Colonic Artery Research Articles

Four cases of laparoscopic colectomy for sigmoid colon and rectal cancer with persistent descending mesocolon

BackgroundPersistent descending mesocolon (PDM) is a congenital anomaly associated with the failure of fixation of the descending colon to the lateral abdominal wall. In the laparoscopic colectomy for colorectal cancer, it has been noticed that there are extensive adhesions and a distinctive anatomy of colonic vessels in cases with PDM. Therefore, it is necessary to have sufficient knowledge about PDM so that it can be appropriately treated during surgery.Case presentationCase 1—a 79-year-old man underwent laparoscopic intersphincteric resection for rectal cancer. Preoperative barium enema (BE) revealed that the sigmoid colon was located at the right side of the abdomen. An enhanced computed tomography (CT) showed that the common trunk of the left colic artery (LCA) and the first sigmoid colonic artery (S1) branched from the inferior mesenteric artery (IMA). Case 2—a 68-year-old man underwent laparoscopic sigmoidectomy for sigmoid colon cancer and laparoscopic distal gastrectomy for gastric cancer synchronously. BE showed that the descending colon ran from the splenic flexure to medial caudal side. An enhanced CT showed that the distance from the LCA to the marginal artery was 1.0 cm. Case 3—a 68-year-old man underwent laparoscopic low anterior resection for rectal cancer. BE showed that the descending colon ran to the medial caudal side. An enhanced CT showed that the mesentery of the descending colon was comparatively shortened. Case 4—a 60-year-old man underwent laparoscopic sigmoidectomy for sigmoid colon cancer. An enhanced CT showed that the descending colon ran to the medial caudal side and predicted that the LCA and S1 formed a common trunk and branched radially from the IMA. We reported four cases with PDM recognized preoperatively as above. Three cases had a shortening of the mesocolon. While dissecting the vessels, although special attention was required to maintain the blood flow to the intestine, none of these cases developed any complications during the postoperative course.ConclusionsWe considered that it is important to have positional awareness of the LCA and the marginal artery to perform the laparoscopic surgery safely when a colorectal cancer with PDM is diagnosed preoperatively using imaging methods.

The feasibility of laparoscopic TSME preserving the left colic artery and superior rectal artery for upper rectal cancer.

BackgroundLaparoscopic tumor-specific mesorectal excision (TSME) preserving the left colic artery and superior rectal artery is still a technically challenging procedure. We conducted this study to demonstrate the feasibility of this procedure for upper rectal cancer.MethodsA total of 184 patients with upper rectal cancer were retrospectively analyzed in our cancer center between April 2010 and April 2017. These patients were treated with either laparoscopic TSME (n = 46) or laparoscopic total mesorectal excision (TME) (n = 138). In the TSME group, the left colonic artery and superior rectal artery were preserved while they were not in the TME group.ResultsThe operation time in the TSME group was longer than that in the TME group (218.56 ± 35.85 min vs. 201.13 ± 42.65 min, P = 0.004). Furthermore, the number of resected lymph nodes in the TSME group was greater than that in the TME group (19.43 ± 9.46 vs. 18.03 ± 7.43, P = 0.024). The blood loss between the TSME and TME groups was not significant. No mortality occurred in either the TSME or TME groups. One patient in the TME group underwent conversion to laparotomy. The total postoperative complication rates in the TSME and TME groups were 8.7% and 17.4%, respectively. There was no difference in severe complications between the two groups (anastomotic leakage and stenosis).ConclusionsLaparoscopic TSME preserving the left colic artery and superior rectal artery can be safely conducted for upper rectal cancer.

Laparoscopic radical resection of rectal cancer with preservation of the left colic artery: anatomical basis and surgical experience

In order to increase the blood supply of anastomosis, surgeons choose to preserve the left colon artery (LCA) during the laparoscopic radical resection of rectal cancer. However, surgeons are always ailed by hemorrhage and incompletely dissection of No. 253 lymph nodes. One reason is the shortage of understanding the relationship between inferior mesenteric artery (IMA), LCA, and inferior mesenteric vein before surgery. Another reason is that surgeon always remove the lymph nodes around LCA, while don't normatively resect No. 253 lymph nodes, which affect the overall survival rate. Therefore, the "medial-to-lateral approach" for laparoscopic preservation with LCA radical resection in rectal cancer was suggested in this article. The CT technique could be used to analyze the IMA classification, which contribuated to the standard conservation of LCA. Laparoscopic radical resection of rectal cancer could be completed of high quality, through accurate definition and exactly dissection of the No. 235 lymph nodes.

