Laparoscopic Subtotal Colectomy Research Articles

Anatomical classification of and laparoscopic surgery for left-sided colorectal cancer with persistent descending mesocolon

Objective: To investigate anatomical morphology and classification of persistent descending mesocolon (PDM) in patients with left-sided colorectal cancer, as well as the safety of laparoscopic radical surgery for these patients. Methods: This is a descriptive study of case series. Relevant clinical data of 995 patients with left colon and rectal cancer who had undergone radical surgery in Fujian Medical University Union Hospital from July 2021 to September 2022 were extracted from the colorectal surgery database of our institution and retrospectively analyzed. Twenty-four (2.4%) were identified as PDM and their imaging data and intra-operative videos were reviewed. We determined the distribution and morphology of the descending colon and mesocolon, and evaluated the feasibility and complications of laparoscopic surgery. We classified PDM according to its anatomical characteristics as follows: Type 0: PDM combined with malrotation of the midgut or persistent ascending mesocolon; Type 1: unfixed mesocolon at the junction between transverse and descending colon; Type 2: PDM with descending colon shifted medially (Type 2A) or to the right side (Type 2B) of the abdominal aorta at the level of the origin of the inferior mesentery artery (IMA); and Type 3: the mesocolon of the descending-sigmoid junction unfixed and the descending colon shifted medially and caudally to the origin of IMA. Results: The diagnosis of PDM was determined based on preoperative imaging findings in 9 of the 24 patients (37.5%) with left-sided colorectal cancer, while the remaining diagnoses were made during intraoperative assessment. Among 24 patients, 22 were male and 2 were female. The mean age was (63±9) years. We classified PDM as follows: Type 0 accounted for 4.2% (1/24); Type 1 for 8.3% (2/24); Types 2A and 2B for 37.5% (9/24) and 25.0% (6/24), respectively; and Type 3 accounted for 25.0% (6/24). All patients with PDM had adhesions of the mesocolon that required adhesiolysis. Additionally, 20 (83.3%) of them had adhesions between the mesentery of the ileum and colon. Twelve patients (50.0%) required mobilization of the splenic flexure. The inferior mesenteric artery branches had a common trunk in 14 patients (58.3%). Twenty-four patients underwent D3 surgery without conversion to laparotomy; the origin of the IMA being preserved in 22 (91.7%) of them. Proximal colon ischemia occurred intraoperatively in two patients (8.3%) who had undergone high ligation at the origin of the IMA. One of these patients had a juxta-anal low rectal cancer and underwent intersphincteric abdominoperineal resection because of poor preoperative anal function. Laparoscopic subtotal colectomy was considered necessary for the other patient. The duration of surgery was (260±100) minutes and the median estimated blood loss was 50 (20-200) mL. The median number of No. 253 lymph nodes harvested was 3 (0-20), and one patient (4.2%) had No.253 nodal metastases. The median postoperative hospital stay was 8 (4-23) days, and the incidence of complications 16.7% (4/24). There were no instances of postoperative colon ischemia or necrosis observed. One patient (4.2%) with stage IIA rectal cancer developed Grade B (Clavien-Dindo III) anastomotic leak and underwent elective ileostomy. The other complications were Grade I-II. Conclusions: PDM is frequently associated with mesenteric adhesions. Our proposed classification can assist surgeons in identifying the descending colon and mesocolon during adhesion lysis in laparoscopic surgery. It is crucial to protect the colorectal blood supply at the resection margin to minimize the need for unplanned extended colectomy, the Hartmann procedure, or permanent stomas.

Laparoscopic total colectomy with ileorectal anastomosis and subtotal colectomy with antiperistaltic cecorectal anastomosis for slow transit constipation.

