Branch Of Middle Colic Artery Research Articles

Oncologic safety of transverse colon cancer surgery without central vessel ligation.

108 Background: Transverse colon cancers (TCC) have mixed embryological and molecular characteristics of right and left colon cancers and they are difficult to classified to right or left colon cancer due to the ambiguity of their location. Therefore, there is a lack of research about TCC alone, and it tended to be excluded in previous large clinical trials. Also, the optimal surgical procedure for each TCC varies depending on the location and stage of the tumor and anatomic structure of the patient. Consequently, standardization of surgery for TCC has not been established, and the oncologic benefits of central vessel ligation (CVL) with complete mesocolic excision and D3 dissection are unclear yet. The aim of the study is to evaluate oncologic safety of TCC surgery without CVL of middle colic artery. Methods: It is a retrospective, observational study. The clinical, surgical, and pathological characteristics were investigated retrospectively and statistical analyses were performed using chi-square test, independent samples T-test, and Kaplan-Meier analysis. Mid TCC was defined as tumor arising in the middle third of transverse colon and determined by intraoperative exploration. Hepatic and splenic flexure colon cancer, which were defined as tumor is adjacent to liver or spleen, were excluded. Radical resection was conducted along the embryological surgical plane, following D2 or D3 dissection. Central vessel ligation was defined as ligation of root of middle colic artery. Results: The numbers of proximal, mid, and distal TCC were 48 (45.3%), 32 (30.2%), and 26 (24.5%), respectively. The numbers of right hemicolectomy, transverse colectomy and left hemicolectomy were 57 (53.8%), 28 (26.4%) and 21 (19.8%). The numbers of No CVL group and CVL group were 47 (44.3%) and 59 (55.7%). The numbers of stage I, II and III were 24 (22.6%), 45 (42.5%), 37 (34.9%), and 49 patients underwent adjuvant treatment. The most frequent organ of recurrence was peritoneum (N=6, 5.6%). There was no statistically significant difference of stage, mean number of retrieved lymph node (24.12 vs. 22.36 p=0.464), mean number of metastatic lymph node (1.53 vs. 0.74, p=0.163), mean proximal margin (19.2 cm vs. 16.7 cm, p=0.139), mean distal margin (9.6 cm vs. 9.9 cm, p=0.753), adjuvant chemotherapy, and the rate of recurrence with lymph node metastasis. Also, there was no statistically significant difference of 6-year DFS survival and OS in stage II and III. Conclusions: When following oncologic plane and adequate lymph node dissection, resection without CVL for TCC is considered to have equal surgical and oncologic outcomes comparing to resection with CVL. Therefore, it is considered that CVL would not be always mandatory for TCC surgery, and a branch of middle colic artery could be preserved, if necessary.

Technique of Antiperistaltic Left Colonic Conduit

We describe a case of total esophagogastrectomy with colonic pull-up, in a case which was initially planned for an Ivor Lewis approach. Reconstruction was done using antiperistaltic left colon conduit based on left branch of middle colic artery. What inspired us to write this report is that, this procedure finds place in many discussions of various studies but nowhere is its detailed technique described. Gastric conduit is the workhorse of esophageal cancer surgery, but sometimes an alternative is required when primary conduit has failed or the stomach is not available due to previous surgery or disease extension.

An unusual origin of the right colic artery from the right branch of middle colic artery - case report

Vascular variations are common and disseminated in the specialized literature, for practical reasons due to semiological and surgical possibilities, which provides safe procedures, innovative techniques and minimal iatrogenic. The arterial variations of the abdomen, mainly the visceral, are a chapter apart from the descriptive anatomy and are highly complex. The arterial variant this article consisted of the origin of the right colic artery from the right branch of the middle colic artery. This led us, at first, to consider, by misinterpretation of this distribution architecture, as a common arterial trunk between the middle colic artery and the right colic artery. Thus, considering the various interpretations and their possible intercurrences in surgical procedures associated with this type of finding, we concluded the need for comprehensive studies that can more accurately assess the variations associated with the right colic artery and massify the terminologies related to it.

Esophageal caustic stenosis – difficulties of therapeutic management

Esophageal stenosis is one of the most common sequels of caustic injury. After the ingestion, in the acute phase, the life support is sometimes critical, and the treatment varies from observation to esophagectomy. During the first 6 months, endoscopic dilation can be necessary in order to maintain the patency of the esophageal lumen.
 Usually, endoscopic dilation is the treatment of choice for caustic stenosis of the esophagus. Sometimes this procedure is not possible or too risky and then reconstruction surgery is needed, but no earlier than 6 months.
 We present the case of a 57 years old male who was referred to our clinic for the treatment of a mid-esophageal caustic stenosis, after the accidental ingestion of a concentrated alkaline substance 6 months before. After an initial successful endoscopic dilation, in the second attempt, due to the asymmetric position of the stenosis and the high risk of perforation, we decided to perform an esophageal by-pass. We chose to use the left colon for interposition, with the left branch of middle colic artery as the feeding source and the sigmoid trunk as the second arcade. The surgical procedure went uneventful, with restoration of normal oral feeding.