Epicardial access for VT ablation: analysis of two different puncture techniques, incidence of adhesions and complication management

IntroductionPericardial access for ablation of ventricular arrhythmias (VA) can be gained either by an anterior-oriented or inferior-oriented epicardial puncture under fluoroscopical guidance. We retrospectively sought to assess the safety of these two puncture techniques and the incidence of epicardial adhesions and introduce our algorithm for management of pericardial tamponade.Methods and resultsIn 211 patients (61.4 ± 15.6 years, 179 males; 84.8%) 271 epicardial ablation procedures of VA were performed using either an anterior- or inferior-oriented approach for epicardial access. Puncture-related complications were systematically analyzed. Furthermore, the incidence of adhesions was evaluated during first and repeated procedures.A total of 34/271 (12.5%) major complications occurred and 23/271 (8.5%) were directly related to epicardial puncture. The incidence of puncture-related major complications in the anterior and inferior group was 4/82 (4.9%) and 19/189 (10.1%), respectively. Pericardial tamponade was the most common major complication (15/271; 5.5%). Collateral damages of adjacent structures such as liver, colon, gastric vessels and coronary arteries occurred in 6/189 (3.2%) patients and only within the inferior epicardial access group. Adhesions were documented in 19/211 (9%) patients during the first procedure and in 47.1% if patients had 2 or more procedures involving epicardial access.ConclusionAnterior-oriented epicardial puncture shows an observed association to a reduced incidence of pericardial tamponades and overall puncture-related complications in epicardial ablation of VA. In cases of repeated epicardial access adhesions increase significantly and may lead to ablation failure.

Surgical key points of precision functional sphincter-preserving surgery

The principle of sphincter-preserving surgery is to preserve the anal sphincter function under the premise of radical resection. Due to low position of rectal tumor, conventional laparoscopic surgery has difficulties in operating in the deep and narrow pelvis, which may lead to inaccurate tissue dissociation, imprecise positioning of tumor edge, excessive stretch of the anal sphincter complex, and excessive removal of distal rectal mucosa. Moreover, pain from abdominal auxiliary incision has an unavoidable side effect for postoperative recovery. With the help of the Liu's transanal microsurgery system, precision functional sphincter-preserving surgery (PPS) can be successfully performed. PPS tries to preserve left colonic artery and pelvic autonomic nerve in the transabdominal operation. In the part of transanal surgery, measurement, localization and resection of the lower edge of the tumor are conducted under a clear and open visual field with the transparent screw anal dilator. After the rectum is cut off, the specimen is taken out through the anus to avoid abdominal incision. Inserting the intestinal supporter to support the bowel stump, full thickness of bowel stump is then sutured with anal canal by vertical mattress suture. Special transanal tube is placed afterwards without routine prophylactic stoma. PPS can achieve precise tumor resection and sphincter preservation simultaneously.

Clinical Effect of Preservation or Nonpreservation of Left Colic Artery in Total Mesorectal Excision under Laparoscopy: A Meta-analysis

Background and Aims To investigate the clinical effect of preservation or nonpreservation of the left colic artery (LCA) in total mesorectal excision (TME) under laparoscopy. Methods The words, like “rectal cancer,” “left colonic artery,” and “laparoscopy,” were used as the retrieval terms, and the keyword retrieval method was adopted. The retrieval period was set as from January 1, 2013, to June 1, 2018. We searched databases including PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) to collect randomized and controlled trials which compared the effect of preservation or nonpreservation of the LCA in TME under laparoscopy. Two researchers independently carried out literature screening, data extraction, and literature quality evaluation; Review Manager 5.3 was used for the meta-analysis. Results Seven studies including 1467 cases were identified for the meta-analysis. As showed by the meta-analysis, compared with the LCA nonpreservation group, the LCA preservation group had significantly reduced incidence of anastomotic leakage (OR = 0.44, CI = [0.30, 0.65], P < 0.0001) and postoperative urinary and sexual dysfunction (OR = 0.26, CI = [0.09, 0.78], P = 0.02) and significantly shorter time for intestinal function recovery (WMD = −0.26, CI = [−0.41, −0.11], P = 0.0008). There were no significant differences between the two groups in the duration of surgery, blood loss, number of dissected lymph nodes, or postoperative hospital stay. Conclusions From the results, the LCA preservation group seems to achieve comparable success with acceptable safety outcomes. Therefore, this surgical method can be recommended in the clinical practice.