To investigate the clinical efficacy of laparoscopic total colectomy with ileorectal anastomosis (TC-IRA) and laparoscopic subtotal colectomy with antiperistaltic cecorectal anastomosis (SC-ACRA) on adults with slow transit constipation (STC). One hundred and three patients with STC were assigned to the TC-IRA group (n = 53) and the SC-ACRA group (n = 50). The clinical data were analyzed. The surgery was successful in all patients (100%). Significantly (P = 0.03) more patients took anti-laxatives during hospitalization in the TC-IRA than the SC-ACRA group (39.62% vs. 20.00%). Abdominal pain and distension was present in 33.96% and 32.00% patients in the TC-IRA and SC-ACRA group, respectively, which decreased insignificantly (P > 0.05) to 18.87% and 18.00% 24months after surgery, respectively. The postoperative Wexner and gastrointestinal quality of life (GIQLI) scores were not significantly different (P > 0.05) at all times after surgery in both groups. The defecation frequency decreased in both groups, and the average defecation frequency was significantly (P < 0.05) higher in the TC-IRA than the SC-ACRA group (3.91 ± 1.23 vs. 3.14 ± 1.15 times/day) at 3months. Three months after surgery, significantly (P < 0.05) fewer patients were satisfied with defecation frequency in the TC-IRA than the SC-ACRA group (29 vs. 37 patients), whereas the number of patients who were willing to choose the same procedure again was not significantly (P > 0.05) different between the two groups. The WIS score of patients was significantly (P = 0.035) higher in the TC-IRA than the SC-ACRA group (6 vs. 5) 3months later. TC-IRA and SC-ACRA are both safe and effective for adult slow transit constipation, and can significantly improve the quality of life of patients. Even though SC-ACRA has better early defecation frequency, postoperative antidiarrheal application and satisfaction, the long-term follow-up effects are similar.

Successful pregnancy of a patient with primary sclerosing cholangitis awaiting liver transplantation

In women, primary sclerotising cholangitis (PSC) associated with ulcerative colitis and intrahepatic cholestasis is a rare disease. To date, there are no data from Hungary on the fertility and pregnancy outcome of women with this chronic liver disease. Our aim is to present the favorable pregnancy outcome of a woman with PSC associated with ulcerative colitis, intrahepatic cholestasis and postpartum colectomy, and review of the literature. A young nulligravida was first diagnosed with ulcerative colitis. Five years later, PSC developed with progressive fibrosis and cholestasis necessitating liver transplantation. While on waiting list, spontaneous conception occurred. Except for pregnancy-induced hypertension, pregnancy uneventfully progressed until the third trimester when 8 g oral cholestyramine/day was administered to lower high maternal (over 100 μmol/L) total bile acid (TBA) level. In the 36th week of gestation acute exacerbation of ulcerative colitis resulted in maternal fever and chorioamnionitis leading to fetal distress. Elective delivery of the eutrophic neonate followed by emergency cesarean section. In the early puerperium, colitis progressed to septic pancolitis resistant to medical treatment. 12 days after laparoscopic subtotal colectomy, the patient was discharged in good health condition. 3 months later, ileostomy was closed and she got back on the transplantation waiting list. Our data correspond with previous reports and suggest that women with PSC with underlying ulcerative colitis and cholestasis have a good chance for favorable pregnancy outcome. However, both PSC and underlying colitis might progress during pregnancy and puerperium. Oral cholestyramin is an effective and safe treatment for high maternal TBA levels. Orv Hetil. 2023; 164(6): 234-240.

How to Do It: Laparoscopic Total Abdominal Colectomy with Complete Mesocolic Excision (CME) for Transverse Colon Cancer in Ulcerative Colitis

BackgroundUlcerative colitis (UC) is a chronic mucosal inflammatory bowel disease of the colon and rectum. After 10 years of having the disease, there is a significant risk of dysplasia or cancer in the affected colon and rectum, and because of the often aggressive biology of these tumors, frequent endoscopic surveillance is warranted. Over a third of patients with UC will ultimately require an operation, and although for specific cases alternative operations can be pursued, most patients prefer an ileal pouch-anal anastomosis (IPAA) with J-pouch construction. CaseA staged IPAA removes the affected colon and rectum treating UC and also restores intestinal continuity. However, the standard colectomy for UC includes low ligations of the main colonic vascular pedicle branches (ileocolic, right colic, middle colic and inferior mesenteric) that does not address a proper oncologic operation. A high ligation of the named vessels as well as a proper resection of the affected colon with its mesentery and lymph node package are needed to treat colon cancer. Analogous to a total mesorectal exicision for rectal cancer, a more radical procedure to remove the tumor and lymph node packet for colon cancer is described as a complete mesocolic exision (CME) in efforts to increase disease free survival. DiscussionWe demonstrate a laparoscopic subtotal colectomy for UC, with an oncologic complete mesocolic excision for a left transverse colon carcinoma in the setting of chronic mucosal inflammation secondary to chronic UC as the first procedure in a 3-staged IPAA. In the video, it is also demonstrated how the lymph node dissection is extended towards the greater gastric curvature and comprising omentum and gastrocolic ligament. There were no postoperative complications in the 44-year old male patient.