Colonic splenic flexure carcinoma: is laparoscopic segmental resection a safe enough oncological approach?

The surgical approach to the colonic splenic flexure cancer (SFC) is yet to be technically standardized. The aim of this study has been to retrospectively evaluate the oncologic long-term results of our cases comparing our data with other authors' experiences. Clinical data of patients with SFC operated on at our institute were retrospectively analyzed. The laparoscopic approach was used in the whole series, with limited resection distally and proximally to splenic flexure and the origin ligation of left colic artery and left branch of middle colic artery. Data on the oncological long-term safety were compared to our laparoscopic series of extended right colectomy for proximal two-third transverse colon cancer and high anterior resections for sigmoid-high rectal cancer and to the main evidences in the literature, found after a comprehensive review. From March 2008 to May 2018, we completed 53 laparoscopic splenic flexure resections (26 female and 27 male, age 71.5 ± 15.4years). The conversion rate was 3.8%. Most of the cases were stage II (pT3 73.5%, the mean number of lymph nodes harvested was 19.1, with positivity for malignancy in 45.3%). During the FU (43.5months), 2 patients dropped out. Out of the 51 residual cases, 37 were alive (72.5%) and 14 are deceased (27.5%). Compared to the literature, our survival rate does not show significant differences. The other oncological outcomes seem to be comparable with the data evaluated. More extended resections seem not to confer an increase of the overall survival rate.

Laparoscopic right hemicolectomy with complete mesocolic excision

Complete mesocolic excision (CME) has recently been reemphasized as a technical approach for anatomical dissection during colon cancer surgery. Although a laparoscopic approach for right colon cancer is performed frequently, identifying an adequate dissection plane is not always easy. In our practice, the patient lies in a modified lithotomy position. The first step is ileocolic area mobilization, followed by adequate retraction of the cecum laterally. This procedure enables discrimination of the ileocolic vessels and superior mesenteric vessels. Importantly, this method facilitates identification of the superior mesenteric vein (SMV), followed by the identification of the root of ileocolic pedicles. After that, sharp dissection along the SMV in an upward direction helps to safely identify the middle colic artery (MCA). Dissection then continues to the level of the origin of MCA, after which the right branch of MCA can be divided. A total of 128 consecutive patients (63 males) who underwent laparoscopic CME for right colon cancer by a single surgeon were analyzed in this study. There was no conversion to open surgery. The median operation time was 192min (interquartile range [IQR] 118-363min). The median proximal and distal resection margins were 11 and 10cm, respectively. The median number of harvested lymph nodes was 28 (IQR 3-88). There were six postoperative complications (4.6%). The median hospital stay was 5days (IQR 4-37days). The video demonstrates a laparoscopic CME for a patient who had advanced distal ascending colon cancer. In conclusion, identifying the anatomical location of the SMV and performing meticulous dissection along the SMV is an essential procedure for containing all potential routes of metastatic tumors. Initial ileocecal mobilization with adequate counter traction of the cecum may be useful for novice surgeons attempting to identify the location of SMV during laparoscopic CME for right colon cancer.