Analysis of robotic natural orifice specimen extraction surgery on 162 cases with rectal neoplasms

Objective: To explore the safety and feasibility of da Vinci robot surgical systems in natural orifice specimen extraction surgery (NOSES) for rectal neoplasms. Methods: A descriptive cohort study was used. Inclusion criteria: (1) age ≥18 years old; (2) diagnosis of rectal cancer by biopsy via colonoscopy or benign neoplasm locating in rectum that could not be resected locally through the anus; (3) R0 resection can be achieved by preoperative evaluation; (4) the CDmax (maximum circumferential diameter) was ≤5 cm or specimens could still be extracted from the anus despite a CDmax exceeding 5 cm but was along the longitudinal axis of the rectum. Exclusion criteria: (1) emergency operation due to gastrointestinal obstruction, perforation, or bleeding; (2) distal metastasis, induding lung, bone, or liver, that could not be resected simultaneously; (3) history of abdominal surgery or any other contraindications for robotic surgery. Clinicopathological data of 162 patients with rectal neoplasms who underwent robotic NOSES at the General Surgery Department of the Second Xiangya Hospital of Central South University from March 2016 to July 2019 were retrospectively collected. Of 162 patients, 94 were male and 68 were female; the average age was (57±13) years; the average BMI was (23.5±3.2) kg/m(2); the average distance from tumor to the anal verge was (8.2±2.9) cm. Five trocars were used to perform total mesorectal excision (TME), and the descending colon artery was preserved. Sterile endoscope sleeve for the specimen extraction was inserted into the pelvic cavity through the anus, and the resected specimen was pulled out through the sleeve. Outcomes of safety (operation time, intraoperative blood loss and postoperative morbidity of complication) and oncological outcomes (number of lymph nodes harvested, rate of lymph node metastasis and rate of positive resection margin) were collected. Results: All the 162 cases completed robotic NOSES successfully with no conversion to laparotomy. The average operation time was (188.7±79.8) minutes; the average blood loss was (47.1±33.2) ml; the average and the maximum CDmax of specimens were (3.4±1.5) cm and 12 cm respectively. A total of 154 patients underwent robotic TME. One underwent robotic TME plus resection of liver metastasis; one underwent robotic TME plus partial transverse colectomy; two patients underwent robotic TME plus ovariectomy; another two underwent robotic TME plus hysterectomy; one patient underwent robotic TME plus left partial nephrectomy due to renal angioleiomyoma; another one underwent robotic TME plus ureteral repair due to intraoperative injury of the left ureter. All the specimens were extracted through the anus. Protective ileostomy was performed in 6.8% (11/162) of the patients. The average number of lymph node harvested was 14.9±5.1. According to pathological reports, 156 neoplasms were adenocarcinoma. Tis stage was 1.3% (2/156), T1 stage was 9.0% (14/156), T2 stage was 26.3% (41/156), T3 stage was 35.9% (56/156), and T4 stage was 27.6% (43/156). Lymph node metastasis accounted for 34.6% (54/156), and simultaneous liver metastasis was observed in one case. Circumferential resection margins (CRMs) and upper and lower resection margins were negative in all the patients. The average postoperative feeding time and postoperative hospital stay were (4.2±4.1) days and (11.4±7.7) days, respectively. Postoperative morbidity of complication was 12.3% (20/162). The incidence of anastomotic leakage was 4.9% (8/162), of which only 4 cases (2.5%) received ileostomy. Within postoperative 90-day, no anal dysfunction or death were found. Conclusion: Robotic NOSES for rectal neoplasms is safe and feasible.

Preoperative evaluation using multi-slice spiral CT angiography of right-side colon vascular in laparoscopic radical operation for right colon cancer

Objectives: To examine the value of multi-slice spiral CT angiography (MSCTA) in the analysis of anatomical variation and structural classification of right colon vessels. Methods: From August 2015 to August 2017, 198 patients (96 of whom underwent laparoscopic radical resection of right colon cancer) at Department of General surgery of Peking University First Hospital were retrospectively collected, and the results of abdominal enhanced CT scan were collected and three-dimensional reconstruction of blood vessels was performed. There were 104 males and 94 females. The age was 64(27) years (M(Q(R)), range: 19 to 87 years). Right gastroepiploic vein, anterior superior pancreaticoduodenal vein, right colonic vein (RCV), superior right colonic vein, ileocolon artery or vein (ICA or ICV), middle colon artery or vein (MCA or MCV) and Henle trunk were observed and recorded respectively. The anatomical relationship between the positions of blood vessels, the length of Henle trunk and surgical trunk were measured. Results: ICV and ICA were the most constant anatomic structures. The ICV/ICA of all patients came directly from SMV/SMA, 36.9% (73/198) ICV going in front of SMV and 63.1% (125/198) behind SMV. 72.2% (143/198) of the patients had RCV imported into Henle trunk and the rest into SMV. Middle colonic vein (MCV) could be observed in 81.3% (161/198) of the cases. 81.4% (131/161) of MCV were imported into SMV, 16.8% (27/161) into Henle trunk, 1.2% (2/161) into the first jejunal vein and 0.6% (1/161) into the splenic vein. Henle trunk was divided into 4 types, among which the occurrence probability of gastric node and pancreatic trunk was the highest. The dry length of Henle trunk was (0.82±0.39) cm (range: 0.37 to 1.68 cm). The length of surgical trunk was (2.54±0.83) cm (range: 1.57 to 3.95 cm). Accuracy of MSCTA results was 96.9%(93/96). Conclusions: Anatomical variation of blood vessels in the right colon is common. Abdominal CT angiography can accurately determine the anatomical structure of the blood vessels in the right colon.

