Flexure Of Colon Research Articles

Perfusion monitoring using laser speckle contrast imaging during endorectal pull-through for Hirschsprung's disease

Surgical treatment of Hirschsprung's disease commonly involves resection of the aganglionic segment of the colon and endorectal pull-through. Postoperative complications include anastomotic leakage and/or stricture, both believed to be caused by inadequate perfusion of the mobilized bowel or high tension in the anastomosis, but this has never been investigated. In this case, laser speckle contrast imaging (LSCI) was used for the first time to monitor colonic perfusion during endorectal pull-through. A 6-week-old child with a 24-cm aganglionosis underwent laparoscopic-assisted endorecto pull-through with mobilization of the left colonic flexure to be able to reach the anus. LSCI perfusion monitoring showed that perfusion was 41% in the tip of the colon without tension, and was reduced 17% by a stretching force of 2 N. In conclusion, perfusion of the colonic end can be monitored by LSCI during surgery for Hirschsprung's disease. This provides new opportunities to evaluate the effects of such surgical interventions in the future.

Preferential Mobilization of Colonic Hepatic Flexure Facilitates Pancreaticoduodenectomy Procedures.

Several studies recommend that colonic hepatic flexure (CHF) should be mobilized preliminarily in minimally invasive pancreaticoduodenectomy (PD). However, there are little data to support that preferential mobilization of the CHF can positively affect the perioperative events of PD. We aimed to assess the effect of preferential mobilization of the CHF in PD. A retrospective cohort study of patients who underwent PD was performed between 2016 and 2019. Clinical characteristics, operative data, and postoperative surgical complications were recorded. The study included 668 patients; 486 patients underwent open pancreaticoduodenectomy (OPD) and 182 patients underwent laparoscopic pancreaticoduodenectomy (LPD). Patients were divided into CHF-M (OPD, n=129; LPD, n=95) and conventional (OPD, n=357; LPD, n=87) groups according to preferential CHF mobilization. There were no differences between the groups regarding most demographics. Within patients who underwent OPD, decreased estimated blood loss (EBL) (251.2±146.4 vs. 307.3±173.5 mL, P<0.05) was observed in CHF-M group. Within patients who underwent LPD, operative time (328.7±66.3 vs. 406.5±85.5 min, P<0.001), EBL (166.8±96.4 vs. 271.8±130.7 mL, P<0.001), the incidence of clinically relevant pancreaticfistula (7.4% vs. 23.0%, P<0.05), and length of stay (12.3±5.1 vs. 16.0±7.4 d, P<0.05) were decreased in CHF-M group. Moreover, patients with high body mass index who underwent LPD showed more significant differences in operative time (336.0±67.7 vs. 431.9±79.1, P<0.001) and EBL (179.6±97.8 vs. 278.2±135.6, P<0.001) between groups. We first demonstrated that preferential mobilization of the CHF can facilitate PD. The patients who underwent minimally invasive surgery and the patients with high body mass index may benefit more from this technique.

Pneumatosis cystoides intestinalis in a trauma patient presenting with pneumoperitoneum: a case report

BackgroundPneumatosis cystoides intestinalis is a rare and usually benign condition in which multiple thin-walled cysts develop in the submucosa or subserosa of the gastrointestinal tract. While usually asymptomatic, severe cases can result in pneumoperitoneum, which can be managed surgically or medically depending on circumstances. We present a case of a patient with pneumatosis cystoides intestinalis, which presented as pneumoperitoneum following trauma. To our knowledge, there are no other published cases in which a trauma patient with pneumoperitoneum was found to have radiologic evidence of pneumatosis cystoides intestinalis.Case presentationWe present the case of a 37-year-old Hispanic male admitted to the hospital after being involved in a motorcycle accident. Computed tomography imaging of the abdomen and pelvis with oral and intravenous contrast demonstrated trace pneumoperitoneum, possibly originating from the splenic flexure of the colon without evidence of extravasation of oral contrast. Laparoscopy with conversion to exploratory laparotomy revealed bowel abnormalities at the distal transverse colon and splenic flexure, which were identified as pneumatosis cystoides intestinalis by pathology. There was no evidence of bowel perforation. A panel of abdominal radiologists attended the computed tomography interpretation to note that incidental atraumatic or traumatic rupture of the cysts could have caused the pneumoperitoneum. The patient had an uncomplicated postoperative course and was transferred to another facility per insurance request.ConclusionsWhen presenting in the context of trauma, pneumatosis cystoides intestinalis can lead to difficult management decisions. To our knowledge, there are no existing evidence-based guidelines for the scenario of concurrent pneumatosis cystoides intestinalis, blunt abdominal trauma, and pneumoperitoneum in a patient with a benign abdominal exam. This patient’s pneumoperitoneum was likely caused by rupture of preexisting cysts rather than frank bowel perforation. Patients who are asymptomatic, lack signs of clinically worrisome disease, and have a low pretest probability will likely not benefit from surgery and can be medically managed. Thorough discussion between surgeons and radiologists can be helpful when evaluating the clinical significance of a patient’s pneumatosis cystoides intestinalis and aid in the decision to perform surgery.

