	2.885	0.884-8.459	0.048	3.575	1.194-10.710	0.023
MSI low/High	1.261	0.392-3.992	0.708

Bolded values significant at p < 0.05.

Comparison of Tumor Localization

Since there was a difference in tumor location in the OS and DFS analyses, the patients were re-analyzed by taking their tumor location into consideration. While 59 patients had Hepatic Flexura tumor(HF), 26 patients had proximal transverse colon tumor (TC). While RHC (57%) was generally performed in the HF group, ERHC(73%) was seen to be the preferred surgical procedure in the TC group. In this comparison, the statistically significant differences were the type of surgical procedure performed, proximal surgical margin (23 cm vs 15 cm, P: 0.023), and distal surgical margin (8 cm vs 5 cm, P: 0.018). As we are comparing these procedures, by their anatomy they are different procedures and have different obvious margins. In the Survival analysis, OS was found to be statistically higher in the HF group (Figure 5, Log-Rank: 0.025). In the analysis of DFS according to tumor location, it was seen that DFS was higher in the HF group, which was not statistically significant (Figure 6, Log-Rank: 0.121).

Figure 5.

Overall Survival According to Tumor Localization

Figure 6.

Disease-Free Survival According to Tumor Localization

Discussion

This study showed that both right colon cancer groups have similar long-term OS and DFS outcomes regardless of mesenteric and vascular dissection. Although the complication rates were expected to be higher in extended resections, our results did not support it. The obtained results emphasize the importance of tumor microbiology and behavior being more effective in oncological outcomes. Therefore, the extent of surgical procedures to be performed needs to be thoroughly examined.

The 5-year OS and DFS in this study were (77% vs 69% and 87% vs 81%, respectively) similar to the existing literature.^14,15 The results indicate that the extent of resection does not have a significant effect on long-term survival. Furthermore, tumor localization might have a crucial role in OS, since hepatic flexure tumors were shown to have better outcomes than proximal transverse colon cancers. This finding emphasizes that the tumor biology and location may have a more significant effect than the extent of surgical resection. Recent studies have highlighted the heterogeneity of colorectal cancer based on tumor location, with complex genetic and molecular characteristics that might affect oncological outcomes.^16,17 Furthermore, the majority of patients with TC tumors underwent ERHC surgery, which may explain why ERHC surgery did not show a survival advantage in the present study. Extended lymph node dissections might show an advantage regarding OS and local recurrences.¹⁸ However, some studies found an increased risk of postoperative complications.¹⁹ In addition, especially for right colonic cancers, molecular types and microsatellite instability status might enhance the prognosis.²⁰ Therefore, especially for hepatic flexure tumors, the extension of the surgery should be handled on a case-by-case basis.

The dissection of a higher number of lymph nodes in the ERHC group (27 vs 22 in RHC, P = 0.022) aligns with the concept that extended surgical resections may yield a more extensive lymphadenectomy. Recent studies found that obtaining a sufficient number of lymph nodes is essential for the proper detection of the stage and prognosis of colorectal cancer.²¹ Nevertheless, this study fails to demonstrate any improvement in OS or DFS. This supports that collecting more lymph nodes may not provide substantial advantages in terms of survival. This is similar to the existing studies that have shown extended lymphadenectomy does not consistently correlate with improved oncological outcomes.²² Some studies found that pericolic lymph node metastasis longer than 10 cm is extremely rare.^23,24 This might be an explanation for the insufficient effect of the total dissected lymph nodes on prognosis.

Several studies have argued about the optimal operation procedure for transverse colon cancer.^25,26 It was found that transverse colectomy has comparable short and long-term outcomes with extended right or left resections. Milone et al. found that although the transverse colectomy group yielded a lesser number of harvested lymph nodes, there were no significant differences regarding postoperative complications, 5-year OS, and DFS.²⁷ Leijssen et al identified 103 patients who underwent a transverse colectomy (TC) vs extended right or left colectomy (EC). Of 103 patients, 63% underwent EC (right 47%, left 17%) and 37% TC. They noticed that OS and DSF were similar between the two groups, but there were fewer lymph nodes harvested and worse short-term outcomes in the TC group.²⁸ In our clinic, TC is rarely performed for transverse colon cancer. Hence, although the present study focused on a limited location of the colon, the results were in concordance with the existing literature.

One important concern regarding extended resection is the increased risk of postoperative complications. In their large population-based study,²⁹ Olofsson et al found that early postoperative mortality was significantly increased in extended resection. In contrast, the majority of studies showed no significant risk of complications in extended colonic resections.^30,31In this study, postoperative complication rates were similar between the groups, and no postoperative 30-day mortality was observed.

Although the discussion around the optimal surgical strategy for colon cancers continues, it is obvious that current and future treatment strategies will focus on tumor microbiology and genetic background. In their phase 2 trial, Chalabi et al obtained almost 70 % complete responses in MSI-H colonic cancers after neoadjuvant immunotherapy.^32,33 Right-sided colon cancers are more likely to be tumors with a high risk of MSI. In the present study, 24 % of the patients have MSI-H colon cancers. However, this may be a consequence of pathological examinations for MSI being routinely performed at our institute after 2017. Moreover, these improvements might limit the extent of surgical resections in the near future.

This study also has some limitations. First, the retrospective nature of the study might lead to some selection biases. Second, the relatively low number of patients limits the generalization of the results. Finally, even though the surgical procedures were performed in a single center, the type of surgery was decided according to the surgeon’s preference, which also might affect the results.

Conclusion

In conclusion, our study suggests that while ERHC leads to a higher lymph node yield, it does not significantly improve survival outcomes compared to RHC in patients with hepatic flexure and proximal transverse colon tumors. Tumor localization appears to play a critical role in prognosis, emphasizing the need for a personalized approach to surgical planning in colorectal cancer. Further research is needed to optimize surgical strategies and improve patient outcomes.

Footnotes

Hilmi Yazici

Ahmet Cem Esmer

Sena Altunsu

Barış Dağdemir

Aysenur Yildiz

Sevket Cumhur Yegen

Ethical Considerations

This study was approved by the Ethics Committee of Marmara University (date: 05.11.2024,with approval number 09.2024.891),and it was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Author Contributions

Hilmi Yazici,Sena Altunsu,Aysenur Yildiz,Barış Dağdemir: Data curation,Writing- Original draft preparation. Hilmi Yazici Ahmet Cem Esmer: Conceptualization,Methodology,Software Hilmi Yazici,Ahmet Cem Esmer: Visualization,Investigation,Writing- Reviewing and Editing. Hilmi Yazici,Ahmet Cem Esmer,Sevket Cumhur Yegen : Supervision,Software,Validation.

Funding

The authors received no financial support for the research,authorship,and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. *

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Long-Term Prognostic Outcomes of Right Hemicolectomy and Extended Right Hemicolectomy Performed for Hepatic Flexura and Proximal Transverse Colon Tumors

Abstract

Introduction

Methods

Results

Conclusion

Keywords

Introduction

Material-Method

Patient Selection

Statistical Analysis

Results

Overall Survival Analysis Between RHC and ERHC

Disease-free Survival Between RHC and ERHC

Comparison of Tumor Localization

Discussion

Conclusion

Footnotes

Ethical Considerations

Author Contributions

Funding

Declaration of Conflicting Interests

Data Availability Statement

References