A case of transverse colon artery malformation with multiple digestive tract diseases

胃肠道血管畸形(GIVM)是胃肠道常见的血管异常病变，表现为管壁变薄、血管扩张，病变可位于整个肠道，以胃、十二指肠、右半结肠和小肠多见，以横结肠动脉畸形破裂出血的病例报道较少见。本文报道1例横结肠动脉畸形合并多种消化道疾病的老年患者临床资料及经验教训，结合文献分析横结肠动脉畸形在对该类患者进行诊疗过程中的影响及预后。患者经局部金属钛夹止血后疗效显著。

Safety, Survival, and Efficacy of Preserving Left Colonic Artery in Rectal Cancer Surgery: A Meta-Analysis and Review.

Purpose: This study analyzes the effect, long-term survival rate, and complications about preserving the left colonic artery (LCAP) in rectal cancer surgery. Methods: Relevant articles were systematically retrieved from multiple electronic databases, for example, EMBASE, BioMed Central, PubMed, Web of Science, and Cochrane. The time for retrieving was from the establishment of the database to December 31, 2018. Evaluated endpoints were effect of LCAP on the curative effect of rectal neoplasms, such as operation time, the amount of bleeding during the operation, root lymph nodes positive number, and the related complications (anastomotic leakage, etc.), postoperative urinary retention, 5-year survival rate, and recurrence differences in rates. Results: Totally 12 studies were included in this review. The meta-analysis showed that LCAP has less operation time and lower anastomotic leakage incidence. Intraoperative bleeding, root lymph nodes, and other complications did not show any significant difference. Conclusions: LCAP in radical rectal cancer surgery ensures both the radical resection of the tumor and the safety of the operation. So it can provide a new approach to the management of blood vessels and lymph nodes.

Clinical efficacy of radical resection with individualized surgical approach for borderline resectable pancreatic head carcinoma