Laparoscopic and open complete mesocolic excision with central vascular ligation for right colonic adenocarcinoma: a retrospective comparative study.

BackgroundTo examine the outcome of patients treated with complete mesocolic excision (CME) with central vascular ligation (CVL) after conventional and laparoscopic surgery.MethodsWe retrospectively evaluated stage I–IV colon adenocarcinoma patients treated by the same surgeon (L.M.) from 2013 to 2018. Postoperative complications, recurrences and survival are assessed.ResultsFifty‐one patients (M/F: 24/27) underwent laparoscopic right hemicolectomy with CME (L‐CME) or open CME (O‐CME) plus CVL. Tumour location was the caecum in 39.2% of cases, the transverse in 23.5%, the hepatic colonic flexure in 21.5%, and the ascending colon in 15.6%. Twenty‐four patients underwent L‐CME while 27 underwent O‐CME. More than 15 harvested lymphnodes are reported in 74.1% of O‐CME patients and in 66.7% of L‐CME patients (p = 0.562). Postoperative complications occurred in 7 O‐CME and 5 L‐CME patients, respectively (p = 0.669). Three‐year overall survival, including stage IV, was of 75% versus 77.8% for L‐CME and O‐CME patients, respectively, while for stage I–III, was of 88.9% vs. 80% in L‐CME and O‐CME, respectively (p = 0.440). The median follow‐up was of 2.43 years.ConclusionCME with CVL is a meticulous, complex but feasible technique. In our experience, oncological results in terms of recurrences and overall survival, after conventional and laparoscopic CME plus CVL, are comparable. Patients with stage I–III colon adenocarcinoma have a better prognostic trend especially when more than 15 lymphnodes are removed. The respect of oncological radicality and the correct indication to minimally invasive surgery are the undiscussed key outcome variables.

S175 Water Exchange Increased Advanced Adenoma Detection in the Ascending and Proximal Colon As Compared to Air Insufflation

Introduction: Randomized control trials (RCT) showed significant increase in adenoma detection rate (ADR) with water exchange (WE) compared with usual air or CO2 insufflation colonoscopy. Advanced adenoma detection rate (AADR) is a validated surrogate marker for colorectal cancer risk (GI Endosc Clin N Am 2002;12:1). There was limited data of the impact of WE on AADR, probably due to the small sample sizes of RCT. Pooled analysis of 6 published RCT suggested that WE significantly increased overall ADR and overall AADR of the entire colon (JCG 2020;54:212). The impact of WE on ADR and AADR in the ascending colon, where interval cancers tend to cluster (AJG 2014;109:1375), is unknown. We test the hypothesis that WE increased AADR by aggregating the data of 4 RCTs conducted by our group in Chiayi and Hualien, Taiwan. Methods: Data from 4 RCTs (NCT01894191, NCT02737514, NCT01535326, and NCT01699399) comparing WE and air insufflation were aggregated. The demographic characteristics, procedure related outcomes, ADR and AADR were tabulated. Results: Both the WE and air insufflation group included 503 patients. Table 1 shows that the demographic characteristics were similar between the two groups. WE had significantly shorter withdrawal time [mean (SD), 13.0 (6.8) vs 12.6 (8.5), P=0.017], and higher Boston Bowel Preparation Scale scores than the air insufflation group. The ratio of aspirate water volume to infused water volume at cecum (107%) indicated proper implementation of WE (Table 1). The WE group had significantly higher overall ADR (46.4% vs 54.9%, P=0.008), with the difference mainly occurring in the ascending colon (23.0% vs 30.9%, P=0.005) than the air insufflation group. The WE group had significantly higher AADR in the ascending (4.6% vs 7.8%, P=0.048) and proximal (6.4% vs 10.5%, P=0.023) colon. The overall AADR (16.3% vs 19.7%) was numerically higher in the WE group (P=0.189, possibly a type II error) (Table 1). Conclusion: Interval cancers tend to occur in the right and proximal colon. The beneficial effect for WE to increase right and proximal colon AADR (a validated surrogate marker for colorectal cancer risk) might hold the potential to reduce the occurrence of interval cancers. The aggregated data of 4 RCTs showed WE had significantly higher AADR in the right colon and proximal colon as compared to air insufflation. Future studies to evaluate the impact of WE on the occurrence of interval cancers are justified.Table 1.: †Chi-square test; ††Fisher’s exact test; *Mann-Whitney test; ADR, adenoma detection rate; AADR, advanced adenoma detection rate; BBPS, Boston Bowel Preparation Scale. Advanced adenoma was defined as an adenoma with a diameter of ≥ 10 mm, significant villous features (> 25%), or high-grade dysplasia. The ascending colon included the cecum, ascending colon and hepatic flexure. The proximal colon included the cecum, ascending and transverse colon.

