Quality assurance of surgical techniques for right colon cancer: Systematic review

Following the footprints of Bill Heald with total mesorectal excision (TME) in rectal cancers, Hohenberger applied the same approach to right-sided colon cancers by introducing the complete mesocolic excision (CME) resection. As a relatively new technique, there are few randomised controlled trials (RCTs) with no reporting of long-term oncological outcomes. Additionally, despite the available evidence defining the core principles of the technique, there are still variations in its application. This systematic review is aimed to assess the impact of standardisation of surgical techniques on outcomes of CME and standard right hemicolectomy (SRH).

Three RCTs and 15 non-randomised interventional studies (NRIS) were selected after a broad search of online databases. They were evaluated within the quality assurance framework provided through the 10-point checklist, defining how to standardise a surgical technique and minimising variations between the different surgeons and cases. Regression modelling was used to identify associations between the 10-point checklist and the dependent variables examined in CME and SRH.

RCTs showed that the standardisation of the lymphadenectomy (p = 0.005), the case volume of the surgeons (p = 0.041 and p = 0.021) and the monitoring of the videos (p = 0.005) were associated with reduced postoperative complications. The mortality rate was lower when the trials had standardised lymphadenectomy (p = 0.009), video assessment of the surgeons (p = 0.021) and video monitoring (p = 0.009). The coefficient of variation of lymph nodes harvested was reduced when the surgeons were assessed through videos (p = 0.031).

Adherence to robust quality assurance of surgical technique in complete mesocolic excision is associated with better outcomes.