Objective To explore the clinical efficacy of radical resection with individualized surgical approach for borderline resectable pancreatic head carcinoma. Methods The retrospective descriptive study was conducted. The clinicopathological data of 54 patients with borderline resectable pancreatic head carcinoma who underwent radical resection with individualized surgical approach in the West China Hospital of Sichuan University from January 2015 to January 2018 were collected. There were 37 males and 17 females, aged from 37 to 73 years, with a median age of 59 years. For venous type borderline resectable pancreatic head carcinoma, surgery for pancreatic head carcinoma and (or) pancreatic head and neck carcinoma was performed via inferior mesenteric vein, and surgery for pancreatic uncinate process carcinoma was performed via inferior colon artery. For arterial type borderline resectable pancreatic head carcinoma, surgery for pancreatic head carcinoma and (or) pancreatic head and neck carcinoma was performed via medial uncinate artery, and surgery for pancreatic uncinate process carcinoma was performed via left posterior artery. Observation indicators: (1) surgical situations; (2) postoperative complications; (3) postoperative pathological examination; (4) follow-up. Patients were followed up by outpatient examination or telephone interview once every 3 months to detect survival up to March 2019. Measurement data with normal distribution were represented by Mean±SD. Measurement data with skewed distribution were represented by M (range), and count data were represented by absolute numbers or percentage. Kaplan-meier method was used to draw the survival curve and calculate the survival rate. Results (1) Surgical situations: all the 54 patients underwent expanded pancreatoduodenectomy combined with superior mesenteric vein/portal vein (SMV/PV) resection, including 15 via inferior mesenteric vein, 20 via inferior colon artery, 12 via medial uncinate artery, and 7 via left posterior artery. The operation time was (320±83)minutes, and the volume of intraoperative blood loss was (865±512)mL. (2) Postoperative complications: of 54 cases, 28 had postoperative complications, including 13 with grade 1 Clavien-Dindo complications, 12 with grade 2 Clavien-Dindo complications, 3 with grade 3 or above Clavien-Dindo complications. One of the 28 patients with postoperative complications died and 27 were improved after symptomatic and supportive treatment. (3) Postoperative pathological examination: of 54 patients, 31 had R0 resection and 23 had R1 resection. In the 23 patients with R1 resection, 5 underwent surgery via the inferior mesenteric vein (4 with involvement of pancreatic anterior surface, 1 with involvement of both pancreatic anterior and posterior surface), 9 underwent surgery via the inferior colon artery (2 with involvement of both pancreatic anterior and posterior surface, 2 with involvement of superior mesenteric artery margin, 2 with involvement of pancreatic posterior surface, 2 with involvement of pancreatic anterior surface, 1 with involvement of superior mesenteric artery margin and pancreatic posterior surface), 5 underwent surgery via the medial uncinate process artery (2 with involvement of superior mesenteric artery margin, 2 with involvement of both pancreatic anterior and posterior surface, 1 with involvement of pancreatic neck transected margin), and 4 underwent surgery via the left posterior artery (3 with involvement of superior mesenteric artery margin, 1 with involvement of both pancreatic anterior and posterior surface). Of 54 patients, 16 had no positive lymph nodes, 26 had 1-3 positive lymph nodes, and 12 had 4 or more positive lymph nodes. The tumor diameter was (3.20±0.14)cm. There were 48 of 54 patients with nerve infiltration, 41 with superior mesenteric vein and/or portal vein infiltration, and 11 with vascular thrombus. There were 17 of 54 patients with high differentiation and medium differentiation, and 37 with low differentiation and undifferentiation. (4) Follow-up: 54 patients were followed up for 1-42 months, with a median time of 19 months. The 1-, 3-year overall survival rate was 78.0%, 11.4%. Conclusion As for the borderline resectable pancreatic head cancer, individualized and customized surgical approach according to the location of tumor and the relationship with blood vessels is helpful to standardize the radical resection and avoid R2 resection. Key words: Pancreatic neoplasms; Pancreatic cancer; Borderline resectable; pancreaticoduodenectomy; Surgical approach; R2 resection; Efficacy

Enhanced nitric oxide signaling amplifies vasorelaxation of human colon cancer feed arteries.

Inadequate perfusion of solid cancer tissue results in low local nutrient and oxygen levels and accumulation of acidic waste products. Previous investigations have focused primarily on tumor blood vessel architecture, and we lack information concerning functional differences between arteries that deliver blood to solid cancer tissue versus normal tissue. Here, we use isometric myography to study resistance-sized arteries from human primary colon adenocarcinomas and matched normal colon tissue. Vasocontraction of colon cancer feed arteries in response to endothelin-1 and thromboxane stimulation is attenuated compared with normal colon arteries despite similar wall dimensions and comparable contractions to arginine vasopressin and K+-induced depolarization. Acetylcholine-induced vasorelaxation and endothelial NO synthase expression are increased in colon cancer feed arteries compared with normal colon arteries, whereas vasorelaxation to exogenous NO donors is unaffected. In congruence, the differences in vasorelaxant and vasocontractile function between colon cancer feed arteries and normal colon arteries decrease after NO synthase inhibition. Rhythmic oscillations in vascular tone, known as vasomotion, are of lower amplitude but similar frequency in colon cancer feed arteries compared with normal colon arteries. In conclusion, higher NO synthase expression and elevated NO signaling amplify vasorelaxation and attenuate vasocontraction of human colon cancer feed arteries. We propose that enhanced endothelial function augments tumor perfusion and represents a potential therapeutic target. NEW & NOTEWORTHY Local vascular resistance influences tumor perfusion. Arteries supplying human colonic adenocarcinomas show enhanced vasorelaxation and reduced vasocontraction mainly due to elevated nitric oxide-mediated signaling. Rhythmic oscillations in tone, known as vasomotion, are attenuated in colon cancer feed arteries.

Three-dimensional computed tomographic angiography with computed tomographic colonography for laparoscopic colorectal surgery.

To prospectively correlate the preoperative vessel anatomy in three-dimensional computed tomographic angiography with computed tomographic colonography (3D-CTA with CTC) with that in laparoscopic surgery for colorectal cancer. The study protocol was approved by our institutional review board. The study population consisted of 101 patients with colon cancer who underwent 3D-CTA with CTC between June 2016 and January 2018. Two radiologists assessed the branching patterns of sigmoid arteries (SAs) and right colonic artery (RCA), the position between the ileocolic artery (ICA) and superior mesenteric vein (SMV), and the existence of an accessory middle colonic artery (aMCA). The vessel anatomy on 3D-CTA with CTC was correlated with that of intraoperative findings. Ninety-eight examinations (97.0%) were technically successful. Between preoperative and intraoperative vessel anatomy, the branching patterns of SAs were concordant in all 29 cases with rectosigmoid and descending colon cancer. The branching patterns of RCA and the position between the ICA and SMV were completely concordant in 32 cases of cecal and ascending colon cancer. No aMCA was identified either intraoperatively or by imaging analysis. 3D-CTA with CTC guided the surgeons to determine the resection margin of the relevant vessels for laparoscopic colorectal surgery.