S1851 Chilaiditi Syndrome: A Case Report

Introduction: Chilaiditi’s sign was first defined over one hundred years ago by Demetrius Chilaiditi. Chilaiditi sign has a 0.025% to 0.28% incidence worldwide with a male to female ratio of 4:1. The bowel segments most commonly found interposed between the liver and diaphragm are the colonic hepatic flexure and transverse colon, however interposition of the small bowel can also occur. The following criteria must be met to diagnose Chilaiditi sign based on radiological findings: the right hemidiaphragm must be elevated above the liver by the intestine, the bowel must be distended by air to illustrate pseudo-pneumoperitoneum, and the superior margin of the liver must be depressed below the level of the left hemidiaphragm. Case description/methods: A 75 year-old-male presented with right sided flank pain for the past 9 months. He denied symptoms of nausea, vomiting, fever, chills, change in appetite, unexplained weight change, night sweats, melena or hematochezia. He reported chronic intermittent constipation, but he typically stooled daily or every other day. He had normal colonoscopy one year prior. Due to chronic nature of his pain, CT abdomen and pelvis was obtained. It showed anterior interposition of the hepatic flexure of the colon along the liver and right hemidiaphragm; this may be seen with Chilaiditi syndrome (Figure 1). Surgical correction was discussed, but conservative measures including diet, stool softeners, and exercise to promote weight loss and bowel regularity was instituted with resolution of gastrointestinal symptoms. Discussion: Patients with anatomical variants including absence, laxity, or elongation of the suspensory ligament are at increased risk for developing pathologic interposition. In patients with Chilaiditi syndrome, most common presenting symptoms abdominal pain, abdominal distention, nausea, emesis, constipation, and obstipation. The differential of Chilaiditi syndrome includes bowel obstruction, volvulus, intussusception, ischemic bowel, diverticulitis, appendicitis, subphrenic abscess, and pneumoperitoneum. In asymptomatic patients with Chilaiditi sign, treatment is usually conservative with stool softeners/laxatives and no interventions needed. Surgical intervention is indicated when the obstruction does not resolve with conservative management or there is evidence of bowel ischemia. The appropriate surgical approach depends on which segment of colon is interposed.Figure 1.: CT shows anterior interposition of the hepatic flexure of the colon along the liver and right hemidiaphragm.

S1911 Primary Colon Burkitt’s Lymphoma Presenting as Colonic Obstruction

Introduction: Primary colon lymphomas are very rare colon malignancies and Burkitt´s lymphoma (BL) variant is usually diagnosed in children and immunocompromised patients. BL is a highly aggressive malignancy and is the fastest growing human cancer. Primary colon BL (PCBL) is very rare in adults with few reported cases located around ileocecal valve region. There are only two published cases of PCBL causing colonic obstruction due to ileocecal valve region involvement. We present a unique PCBL case located in splenic flexure of colon causing colonic obstruction. Case description/methods: A 56-year-old female presented with 10-day history of worsening diffuse abdominal pain, nausea, vomiting & inability to pass gas. She had diffuse abdominal tenderness & hyperactive bowel sounds. Labs were unremarkable. Abdominal CT scan revealed complete colonic obstruction from splenic flexure exophytic colonic mass measuring 14 x 10 x 10 cm with small mesenteric & hepatic lesions. Emergent laparoscopic transverse colon diverting loop colostomy performed due to high tumor burden that appeared to be unresectable. Subsequent colonoscopy showed large obstructing colon mass at splenic flexure of colon & proximal colon segments were dilated with decompressed distal colon. Biopsies from colon mass were indicative for diffuse large B-cell lymphoma with extensive necrosis, high proliferation index, Ki-67 80% positive. Ultrasound guided liver biopsy revealed high grade B-cell lymphoma. FISH analysis revealed findings of MYC/IGH fusion in approximately 100% of nuclei without rearrangement of BCL2 or BCL6, consistent with PCBL. Chemotherapy initiated (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, rituximab) with an excellent response. Surveillance colonoscopy at 5-year post-treatment showed no concerns for disease recurrence. Discussion: PCBL is not only very rare in adults but also rare outside of ileocecal area, where concentration of lymphoid tissue is relatively increased. In english literature there are only 2 published cases of PCBL at ileocecal valve location causing colonic obstruction. To the best of our knowledge, our PCBL case is unique as being the first case of PCBL atypically located in distal colon & causing colonic obstruction. Older age or atypical GI locations cannot exclude the possibility of PCBL & should be considered as part of differential diagnosis for high-grade GI lymphomas. With advances in chemotherapy, PCBL may respond well to therapy even in disseminated stage with colonic obstruction.Figure 1.: A: Nuclear medicine PET CT scan showing multiple FDG avid mesenteric masses consistent with lymphoma and evidence of hepatic metastasis. Figure B: CT scan abdomen revealing large splenic flexure exophytic colonic mass causing colonic obstruction. Figure C: Large obstructing colon mass seen at the splenic flexure of colon during colonoscopy. Figure D: Colon mass biopsy with hematoxylin & eosin stain at 200x magnification showing extensive necrosis with crush artifact and rare clusters of viable large neoplastic cells.

Novel intrinsic neurogenic and myogenic mechanisms underlying the formation of faecal pellets along the large intestine of guinea-pigs.