S2877 Weight Loss Utilizing Endoscopic Sleeve Gastroplasty (ESG), Benefit for Ostomy Reversal in Obese Patient With Ulcerative Colitis (UC)

Introduction: Over the last thirty years, the prevalence of both obesity and inflammatory bowel disease has increased globally. Surgical management in ulcerative colitis (UC) is reserved for medically refractory UC, most typically in a three-stage pattern: initial removal of the colon and creation of an end ileostomy, followed by removal of the rectum and construction of ileal pouch anal anastomosis and diverting ileostomy, followed by reversal of the ileostomy. Proctectomy is particularly difficult in obese patients due to increased visceral adiposity, thickened abdominal wall, adhesions, and reduced mobility secondary to bulky mesentery. Patients with Body Mass Index (BMI) greater than 30 are found to have greater risk for complications in comparison to normal BMI counterparts. Endoscopic sleeve gastroplasty (ESG) is a newer, minimally invasive procedure for the treatment of obesity which endoscopically reduces gastric volume through an endoscopic suturing system. We present a novel case where ESG was used as a tool for weight loss in a patient who encountered delayed ostomy reversal due to morbid obesity. Case Description/Methods: A 39-year-old man with medical history significant for morbid obesity and medically refractory UC became a candidate for proctocolectomy with an ileal pouch anal anastomosis. However, given the patient’s obesity, there was concern of the J-pouch-end ileostomy being unable to reach the patient’s pelvis. Patient underwent a da Vinci assisted laparoscopic subtotal colectomy with end ileostomy in order to preserve the rectum for a potential J-pouch after his weight loss. Post subtotal colectomy and end ileostomy, patient was referred for endoscopic sleeve gastroplasty due to additional weight gain post-op due to symptom mediated inactivity, thereby further delaying his ostomy reversal and placement of ileoanal J-pouch. Patient underwent endoscopic sleeve gastrectomy (ESG) with effective weight loss, anatomically allowing successful ostomy reversal, completion proctectomy, and J-tube construction. (Figure) Discussion: Future studies are required to determine whether ESG weight loss should be an integral initial step of medical management of IBD in obese patients to inevitably avoid surgical intervention. In summary, ESG may be a pivotal modality as a tool for weight loss in patients with UC and morbid obesity who may encounter delayed proctectomy and ostomy reversal, overall helping contribute to decreased surgical morbidity, complications, and faster improvement in overall quality of life.Figure 1.: Clinical management and BMI over patient's clinical course.

Robotic multiquadrant colorectal procedures: A single-center experience and a systematic review of the literature.

PurposeRobotic surgery has been progressively implemented for colorectal procedures but is still limited for multiquadrant abdominal resections. The present study aims to describe our experience in robotic multiquadrant colorectal surgeries and provide a systematic review and meta-analysis of the literature investigating the outcomes of robotic total proctocolectomy (TPC), total colectomy (TC), subtotal colectomy (STC), or completion proctectomy (CP) compared to laparoscopy.MethodsAt our institution 16 consecutive patients underwent a 2- or 3-stage totally robotic total proctocolectomy (TPC) with ileal pouch-anal anastomosis. A systematic review of the literature was performed to select studies on robotic and laparoscopic multiquadrant colorectal procedures. Meta-analyses were used to compare the two approaches.ResultsIn our case series, 14/16 patients underwent a 2-stage robotic TPC for ulcerative colitis with a mean operative time of 271.42 (SD:37.95) minutes. No conversion occurred. Two patients developed postoperative complications. The mean hospital stay was 8.28 (SD:1.47) days with no readmissions. Mortality was nil. All patients underwent loop-ileostomy closure, and functional outcomes were satisfactory. The literature appraisal was based on 23 retrospective studies, including 736 robotic and 9,904 laparoscopic multiquadrant surgeries. In the robotic group, 36 patients underwent STC, 371 TC, 166 TPC, and 163 CP. Pooled data analysis showed that robotic TC and STC had a lower conversion rate (OR = 0.17;95% CI, 0.04–0.82; p = 0.03) than laparoscopic TC and STC. The robotic approach was associated with longer operative time for TC and STC (MD = 104.64;95% CI, 18.42–190.87; p = 0.02) and TPC and CP (MD = 38.8;95% CI, 18.7–59.06; p = 0.0002), with no differences for postoperative complications and hospital stay. Reports on urological outcomes, sexual dysfunction, and quality of life were missing.ConclusionsOur experience and the literature suggest that robotic multiquadrant colorectal surgery is safe and effective, with low morbidity and mortality rates. Nevertheless, the overall level of evidence is low, and functional outcomes of robotic approach remain largely unknown. Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/, identifier: CRD42022303016.