Impact of Left Colonic Artery Preservation on Anastomotic Leakage in Laparoscopic Sigmoid Resection and Anterior Resection for Sigmoid and Rectosigmoid Colon Cancer.

To investigate the effect of left colonic artery (LCA) preservation on laparoscopic sigmoidectomy outcomes METHODS: We identified 447 consecutive patients who underwent laparoscopic sigmoidectomy at our hospital group between January 2010 and December 2016. We divided the patients into groups with and without LCA preservation and with and without anastomotic leakage (AL). We compared the patient age and gender, tumor location, stage, D2/D3 lymph node dissection, comorbidities, operating time, and blood loss between these groups. Univariate and multivariate analyses were performed to determine the risk factors for AL. There were significant differences in age, sex, tumor location, D2/D3 lymph node dissection, hypertension, operating time, blood loss, and AL for groups with and without LCA preservation. There were significant differences in sex, tumor location, and LCA preservation for groups with and without AL. Multivariate analysis showed male sex (hazard ratio (HR) = 6.37, 95% confidence interval (CI) 2.39-20.6; p < 0.0001), non-LCA preservation (HR = 5.01, 95% CI 1.41-31.8.0; p = 0.01), and rectosigmoidal tumor location (HR = 2.51, 95% CI 1.15-5.61; p = 0.01) as significant independent risk factors for AL. Based on the results obtained by performing laparoscopic operation for sigmoid colon cancer and rectosigmoid cancer, the LCA preservative procedure is warranted for prevention of AL.

Value of the multi-slice spiral CT angiography, CT colonography and image fusion technology in preoperative evaluation of laparoscopic right colon cancer

Objective To observe the distribution and variation of right colonic vessels, and investigate the clinical value of computed tomography angiography (CTA), computed tomography colonography (CTC) and image fusion technology in preoperative evaluation of laparoscopic right colonic cancer (RCC). Methods The retrospective and descriptive study was conducted. The clinicopathological data of 38 patients who underwent laparoscopic extended radical resection of RCC + D3 lymphadenectomy in the Affiliated Wuxi Second People′s Hospital of Nanjing Medical University between January 2015 and July 2017 were collected. Patients received preoperative plain and enhanced scans of abdominal and pelvic CT. The original images were reconstructed and fused by CTA and CTC, and then coming out with three-dimensional images of blood vessels and gut. Observation indicators: (1) branches of superior mesenteric artery (SMA); (2) positional relationship between SMA and superior mesenteric vein (SMV); (3) composition of gastrocolic venous trunk. Results Scan images of 38 patients had fused with scan images of vessels and primary tumors and reached the diagnostic standard, with a good imaging performance. Distribution of blood vessels of virtual reality (VR) images and were compared with that of naked blood vessels under intraoperative laparoscopy, showing a coincidence rate of 100.0%(38/38). (1) Branches of SMA: results of CTA and intraoperative anatomy showed that the occurrence rate of the right colonic artery, middle colonic artery and ileocolic artery were respectively 94.7%(36/38), 92.1%(35/38) and 100.0%(38/38). A right colonic artery was found in 28 patients. Ten patients had structure variation of right colonic artery, including 3 with 2 right colonic arteries and 2 without right colonic artery. The right colonic artery and middle colonic artery merged into the same trunk and then flowed into SMA were detected in 2 patients; the right colonic artery and ileocolic artery merged into the same trunk and then flowed into SMA were detected in 3 patients. (2) Positional relationship between SMA and SMV: results of CTA and intraoperative anatomy showed that the occurrence rate of both SMA and SMV was 100.0%(38/38). The SMA in 20 patients was located in the ventral side of SMV; SMA in 18 patients was located in the dorsal side of SMV. (3) Composition of gastrocolic venous trunk: results of CTA and intraoperative anatomy showed that 29 of 38 patients had gastrocolic venous trunks, which belonged to four sources, including right colonic vein, middle colonic vein, right gastric epiploic vein and anterior superior pancreaticoduodenal vein. Among 29 patients, 18 had 2- or 3-branch type of gastrocolic trunk that consisted of the right gastric epiploic vein, middle colonic vein and right colonic vein; 3 had 2-branch type of gastric pancreatic trunk that consisted of the right gastric epiploic vein and anterior superior pancreaticoduodenal vein; 8 had 3- or 4-branch type of stomach-pancreas-colon trunk that consisted of right gastric epiploic vein, anterior superior pancreaticoduodenal vein, right colonic vein and middle colonic vein. Conclusion CTA, CTC and image fusion technology can intuitively show the anatomy and variation of right colonic vessels, with a high clinical value. Key words: Colonic neoplasms; Preoperative evaluation; Vascular reconstruction; Computed tomography angiography; Computed tomography colonography; Extend right hemicolectomy; Laparoscopy