Soft faecal material is transformed into discrete, pellet-shaped faeces at the colonic flexure. Here, analysis of water content in natural faecal material revealed a decline from cecum to rectum without significant changes at the flexure. Thus, pellet formation is not explained by changes in viscosity alone. We then used video imaging of colonic wall movements with electromyography in isolated preparations containing guinea-pig proximal colon, colonic flexure and distal colon. To investigate the pellet formation process, the colonic segments were infused with artificial contents (Krebs solution and 4-6% methylcellulose) to simulate physiological faecal content flow. Remarkably, pellet formation took place in vitro, without extrinsic neural inputs. Infusion evoked slowly propagating neurogenic contractions, the proximal colon migrating motor complexes (∼0.6cpm), which initiated pellet formation at the flexure. Lesion of the flexure, but not the proximal colon, disrupted the formation of normal individual pellets. In addition, a distinct myogenic mechanism was identified, whereby slow phasic contractions (∼1.9cpm) initiated at the flexure and propagated short distances retrogradely into the proximal colon and antegradely into the distal colon. There were no detectable changes in the density or distribution of pacemaker-type interstitial cells of Cajal across the flexure. The findings provide new insights into how solid faecal content is generated, suggesting the major mechanisms underlying faecal pellet formation involve the unique interaction at the colonic flexure between antegrade proximal colon migrating motor complexes, organized by enteric neurons, and retrograde myogenic slow phasic contractions. Additional, as yet unidentified extrinsic and/or humoral influences appear to contribute to processing of faecal content in vivo. KEY POINTS: In herbivores, including guinea-pigs, clearly defined faecal pellets are formed at a distinct location along the large intestine (colonic flexure). The mechanism underlying the formation of these faecal pellets at this region has remained unknown. We reveal a progressive and gradual reduction in water content of faecal content along the bowel. Hence, the distinct transition from amorphous to pellet shaped faecal content could not be explained by a dramatic increase in water reabsorption from a specific site. We discovered patterns of anterograde neurogenic and retrograde myogenic motor activity that facilitate the formation of faecal pellets. The formation of 'pellet-like' boluses at the colonic flexure involves interaction of an antegrade migrating motor complex in the proximal colon and retrograde myogenic slow phasic contractions that emerge from the colonic flexure. The findings uncover intrinsic mechanisms responsible for the formation of discrete faecal scybala in the large intestine of a vertebrate.

Descending-sigmoid colon flexure – An important but surprisingly ignored landmark

BackgroundIn invasive examinations of the colon, e.g. colonoscopy, the tortuosity of the colon is a crucial factor for successful completion of the procedure. If adjacent segments of the colon bend at acute angles (under 90°), endoscopy may become difficult and troublesome. MethodsWe retrospectively enroled 227 individuals (96 female, 131 male) who underwent abdominopelvic computed tomography examination. For inclusion, subjects were required to have a negative history for colonic disease and abdominopelvic surgery. We measured the angle between the descending colon and the proximal part of the sigmoid (in degrees). In addition, the position of the descending-sigmoid flexure was assessed in relation to the left anterior superior iliac spine, the median plane, and anterior aspect of the 5th lumbar vertebra (in mm). The study protocol was reviewed and approved by the local ethics committee. ResultsWe visualised the descending-sigmoid flexure in all 227 subjects. In one third of cases, the flexure formed an angle smaller than/or 90°. In females, this landmark (mean ± standard deviation) was located 30.2 ± 8.4 mm from the left anterior superior iliac spine, 88.6 ± 14.2 mm from the median plane, and 115.4 ± 21.4 mm from the anterior aspect of the 5th lumbar vertebra. In males, the dimensions were: 32.1 ± 12.8 mm, 97.6 ± 15.8 mm, and 123.9 ± 22.9 mm, respectively. This landmark distance remained constant from the left anterior superior iliac spine regardless of subject age, height and weight. The other measured distances were related to age, height, weight or BMI. ConclusionsThe descending-sigmoid flexure is an important landmark in large intestine morphology situated approximately width of two fingers (3 cm) from the left anterior superior iliac spine and one hand width (9–10 cm) from the median plane. In approximately one third of the subjects, the flexure formed an angle of less than/or 90°, which can cause a problem during colonoscopy.

Arterial supply to the rat colon.

Rats are often used as animal models in studies such as on intestinal transplantation and anastomosis healing, which require colectomy. Although detailed information regarding arterial supply is important to establish accurate and reproducible experimental procedures, this has not been studied in the rat colon. Therefore, we analysed the detailed arterial distribution pattern and its individual variations in the colon of 34 rats. The rat colon received colic branches of the ileocolic artery, and the right, middle and left colic arteries. The single left colic artery constantly arose from the caudal mesenteric artery and was distributed to the descending colon, whereas the others showed variations in number and distribution. The ileocolic artery gave rise to one (12%) or two (88%) colic branches supplying the proximal ascending colon, and these branches formed rich, mesh-like anastomoses along the initial portion of the ascending colon. One (74%) or two (26%) right colic arteries originated from the cranial mesenteric artery and supplied the ascending colon and right colic flexure. Moreover, one (38%), two (56%) or three (6%) middle colic arteries emerged from the cranial mesenteric artery and were distributed to the transverse colon, left colic flexure and proximal descending colon. In total, we categorized the individual variations in arterial branching and anastomosis into 11 patterns. Arterial supply to the rat colon showed a specific pattern and frequent individual variations. These findings thus provide essential information for establishing reproducible models of rat colic surgery.