Post-operative haemorrhage secondary to cinnamon use. A case report.

IntroductionHerbal medicine plays a significant role in modern medicine. The difficulty in integrating the two, lies in the unknown quantities of active ingredients in herbal remedies. This proved true in this clinical scenario. The quantity of coumarin, in the form of cinnamon ingested by this patient over ten months is unknown. The only quantifiable measure was the derangement in his extrinsic coagulation pathway.Presentation of caseA 49-year-old male with a history of celiac disease presented with haematochezia secondary to a malignant adenocarcinoma of the transverse colon. The patient underwent a laparoscopic subtotal colectomy and on the second post-operative day, he was noted to have peritonitis and a positive Fox sign. Diagnostic laparoscopy confirmed intraabdominal bleeding. Over the next four days, the patient's haemoglobin plummeted from 17.4 g/dL to 8.0 g/dL. Investigations revealed an INR of 1.59, which led to further questioning into dietary practices. The patient admitted he had been taking Ceylon cinnamon one tablespoon daily for ten months in the period leading up to surgery.DiscussionCoumarin is a chemical compound readily available in food items such as cinnamon. Coumarin possesses the ability to inhibit vitamin K epoxide reductase complex 1 which is responsible for the recycling of vitamin K. This impedes the gamma-carboxylation of coagulation factors II, VII, IX, X. Vitamin K antagonism can manifest as a prolonged INR and normal activated partial thromboplastin time.ConclusionBleeding diathesis secondary to dietary coumarin is a rare but dangerous phenomenon that emphasizes the need for a thorough interrogation into a patient's dietary history.

The extent of colorectal resection and short-term outcomes in patients with ulcerative colitis.

There is limited literature on the impact of the extent of resection on short-term outcomes in patients with ulcerative colitis (UC) in an elective setting. The aim of this study was to better understand the impact of approach and extent of resection on short-term outcomes for patients undergoing total proctocolectomy (TPC) and subtotal colectomy (STC) for UC. Patients with UC who underwent elective TPC or STC were captured from the ACS-NSQIP® 2011-2018 database and divided into four cohorts: Open TPC (O-TPC), Laparoscopic TPC (L-STC), Open STC (O-STC), and Laparoscopic STC (L-STC). Baseline and perioperative variables were compared between the four groups alongside 30-day mortality and 30-day complication rates. Of 3387 patients, 368 (10.9%) underwent O-STC, 406 (12%) underwent O-TPC, 1958 (58%) underwent L-STC, and 655 (19%) underwent L-TPC. Overall rate of prolonged length of stay (LOS) was 27% and 9% needed a blood transfusion. There was no difference in the risk of complications between open TPC and open STC. Those who had open surgery had a higher risk of complications and prolonged LOS. Patients who had L-TPC had prolonged LOS compared to patients who had L-STC, but less compared to those who had O-STC. Elective surgery for UC is associated with high rates of prolonged LOS and blood transfusion despite MIS approaches. Short-term outcomes and LOS are more impacted by the operative approach than the extent of resection. Despite this laparoscopic TPC has higher rates of prolonged LOS when compared to laparoscopic STC.

Sequential Approach for a Critical-View COlectomy (SACCO): A Laparoscopic Technique to Reduce Operative Time and Complications in IBD Acute Severe Colitis.

Acute severe colitis is the major indication for surgery in inflammatory bowel diseases (IBD), and in particular, in ulcerative colitis (UC). A laparoscopic approach for abdominal colectomy is recommended, due to better perioperative and long-term outcomes. However, costs, time-spending, and outcomes are still a topic of improvement. We designed a standardized 10-steps, sequential approach to laparoscopic colectomy, based on the philosophy of the “critical view of safety”, with the aim to improve perioperative outcomes (operative duration, estimated blood loss, complications, readmissions, reoperations, and length of postoperative stay). We performed a retrospective cohort study using data from a prospectively maintained clinical database. We included all the consecutive, unselected patients undergoing laparoscopic subtotal colectomy (SCo) for IBD between 2008 and 2019 in a tertiary IBD Italian Centre. Starting from 2015, we regularly adopted the novel Sequential Approach for a Critical-View Colectomy (SACCo) technique. We included 59 (40.6%) patients treated with different laparoscopic approaches, and 86 patients (59.4%) operated on by the SACCo procedure. The mean operating time was significantly shorter for the SACCo group (144 vs. 224 min; p < 0.0001). The SACCo technique presented a trend to fewer major complications (6.8% vs. 8.3%), less readmissions (2.3% vs. 13.5%; p = 0.01), and shorter postoperative hospital stay (7.2 vs. 8.8 days; p = 0.003). Laparoscopic SACCo-technique is a safe and reproducible surgical approach for acute severe colitis and may improve the outcomes of this demanding procedure.