Laparoscopic radical treatment with preservation of left colon artery and superior rectal artery for sigmoid colon cancer

During the classical radical treatment for sigmoid colon cancer, ligation of the inferior mesenteric artery (IMA) at its root is typically performed to achieve better dissection of central and intermediate lymph node groups and improve the surgical outcomes. However, the blood supply to the left colon artery (LCA), sigmoid artery, and superior rectal artery (SRA) is blocked after the ligation at the root of the IMA. Here, we report laparoscopic radical treatment with preservation of the LCA and SRA for sigmoid colon cancer to preservation of blood supply to the anastomosis. The method was indicated to treat cancer at the middle portion of sigmoid colon. In the operation, we careful dissection of IMA exposes the trunk of IMA. The surrounding lymphatic tissue is dissected from the IMA root to its distal end. The LCA is preserved. After IMA divides LCA, 2–5 sigmoid colon arteries are transected one after another at the distal end of the LCA until it further divides into left and right rectal arteries before entering the lateral wall of rectum. The inferior mesenteric vein (IMV) is transected at the lower edge of the pancreas, and the mesorectum is cut open towards the spleen curvature at the lower edge of the pancreas. Other procedures are similar with IMA high ligation surgery. Generally, LCA and SRA can be successfully preserved, and if necessary, the colonic splenic flexure should be mobilized to ensure that there is no tension at the anastomosis. The operation doesn’t significantly prolonged operation, but retrieved comparable lymph node counts with IMA high ligation surgery. Dissection of the lymphoadipose tissues at the root of IMA with the preservation of LCA and SRA is an easily performed surgery. It guarantees further prospective clinical research to compare the anastomosis leakage and oncological outcome with IMA high ligation surgery.

Laparoscopic radical treatment with preservation of left colon artery and superior rectal artery for sigmoid colon cancer

: During the classical radical treatment for sigmoid colon cancer, ligation of the inferior mesenteric artery (IMA) at its root is typically performed to achieve better dissection of central and intermediate lymph node groups and improve the surgical outcomes. However, the blood supply to the left colon artery (LCA), sigmoid artery, and superior rectal artery (SRA) is blocked after the ligation at the root of the IMA. Here, we report laparoscopic radical treatment with preservation of the LCA and SRA for sigmoid colon cancer to preservation of blood supply to the anastomosis. The method was indicated to treat cancer at the middle portion of sigmoid colon. In the operation, we careful dissection of IMA exposes the trunk of IMA. The surrounding lymphatic tissue is dissected from the IMA root to its distal end. The LCA is preserved. After IMA divides LCA, 2–5 sigmoid colon arteries are transected one after another at the distal end of the LCA until it further divides into left and right rectal arteries before entering the lateral wall of rectum. The inferior mesenteric vein (IMV) is transected at the lower edge of the pancreas, and the mesorectum is cut open towards the spleen curvature at the lower edge of the pancreas. Other procedures are similar with IMA high ligation surgery. Generally, LCA and SRA can be successfully preserved, and if necessary, the colonic splenic flexure should be mobilized to ensure that there is no tension at the anastomosis. The operation doesn’t significantly prolonged operation, but retrieved comparable lymph node counts with IMA high ligation surgery. Dissection of the lymphoadipose tissues at the root of IMA with the preservation of LCA and SRA is an easily performed surgery. It guarantees further prospective clinical research to compare the anastomosis leakage and oncological outcome with IMA high ligation surgery.