Long splenic flexure carcinoma requiring laparoscopic extended left hemicolectomy with CME and transverse-rectal anastomosis: technique for a modified partial Deloyers in 5 steps to achieve enough reach and preserving middle colic vessels

IntroductionThis How-I-Do-It article presents a modified Deloyers procedure by mean of the case of a 67-year-old female with adenocarcinoma extending for a long segment and involving the splenic flexure and proximal descending colon who underwent a laparoscopic left extended hemicolectomy (LELC) with derotation of the right colon and primary colorectal anastomosis.BackgroundWhile laparoscopic extended right colectomy is a well-established procedure, LELC is rarely used (mainly for distal transverse or proximal descending colon carcinomas extending to the area of the splenic flexure). LELC presents several technical challenges which are demonstrated in this How-I-Do-It article.Technique and methodsFirstly, the steps needed to mobilize the left colon and procure a safe approach to the splenic flexure are described, especially when a tumor is closely related to it. This is achieved by mobilization and resection of the descending colon, while maintaining a complete mesocolic excision to the level of the duodenojejunal ligament for the inferior mesenteric vein and flush to the aorta for the inferior mesenteric artery. Subsequently, we depict the adjuvant steps required to enable a primary anastomosis by trying to mobilize the transverse colon and release as much of the mesocolic attachments at the splenic flexure area. Finally, we present the rare instance when a laparoscopic derotation of the ascending colon is required to provide a tension-free anastomosis. The resection is completed by delivery of the fully derotated ascending colon and hepatic flexure through a suprapubic mini-Pfannenstiel incision. The primary colorectal anastomosis is subsequently fashioned in a tension-free way and provides for a quick postoperative recovery of the patient.ResultsThis modified Deloyers procedure preserves the middle colic since the fully mobilized mesocolon allows for a tension-free anastomosis while maintaining better blood supply to the mobilized stump. Also, by eliminating the need for a mesenteric window and the transposition of the caecum, we allow the small bowel to rest over the anastomosis and the mobilized transverse colon and reduce the possibility of an internal herniation of the small bowel into the mesentery.ConclusionsLaparoscopic derotation of the right colon and a partial, modified Deloyers procedure preserving the middle colic vessels are feasible techniques in experienced hands to provide primary anastomosis after LELC with improved functional outcome. Nevertheless, it is important to consider anatomical aspects of the left hemicolectomy along with oncological considerations, to provide both a safe oncological resection along with good postoperative bowel function.

Analysis of short-term efficacy of overlapping delta-shaped anastomosis in totally laparoscopic left hemicolectomy for digestive tract reconstruction

Objective: At present, though the laparoscopic delta-shaped anastomosis and overlapping delta-shaped anastomosis have been gradually applied to complete laparoscopic radical resection of left hemicolon cancer, the comparative evaluation of their efficacy has not been mentioned in the published literatures. This study aims to explore the safety, feasibility and short-term efficacy of overlapping delta-shaped anastomosis (ODA) in totally laparoscopic left hemicolectomy. Methods: A retrospective cohort study was performed. The clinical and pathological data of patients who underwent totally laparoscopic left hemicolectomy at Department of Colorectal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College from May 2017 to October 2020 were retrospectively analyzed. The case inclusion criteria were as follows: (1) age of 18-75 years; (2) body mass index (BMI) of 18.5-30 kg/m(2); (3) descending colonic and proximal sigmoid colonic adenocarcinoma was confirmed by preoperative colonoscopy and pathology. The exclusion criteria: (1) multiple primary colorectal cancers; (2) uncontrolled or poorly controlled diabetes mellitus, immune system diseases, or hematological diseases; (3) severe intestinal obstruction; (4) left transverse colonic or splenic flexure colonic adenocarcinoma; (5) distant metastasis of liver, lung and other viscera determined by enhanced computed tomography in the chest, abdomen and pelvis. According to the above criteria, a total of 115 patients with left hemicolon cancer were enrolled. All the patients underwent totally laparoscopic left hemicolectomy. Patients who underwent laparoscopic traditional delta-shaped anastomosis were selected as the control group. Patients who underwent laparoscopic ODA were selected as the ODA group. Effects of these two laparoscopic reconstruction methods on postoperative recovery and perioperative complications were analyzed and compared. Results: A total of 60 patients were enrolled in the ODA group, including 32 males and 28 females, with mean age of (57.3±10.4) years and body mass index (BMI) of (25.0±3.1) kg/m(2). While mean 55 patients were enrolled in the control group, including 31 males and 24 females, with mean age of (56.7±9.9) years and BMI of (24.4±2.9) kg/m(2). There was no statistically significant differences between the two groups in gender, age, BMI, American Society of Anesthesiologist (ASA) classification, TNM staging, preoperative abdominal surgery history, neoadjuvant chemotherapy and nutritional status (levels of hemoglobin, lymphocyte count, prealbumin, and albumin) (all P>0.05). All the patients in both groups received R0 resection without conversion to open laparotomy or conversion to extra-abdominal anastomosis. The digestive tract reconstruction time of the ODA group was significantly shorter than that of the control group [(15.1±1.7) minutes vs. (15.9±2.4) minutes, t=-2.053, P=0.042]. There were no statistically significant differences in the total operation time, intraoperative blood loss, length of skin incision, tumor size, proximal and distal margins, harvested lymph nodes, postoperative first ambulatory time, and postoperative hospital stay (all P>0.05). However, the time to the first flatus and the first defecation in the ODA group was significantly shorter as compared to control group [(1.5±0.5) days vs. (1.7±0.5) days, t=-2.028, P=0.045; (3.1±0.6) days vs. (3.4±0.7) days, t=-2.095, P=0.039], indicating faster intestinal function recovery in patients with ODA. The morbidity of postoperative complication was 6.7% (4/60) in the ODA group and 7.3% (4/55) in the control group and no significant difference was found (χ(2)=0.016, P=0.898). Two cases of incision infection, 1 case of lung infection, and 1 case of intra-abdominal infection occurred in the ODA group, while 3 cases of lung infection and 1 case of intra-abdominal infection occurred in the control group. All these complications were resolved after conservative treatment, and no secondary operation was performed due to complications. Conclusion: Compared with the traditional delta-shaped anastomosis, ODA is associated with a faster recovery of postoperative intestinal function without increasing the morbidity of postoperative complications, and has the satisfactory short-term efficacy.

