Lymph Node Distribution in the D3 Area of the Right Mesocolon: Implications for an Anatomically Correct Cancer Resection. A Postmortem Study

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Abstract

BACKGROUND:

Data on lymph node distribution in the right colon D3 area are scarce, especially for nodes posterior to the superior mesenteric vessels.

OBJECTIVE:

The aim of this study was to determine whether nodes exist posterior to the superior mesenteric vessels and if arterial crossing patterns affect node distribution.

DESIGN:

This is an anatomical postmortem study.

SETTINGS:

This study was conducted at the following institutions: Department of Gastrointestinal surgery/Pathology, Vestfold Hospital Trust, Norway; Institute for Pathology, University of Belgrade, Serbia; and Anatomy Sector, University of Geneva, Switzerland.

PATIENTS:

Fresh human cadavers were selected to undergo autopsy.

INTERVENTION:

A predefined D3 area was removed from cadavers, fixed in formaldehyde, divided into 3 vertical compartments with regard to the superior mesenteric vessels. Vertical compartments were further divided into 8 compartments. Millimeter slices were analyzed at histology.

MAIN OUTCOME MEASURES:

Lymph nodes ≥1 mm were counted in each compartment.

RESULTS:

Twenty-six cadavers (14 men), median age 76 years, were included. Mean node number per cadaver was 15.9 ± 7.4. Lateral, anterior, and posterior vertical compartments contained median 5.5 (1–11), 5 (2–21), and 5 (0–11) nodes. The effect of the ileocolic artery crossing pattern on node number in the posterior vertical compartment was p = 0.020. Anterior/posterior ileocolic artery compartments contained nodes in 58% and 85% cadavers with median of 1(0–7) and 2(0–5). These compartments showed a significant difference in node numbers depending on the ileocolic artery crossing pattern, p < 0.001 (posterior crossing) and p < 0.001 (anterior crossing). The middle colic artery compartment contained nodes in all cadavers with a median of 2 (1–4). The association between volume and total number of nodes in the D3 area was statistically significant, p < 0.001.

LIMITATIONS:

Nodes posterior to the superior mesenteric vessels do not necessarily have clinical relevance.

CONCLUSION:

Anatomically correct D3 resection implies posterior vertical compartment removal with posterior ileocolic artery crossing. Addition of the lateral vertical compartment to routine right colectomy has an improvement potential of 5 to 6 nodes.

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