Application of retention of the left colon artery and retention of the anal canal in the anterior resection of rectal cancer

Objective To explore the application of left colon artery and retention of anal canal in rectal cancer anterior resection. Methods 134 patients with rectal resection were divided into two groups by random number table.The observation group(n=67) received anterior resection of the left colonic artery and retained anorectal anterior resection.The control group(n=67) received subconjunctival artery root ligation, non-retained anorectal anterior resection of rectal cancer.The number of lymph node dissection and the incidence of postoperative anastomotic leakage were compared between the two groups.The rate of reoperation was compared between the two groups. Results The number of lymph node dissection in the observation group and control group was (4.2±1.3), (4.4±1.2), the difference was not statistically significant(P=0.450). The incidence rate of anastomotic leakage was 2.99% in the observation group, which was 11.94% in the control group, the difference was statistically significant(χ2=3.890, P=0.049). Conclusion In the case of no difference in preoperative and postoperative perioperative management, the left colonic artery and the anal canal were retained in the rectal cancer without affecting the lymph node dissection in No.253 group, but it could provide sufficient blood for the anastomosis, to reduce the risk factor of the occurrence of anastomotic leakage. Key words: Rectal neoplasms; Colorectal surgery; Anastomotic leak

Clinical effect of preservation of the left colonic artery in laparoscopic anterior resection for rectal cancer

Objective: To evaluate the value and feasibility of preservation of the left colonic artery (LCA) in laparoscopic anterior resection for rectal cancer. Methods: The clinical data of 97 patiens who received laparoscopic anterior resection of rectal cancer from 2009.3 to 2015.3 were randomly divided into two groups, including 52 cases with preservation of LCA and 45 cases without preservation of LCA. The operation time, quantity of bleeding, number of lymph nodes removed around the root of inferior mesenteric artery (IMA), the rate of lymph node metastasis around the root of IMA, the incidence of transverse colostomy and anastomotic leak were compared between the two groups. Results: All 97 operations were successfully completed by laparoscopic operation. There were significantly statistical differences in operation time, quantity of bleeding and transverse colon stoma between two groups(P<0.05), but no difference in the number of lymph nodes removed and the rate of lymph node metastasis. Conclusions: The preservation of the left colonic artery in laparoscopic anterior resection of rectal cancer can preserve more supplying vessels for anastomosis and prevent anastomotic leak.

Laparoscopic intersphincteric resection for low rectal cancer

Objective To investigate the surgical techniques and clinical efficacy of laparoscopic intersphincteric resection(ISR) in the treatment of low rectal cancer. Methods A retrospective descriptive study was performed. The clinical data of 12 patients who underwent laparoscopic low rectal anterior resection combined with ISR at the First Affiliated Hospital of Dalian Medical University from May 2014 to October 2014 were collected. The patients underwent abdominal operation including total mesorectal excision (TME)+ sphincter mobilization, then transanal intersphincteric resection, finally colinic anal-anal anastomosis. The operation time, volume of intraoperative blood loss, number of lymph node dissected, postoperative complications, time to anal exsufflation, duration of hospital stay, duration of postoperative hospital stay, pathological stage and follow-up were observed. The patients were followed up by outpatient examination and telephone interview at month 1, 3 and 6 after operation up to April 18, 2015. The follow-up included the prognosis of patients and the recovery of anal function. The function of defecation was evaluated by Wexner scoring system and Kirwan grading. Measurement data with normal distribution were presented as ±s. Results All the 12 patients were completed laparoscopic surgery without conversion to open surgery. Eight patients underwent partial internal anal sphincter resection, and 4 underwent subtotal resection. Four patients in T3 stage underwent lateral lymph node dissection preserving the left colonic artery, hypogastric nerve and pelvic nerve. The operation time was (290±35) minutes. The volume of intraoperative blood loss was (124±80)mL. The number of lymph nodes dissected was 17±8, and the number of positive lymph nodes was 0-4. The distance of the distal margin was (2.0±0.5)cm, and the margin was negative. All the 12 patients were not complicated with infection, bleeding, anastomotic leakage, anastomotic stenosis and other complications. The time to postoperative anal exsufflation was (3±1)days, duration of hospital stay was (20±3)days, and duration of postoperative hospital stay was (12±3)days. The results of TNM stage showed 3 cases of pT1 stage, 5 cases of pT2 stage, 4 cases of pT3 stage, 10 cases of pN0 stage, 1 case of pN1 stage, 1 case of pN2 stage, 8 cases ofⅠstage, 2 cases of Ⅱstage and 2 cases of Ⅲ stage. All the 12 patients were followed up for 6-11 months. The defection frequency and the Wexner score at month 1, 3 and 6 after operation were 12±7, 15±3, 9±5 and 13±4, 5±3, 10±3, respectively. Of the 12 patients, the number of patients with satisfactory Kirwan score, flatus incontinence and loose stool was 1, 3, 8 at month 1 after operation, 3, 3, 6 at month 3 after operation, 10, 2, 0 at month 6 after operation, respectively. Conclusion Laparoscopic ISR is effective in the treatment of low rectal cancer. Key words: Rectal neoplasms, low; Intersphincteric resection; Laparoscopy