Survival of colorectal cancer patients in Brunei Darussalam: comparison between 2002\u201309 and 2010\u201317

BackgroundColorectal cancer (CRC) is a major cause of cancer-related mortality worldwide. It is the second leading cause of cancer death in men and women in Brunei Darussalam in 2017, posing a major burden on society.MethodsThis retrospective cohort study (n = 1035 patients diagnosed with CRC in Brunei Darussalam from 1st January 2002 until 31st December 2017) aims to compare the overall survival rates of CRC patients (2002–2017), to compare survival rates between two study periods (2002–2009 and 2010–2017) and to identify prognostic factors of CRC. Kaplan-Meier estimator and log-rank tests were performed to analyse the overall survival rates of CRC patients. Multiple Cox regression was performed to determine the prognostic factors of CRC with adjusted hazard ratios (Adj. HRs) reported.ResultsThe 1-, 3- and 5-year survival rates of CRC patients are 78.6, 62.5, and 56.0% respectively from 2002 to 2017. The 1-, 3-, and 5-year survival rates of CRC patients for 2002–2009 are 82.2, 69.6, and 64.7%; 77.0, 59.1, and 51.3% for 2010–2017 respectively. A significant difference in CRC patients’ survival rate was observed between the two study periods, age groups, ethnic groups, cancer stages, and sites of cancer (p < 0.05). The Adjusted Hazard Ratios (Adj. HRs) were significantly higher in the 2010–17 period (Adj. HR = 1.78, p < 0.001), older age group ( ≥ 60 years) (Adj. HR = 1.93, p = 0.005), distant cancer (Adj. HR = 4.69, p < 0.010), tumor at transverse colon and splenic flexure of colon (Adj. HR = 2.44, p = 0.009), and lower in the Chinese(Adj. HR = 0.63, p = 0.003).ConclusionThis study highlights the lower survival rates of CRC patients in 2010–2017, Malays, older patients, distant cancer, and tumors located at the latter half of the proximal colon (transverse colon), and predominantly LCRC (splenic flexure, descending colon, sigmoid colon, overlapping lesion colon and colon (NOS), as well as the rectosigmoid junction and rectum (NOS)). Age, ethnicity, cancer stage, and tumor location are significant prognostic factors for CRC. These findings underscore the importance of public health policies and programmes to enhance awareness on CRC from screening to developing strategies for early detection and management, to reduce CRC-associated mortality.

Gastric Volvulus Associated with Eventration of Diaphragm

Diaphragmatic eventration is an abnormally elevated hemidiaphragm in thoracic cavity with poorly developed musculature. This condition can lead to abnormal displacement of intra-abdominal organs. It usually remains asymptomatic in early life. It presents later with respiratory and occasionally gastrointestinal complications. A clinical case of eventration of diaphragm, displacement of the splenic flexure of colon, omentum and spleen into thoracic cavity with gastric volvulus is uncommon. Gastric volvulus occurs when the stomach twists around one of its axis. It is commonly along its long axis (organoaxial volvulus) and less commonly along the vertical axis (mesenteroaxial).Mortality rate of gastric volvulus range from 30%-50%. Hence early diagnosis and prompt intervention prevents development of necrosis and perforation of stomach. We report a case of 30year old male having left sided diaphragmatic eventration associated with organoaxial gastric volvulus and displaced intra-abdominal organs treated with successful surgical intervention. Key words: Eventration; Diaphragm; Gastric; Volvulus; Malrotation; Organo-axial; Mesenteroaxial, Gastric outlet obstruction, Derotation; Gastropexy.

Infrapyloric lymph node dissection in right hemicolectomy for colon cancer: Should prophylactic resection be recommended?