Juvenile polyposis syndrome might be misdiagnosed as familial adenomatous polyposis: a case report and literature review

BackgroundJuvenile polyposis syndrome (JPS) is a rare disorder characterized by the presence of multiple juvenile polyps in the gastrointestinal tract, and germline mutations in SMAD4 or BMPR1A. Due to its rarity and complex clinical manifestation, misdiagnosis often occurs in clinical practice.Case presentationA 42-year-old man with multiple pedunculated colorectal polyps and concomitant rectal adenocarcinoma was admitted to our hospital. His mother had died of colon cancer. He was diagnosed with familial adenomatous polyposis (FAP) and underwent total proctocolectomy and ileal pouch anal anastomosis. Two polyps were selected for pathological examination. One polyp had cystically dilated glands with slight dysplasia. The other polyp displayed severe dysplasia and was diagnosed as adenoma. Three years later, his 21-year-old son underwent a colonoscopy that revealed more than 50 pedunculated colorectal juvenile polyps. Both patients harbored a germline pathogenic mutation in BMPR1A. Endoscopic resection of all polyps was attempted but failed. Finally, the son received endoscopic resection of polyps in the rectum and sigmoid colon, and laparoscopic subtotal colectomy. Ten polyps were selected for pathological examination. All were revealed to be typical juvenile polyps, with cystically dilated glands filled with mucus. Thus, the diagnosis of JPS was confirmed in the son. A review of the literatures revealed that patients with JPS can sometimes have adenomatous change. Most polyps in patients with JPS are benign hamartomatous polyps with no dysplasia. A review of 767 colorectal JPS polyps demonstrated that 8.5% of the polyps contained mild to moderate dysplasia, and only 0.3% had severe dysplasia or cancer. It is difficult to differentiate juvenile polyps with dysplasia from adenoma, which could explain why juvenile polyps have been reported to have adenomatous changes in patients with JPS. Therefore, patients with JPS, especially those with concomitant dysplasia and adenocarcinoma, might be easily diagnosed as FAP in clinical practice.ConclusionsJuvenile polyp with dysplasia is often diagnosed as adenoma, which might lead to the misdiagnosis of JPS as FAP. The differential diagnosis of JPS versus FAP, should be based on comprehensive evaluation of clinical presentation, endoscopic appearance and genetic investigations; not on the presence or absence of adenoma.

Laparoscopic subtotal colectomy in the surgical treatment of chronic constipation in patients with dolichocolon

Laparoscopic subtotal colectomy in the surgical treatment of chronic constipation in patients with dolichocolon

Small Bowel Strangulation in The Lesser Sac Following Laparoscopic Subtotal Colectomy

Small Bowel Strangulation in The Lesser Sac Following Laparoscopic Subtotal Colectomy

Comparison of laparoscopic selective colectomy based on barium-strip examination and subtotal colectomy for adult slow-transit constipation.

BackgroundSurgical management of adult slow-transit constipation (ASTC) can be effective for patients with intractable symptoms. This study aimed to evaluate whether barium-strip examination and selective colectomy improved post-operative outcomes in ASTC patients in comparison with subtotal colectomy.MethodsA retrospective cohort study of 53 cases with refractory ASTC was conducted between June 2008 and June 2014. Patients were evaluated by the barium-strip technique, colonoscopy, defecography and anorectal manometry. Patients in the standard group underwent laparoscopic subtotal colectomy and patients in the laparoscopic selective colectomy (LSC) group underwent LSC at the precise location identified by barium strip. Spontaneous bowel movements, the Wexner Constipation Scale and the Gastrointestinal Quality of Life Index (GIQLI) were assessed post-operatively at 3, 6, 12 and 24 months.ResultsA total of 49 patients were included in the analysis. The median follow-up was 37 months (range, 26–60 months). The mean post-operative hospital stay was 12 days and similar between groups (P = 0.071). The length of colon resection, operative time and intra-operative blood loss were reduced in the LSC group (all P < 0.05). No major complications occurred. A similar number of patients (24 in the standard group and 25 in the LSC group) exhibited hypoganglionosis or aganglionosis in the colon-wall muscle layer (P = 0.986). Although there were no significant differences in post-operative spontaneous bowel movements and the Wexner Constipation Scale between the two groups, the mean GIQLI of the LSC group was significantly higher at 3, 6 and 24 months post-operatively (all P < 0.05).ConclusionsLSC based on barium-strip examination is an appropriate modality for treating ASTC.