English

English

Laparoscopic Hemicolectomy in Ascending Colon Cancer with Situs Inversus Totalis

Introduction: Situs inversus totalis (SIT), occurring at a frequency of 1:5000–1:10,000 live births,1 is characterized by a complete right-to-left transposition of the thoracic and abdominal organs. Only five cases of laparoscopic colon surgery in an SIT patient have been reported. The present case describes a laparoscopic hemicolectomy necessitated by ascending colon cancer in a patient with SIT. Patient and Methods: A 54-year-old woman with ascending colon cancer was referred to our hospital. Preoperative chest radiography showed dextrocardia, and computed tomography showed complete transposition of the abdominal viscera, confirming a diagnosis of SIT. The patient, free of distant metastasis, underwent laparoscopic right hemicolectomy and radical lymphadenectomy, performed by a surgeon experienced in laparoscopic colectomies. After inducing general anesthesia, the patient was placed in a modified lithotomy position, with the operator and scopist situated on the patient's right and the first assistant on the patient's left, similar to the positioning used in laparoscopic anterior resections. A 10-mm umbilicus trocar was inserted for the camera, and 5-mm trocars were placed in the right and left iliac fossa and subcostal areas, as working ports. Trocars were inserted symmetrically, we usually use this trocar system in Rt. hemicolectomy. The ascending colon, located on left side of patient, was mobilized along with the tumor, and the ileocolic vessels and right colic artery were identified and ligated. Radical lymphadenectomy was performed after ligation of the root of the middle colic artery and the right branch of middle colic artery. The umbilical wound was extended by ∼5 cm to allow for extracorporeal anastomosis and removal of the tumor; colon reconstruction was performed using a double-stapling technique. Results and Conclusions: The operation time was 120 minutes, with minimal blood loss. The resected tumor was a 1.5×1.2-cm Bormann type II moderately differentiated adenocarcinoma. The depth of the tumor's invasion into the submucosa was classified as pT1; no lymph node metastasis or angiolymphatic invasion was observed. The patient, discharged 7 days after surgery, did not receive postoperative adjuvant chemotherapy, and was free of complications and evidence of recurrence at her 2-year follow-up examination. Previous reports on cases of laparoscopic surgery in SIT patients1–3,11–14 have described the technical difficulties associated with the abnormal anatomy. In the present case, the surgical team needed to understand the modified vessel anatomy and orientation to avoid confusing the right colic artery with the ileocolic artery. Meticulous preoperative planning, including the selection of proper locations for the trocars, positioning of surgical personnel, and selection of a well-experienced surgeon, was essential for the successful outcome. The authors did not receive any grant or financial support to perform this study. Runtime of video: 7 mins 13 secs

Preoperative evaluation of mesenteric vascular anatomy using 256 multi-slice computed tomography before laparoscopic surgery

To evaluate mesenteric vascular anatomy using 256 multi-slice computed tomography (MSCT) before laparoscopic colorectal surgery. Eleven patients with colorectal cancer underwent 256 MSCT from February 2010 to December 2010. The evaluation items were visualization of mesenteric artery and vein by 3-dimensional CT angiography, which was compared with findings on laparoscopic surgery. Three-dimensional CT angiography correctly demonstrated variations of the mesenteric artery and vein and were consistent with laparoscopic findings. Of the 3 patients undergoing right hemicolectomy, ileocolic artery (ICA) ran ventrally to the superior mesenteric vein(SMV) in 1 patient, whereas ICA ran dorsally to the SMV in 2 patients; the right colic artery (RCA) branched directly from superior mesenteric artery(SMA) in 2 patients; RCA was absent and the left branch of middle colic artery(MCA) fed the tumor in 1 patient. In the patients who had transverse colon resection, MCA branched from SMA. In 2 of 3 patients who underwent sigmoidectomy, sigmoid artery (SA) branched from left colic artery(LCA); in 1 of 3 patients of sigmoid resection, SA branched from inferior mesenteric artery(IMA). In 4 patients with rectal cancer, the superior rectal artery (SRA) fed the tumor. The 256 MSCT is effective for evaluating mesenteric vascular anatomy variation before laparoscopic surgery for colorectal cancer.

Acute Lower Gastrointestinal Hemorrhage: Minimally Invasive Management with Microcatheter Embolization

To evaluate the efficacy of superselective embolization therapy in the management of acute lower gastrointestinal (LGI) hemorrhage, including any bleeding distal to the ligament of Treitz. Between June and August 2007, 20 patients with acute LGI bleeding underwent superselective transcatheter arterial embolization (TAE) at the authors' institution. The bleeding had different causes. All patients were treated with use of microcatheters. The following embolic agents were used: microcoils (n = 16), polyvinyl alcohol (PVA) particles (n = 2), and a combination of microcoils and PVA particles (n = 2). Outcome measures included technical success (complete cessation of bleeding as documented at completion angiography), clinical success (resolution of signs or symptoms of LGI bleeding within 30 days after TAE), and the rate of major and minor complications. The identified bleeding sources were as follows: jejunal branch, branch of middle colic artery, branch of ileocolic artery, ileal branch, branch of left colic artery, branch of sigmoid artery, branch of the superior rectal artery, and branch of the middle rectal artery. Technical success with effective control of active bleeding was achieved in all patients (100%). Clinical success attributed to TAE was documented in 18 of the 20 patients (90%). Major complications included death due to pulmonary embolism, heart infarction, and multiorgan failure in the 3rd week after TAE; a procedure-related colonic infarction occurred in one patient. A minor complication occurred in one patient who developed a groin hematoma. Superselective embolization may be used for effective, minimally invasive control of acute LGI bleeding.