Infrapyloric lymph node dissection in right colon cancer patients remains controversial. We aimed to investigate the pattern of infrapyloric lymph node metastasis in right colon cancer patients. Clinical and pathological data of 140 colon cancer patients who underwent radical right hemicolectomy and infrapyloric lymph node dissection were retrospectively examined. Patient characteristics, intraoperative conditions, postoperative recovery information, postoperative pathological findings, and follow-up data were examined. About 19, 44, 73, and 4 patients had tumors located in the cecum, ascending colon, hepatic flexure, and right side of the transverse colon, respectively. The median number of harvested lymph nodes and that of positive lymph nodes were 24 (16-30) and 1 (0-7.75), respectively. The lymph node metastasis rate was 41.43% (58/140). The corresponding values for infrapyloric lymph nodes were 3 (1-4), 0(0-0), and 0.71% (1/140), respectively. The median follow-up duration was 19 (0-65) months in 131 (93.6%) patients. The 5-year overall and disease-free survival rates were 86.3% and 73.5%, respectively. Given the low rate of infrapyloric lymph node metastasis in right colon cancer, lymph node dissection is recommended in patients with locally advanced colon cancer at the hepatic flexure and those with suspected infrapyloric lymph node metastasis.

Motor patterns in the proximal and distal mouse colon which underlie formation and propulsion of feces

In herbivores, the proximal and distal colonic regions feature distinct motor patterns underlying formation and propulsion of fecal pellets, respectively. Omnivores, such as mice and humans, lack a similar clear anatomical transition between colonic regions. We investigated whether distinct processes form and propel content along the large intestine of a mouse (an omnivore). We recorded propulsive and non-propulsive neurogenic motor activity in mouse large intestine under six different stimulus conditions of varying viscosities. Gut wall movements were recorded by video and smooth muscle electrical behavior recorded with extracellular suction electrodes. Three major neurally mediated motor patterns contributed to pellet formation and propulsion. (1) Pellet-shaped boluses are pinched off near the ceco-colonic junction and slowly propelled distally to a transition located at 40% length along the colon. (2) At this functional colonic flexure, propulsion speed is significantly increased by self-sustaining neural peristalsis. Speed transition at this location also occurs with artificial pellets and with spontaneously formed boluses in the empty colon. (3) Periodic colonic motor complexes (CMCs) were present in all conditions reaching a maximal frequency of about 0.4cpm and extending across the proximal and distal colon with faster speed of propagation. The three motor patterns share a unique underlying fundamental property of the enteric circuits, which involve extended ensembles of enteric neurons firing at close to 2Hz. The demonstration of distinct functional differences between proximal and distal colon in rabbit, guinea pig, and now mouse raises the possibility that this may be an organizational principle in other mammalian species, including humans.

Neoadjuvant Cabozantinib in an Unresectable Locally Advanced Renal Cell Carcinoma Patient Leads to Downsizing of Tumor Enabling Surgical Resection: A Case Report

IntroductionCabozantinib (XL-184) is a small molecule inhibitor of the tyrosine kinases c-Met, AXL, and VEGFR2 that has been shown to reduce tumor growth, metastasis, and angiogenesis. After the promising results from the METEOR and CABOSUN trials, cabozantinib was approved for use in the first- and second-line setting in patients with advanced RCC. Previously, targeted therapies have been used in the neoadjuvant setting for tumor size reduction and facilitating nephrectomies. The increased response rates with cabozantinib in metastatic renal cell carcinoma (mRCC), along with the other neoadjuvant TKI data, strongly support an expanded role for cabozantinib in the neoadjuvant setting.Case DescriptionWe report on a 59-year-old gentleman presenting with an unresectable 21.7 cm left renal cell carcinoma (RCC) with extension to soft tissue and muscles of the thoracic cage, psoas muscle, posterior abdominal wall, tail of pancreas, splenic flexure of colon, and inferior margin of spleen. Presurgical, neoadjuvant systemic therapy with cabozantinib was initiated for 11 months in total. Initially after 2 months of cabozantinib, magnetic resonance imaging (MRI) revealed a significant reduction (44.2%) in tumor diameter from 21.7 to 12.1 cm with decreased extension into adjacent structures. After 11 months total of cabozantinib, the corresponding MRI showed grossly stable size of the tumor and significant resolution of invasion of adjacent structures. After washout of cabozantinib, radical resection, including nephrectomy, was successfully performed without any major complications, either intra-operative or perioperative. Negative margins were achieved.ConclusionsThis is a report of neoadjuvant cabozantinib downsizing a tumor and enabling surgical resection in this patient with locally advanced RCC. Our findings demonstrate that neoadjuvant cabozantinib to facilitate subsequent surgical resection may be a feasible option for patients presenting with unresectable RCC.