Early experience with urgent robotic subtotal colectomy for severe acute ulcerative colitis has comparable perioperative outcomes to laparoscopic surgery.

It has been established that patients undergoing subtotal colectomy for UC benefit from a minimally invasive approach, despite the longer operating times associated with laparoscopic surgery when compared to open surgery (Andersson and Söderholm in Dig Dis 27(3):335-340, 2009; Telem et al. in Surg Endosc 24(7):1616-1620, 2010; Wu et al. in Int J Colorectal Dis 25(8):949-957, 2010). Our objective is to present our early experience with urgent robotic subtotal colectomy (RSTC) and compare them to a matched cohort of patients who underwent urgent laparoscopic subtotal colectomy (LSTC). A prospectively maintained institutional database was queried. Six RSTC patients and 13 LSTC patients were identified from 2015 to 2017. There was no difference in ASA score, body mass index, preoperative steroid use, c. difficile infection, or inflammatory markers between the groups. All patients in the robotic group and eight patients in the laparoscopic group received preoperative biologics. Neither group had intraoperative complications, open conversions, or 30-day mortality recorded. Robotic STC took 29min longer (323.0 vs. 294.0min, p = 0.3). There was no significant difference in blood loss between the two groups (80ml vs. 75ml p = 0.9). There were six postoperative complications (46%) in the laparoscopic group and 1 (20%) in the robotic group. Of these 23% (3/13) for LSTC and 0% (0/5) for RSTC were Grade III or higher. Two laparoscopic and 0 robotic patients required reoperation. The RSTC group had earlier stoma function (1.4 ± 0.8days vs. 2 ± 1.3days) and shorter LOS (3.4 ± 2 vs. 4.6 ± 3.2) than the LSTC group, but these did not reach statistical significance. In conclusion, urgent robotic subtotal colectomy for UC is safe and offers technical advantages.

The feasibility of laparoscopic subtotal colectomy with cecorectal anastomosis in community practice for slow transit constipation

BackgroundThe objective of this paper is to demonstrate if slow transit constipation (STC) can be accurately diagnosed, selecting patients appropriate for surgery, and safely perform laparoscopic subtotal colectomy with cecorectal anastomosis (CRA) with acceptable short and long-term outcomes in the setting of medically complex patients in a community practice. MethodsA retrospective study was performed at a private community surgical practice. Cohort involved 10 patients with up to 10 years in follow-up care with a diverse range of ages, body mass index (BMI) and medical conditions. Pre-operative work-up followed a comprehensive algorithm designed to rule out organic conditions and dyssynergistic defecation. The Sitz Mark Colon Transit Study was used to confirm STC. Laparoscopic subtotal colectomy with CRA techniques were used in all cases. Frequency of BMs and patient satisfaction over the study period were tabulated. ResultsAverage post-operative length of stay (LOS) was five days. One early major post-operative complication occurred, however there were no perioperative deaths, anastomotic leaks or revisions of the original surgery after discharge from the hospital. Two patients died due to non-bowel related causes. An incisional hernia was the single long-term complication. Initial post-operative BMs averaged several per day. In the 1–5 year follow-up, BMs tapered down from 1 to 2/day with some laxative use. By the 5th to 10th year follow-up, constipation occurred with 2–3 BMs/week, all requiring an osmotic laxative. Most patients, however, were satisfied with their bowel pattern. ConclusionSurgical candidates with severe STC can be accurately diagnosed and treated with minimally invasive surgery in community practice with acceptable outcomes as compared to outcomes published in the literature.

Laparoscopic subtotal colectomy with double-end ileosigmoidostomy in right iliac fossa facilitates second-stage surgery in patients with inflammatory bowel disease.