Intraoperative anatomical observation of mesentery morphology of colonic splenic flexure

Objective: At present, surgeons do not know enough about the mesenteric morphology of the colonic splenic flexure, resulting in many problems in the complete mesenteric resection of cancer around the splenic flexure. In this study, the morphology of the mesentery during the mobilization of the colonic splenic flexure was continuously observed in vivo, and from the embryological point of view, the unique mesenteric morphology of the colonic splenic flexure was reconstructed in three dimensions to help surgeons further understand the mesangial structure of the region. Methods: A total of 9 patients with left colon cancer who underwent laparoscopic radical resection with splenic flexure mobilization by the same group of surgeons in Union Hospital of Fujian Medical University from January 2018 to June 2019 were enrolled. The splenic flexure was mobilized using a "three-way approach" strategy based on a middle-lateral approach. During the process of splenic flexure mobilization, the morphology of the transverse mesocolon and descending mesocolon were observed and reconstructed from the embryological point of view. The lower margin of the pancreas was set as the axis, and 4 pictures for each patient (section 1-section 4) were taken during middle-lateral mobilization. Results: The median operation time of the splenic flexure mobilization procedure was 31 (12-55) minutes, and the median bleeding volume was 5 (2-30) ml. One patient suffered from lower splenic vessel injury during the operation and the bleeding was stopped successfully after hemostasis with an ultrasound scalpel. The transverse mesocolon root was observed in all 9 (100%) patients, locating under pancreas, whose inner side was more obvious and tough, and the structure gradually disappeared in the tail of the pancreatic body, replaced by smooth inter-transitional mesocolon and dorsal lobes of the descending colon. The mesenteric morphology of the splenic flexure was reconstructed by intraoperative observation. The transverse mesocolon was continuous with a fan-shaped descending mesocolon. During the embryonic stage, the medial part (section 1-section 2) of the transverse mesocolon and the descending mesocolon were pulled and folded by the superior mesenteric artery (SMA). Then, the transverse mesocolon root was formed by compression of the pancreas on the folding area of the transverse mesocolon and the descending mesocolon. The lateral side of the transverse mesocolon root (section 3-section 4) was distant from the mechanical traction of the SMA, and the corresponding folding area was not compressed by the tail of the pancreas. The posterior mesangial lobe of the transverse mesocolon and the descending mesocolon were continuous with each other, forming a smooth lobe. This smooth lobe laid flat on the corresponding membrane bed composed of the tail of pancreas, Gerota's fascia and inferior pole of the spleen. Conclusions: From an embryological point of view, this study reconstructs the mesenteric morphology of the splenic flexure and proposes a transverse mesocolon root structure that can be observed consistently intraopertively. Cutting the transverse mesocolon root at the level of Gerota's fascia can ensure the complete resection of the mesentery of the transverse colon.

Classification of the colonic splenic flexure based on three-dimensional CT analysis.

BackgroundMobilization of the splenic flexure can be a challenging surgical step in colorectal surgery. This study aimed to classify the splenic flexure based on the three-dimensional (3D) coordinates of the splenic hilum and left renal hilum. This classification was used to compare splenic flexure mobilization during colorectal resection.MethodsCT images of patients with colorectal cancer treated between April 2018 and December 2019 were analysed retrospectively. 3D mutual positioning of the splenic flexure from the ligament of Treitz to the splenic hilum or the left renal hilum was used to classify patients into three groups using cluster analysis. The difference in the procedure time between groups was also analysed in a subset of patients undergoing laparoscopic colectomy with complete splenic flexure mobilization.ResultsOf 515 patients reviewed, 319 with colorectal cancers were included in the study and categorized based on the 3D coordinates of the splenic hilum and left renal hilum as caudal (100 patients), cranial (118) and lateral (101) positions. Male sex (P < 0.001), older age (P = 0.004) and increased bodyweight (P = 0.043) were independent characteristics of the lateral group in multiple logistic regression analysis. Thirty-four patients underwent complete splenic flexure mobilization during the study period; this took significantly longer (mean 78.7 min) in the lateral group than in the caudal and cranial groups (41.8 and 43.2 min respectively; P = 0.006).ConclusionLocating the splenic flexure using 3D coordinates could be helpful in predicting a longer duration for mobilization of the splenic flexure.

Tailored laparoscopic approach for pancreatic tail resection for cancer

Laparoscopic resection is becoming the gold standard for distally located lesions of the pancreas. Changing the standard technique from the medial-to-lateral to lateral-to-medial approach can simplify the procedure in case of previous surgery, a known risk factor for conversion. We report the case of laparoscopic pancreatic tail resection with spleen preservation in a 79 y.o. woman affected by an 18 mm hypervascular lesion (Fig.1); the patient underwent to a left nephrectomy, trough a median laparotomy, thirty-three years before, for a clear cell renal carcinoma. The SUV at Ga68-DOTATOC-PET-CT was 14.9 and at F18-FDG-PET-CT was null. Operative technique: four trocar were positioned in L shape manner in the upper left quadrant of the abdomen, with patient in 30° right lateral position. We started lowering the colonic splenic flexure, exposing the tail of the pancreas and the tumor. The lesser sac was opened below the left gastroepiploic vessels. The body-tail were freed from retroperitoneal tissue, in a lateral-to-medial way. Finally, small arterial and venous branches of the splenic vessels were cut between clips. For parenchymal transection we used a 60 mm linear stapler, vascular cartridge; a suture of the stump was required to complete the hemostasis. The specimen was extracted by an endobag through the supraumbilical incision, and a drain was left close to the stump. After an uneventful postoperative course, the patient was discharged in the fourth postoperative day. The pathological report described a metastasis from clear cell renal carcinoma.