There is no consensus about the most appropriate management of rectal stump in laparoscopic subtotal colectomy (STC) performed for inflammatory bowel disease (IBD). The objective is to report our experience of laparoscopic STC with double-end ileosigmoidostomy in the right iliac fossa for IBD. All patients undergoing laparoscopic STC and double-end ileosigmoidostomy in the right iliac fossa for IBD in 2 European expert centres were included. From 1999 to 2017, laparoscopic STC and double-end ileosigmoidostomy in right iliac fossa was performed in 213 consecutive patients, including 74 patients in an emergency setting (35%). Conversion to laparotomy was necessary in 9 patients (4%). One patient died postoperatively (0.5%). Postoperative morbidity occurred in 53 patients (25%) after STC, and was major in 18 patients (8%). A second stage was performed in 199 patients (94%), with a mean delay of 4.7 ± 6months (range 1.4-77). The second stage was an ileorectal anastomosis (n = 50/199; 25%), performed by an elective open incision in the right iliac fossa in 68% of cases; an ileal pouch-anal anastomosis (IPAA) (n = 139; 70%) successfully performed by laparoscopy in 96% of cases; or an abdominoperineal excision with end ileostomy (n = 10; 5%) successfully performed by laparoscopy in 8 cases. After this second stage, postoperative morbidity occurred in 53 patients (27%), and was major in 15 patients (8%). After a mean follow-up of 3.7 ± 3years (range 0.1-15), stoma rate (end ileostomy and diverting stoma not closed) was 17%, and small bowel obstruction and incisional hernia occurred in 10 (5%) and 25 (12%) patients, respectively. Laparoscopic STC and double-end ileosigmoidostomy in right iliac fossa is safe, feasible, and facilitates the second stage for intestinal continuity by either elective incision or laparoscopy in 100% of ileorectal anastomoses and by laparoscopy in 96% of IPAA.

Feasibility analysis on 3D laparoscopic surgery via transrectal extraction of specimens without abdominal incision in the treatment of slow transit constipation

To investigate the safety and feasibility of 3D laparoscopic surgery via transrectal extraction of specimens without abdominal incision in the treatment of slow transit constipation (STC). From May 2015 to January 2017, 8 STC patients (6 females and 2 males) with informed consent were selected to receive subtotal colectomy with 3D laparoscopy as the no-incision incision group, in which the initial part of ascending colon and rectum were end-to-end anastomosed directly after extraction of the specimen through the rectum. Twelve STC patients (9 females and 3 males) undergoing traditional subtotal colectomy with 3D laparoscopy were selected as the traditional group by case matching method (gender, age, BMI, the difference of receiving operation time less than 12 months, same surgeon team). Perioperative parameters (operation duration, intraoperative blood loss, exhausting time, postoperative hospital stay, complications, postoperative pain score and additional pain management), inflammation index at postoperative day 1 and day 3 (leukocyte, procalcitonin, interleukin 6, C-reactive protein), postoperative peritoneal infection, wound healing, short-term and long-term efficacy, patient satisfaction evaluation (subjective hundred-mark system) at postoperative one year were compared between two groups. There were no significant differences between two groups in operation duration, intraoperative blood loss, exhausting time, postoperative hospital stay and morbidity of complication (all P>0.05). Significantly lower pain scores at postoperative 6-hour (median 3.0 vs. 4.5, U=23.0, P=0.042), lower ratio of additional analgesic at postoperative day 1(1/8 vs. 7/12, P=0.040) were found in the no-incision group. Leukocyte level at postoperative day 1 was significantly lower in the no-incision group [(11.0±3.5)×109/L vs. (14.7±3.6)×109/L, t=-2.281, P=0.035]. C-reactive protein concentration at postoperative day 3 was not significantly different between two groups but with different trend [median 78.1(0.1 to 154.0) mg/L vs. 22.0 (7.0 to 55.9) mg/L,U=33.0, P=0.047]. There were no significant differences of interleukin-6 and procalcitonin between two groups(all P>0.05). All the patients had follow-up for 14-31 months. Subjective effectiveness score was 90±9 in the no-incision group and 94±6 in the traditional group without significant difference(t=-1.099, P=0.286). No long-term complications associated with abdominal infection was observed in the no-incision group. 3D laparoscopic subtotal colectomy via transrectal extraction of specimens without abdominal incision in the treatment of STC has similar short-term and long-term efficacies compared with traditional laparoscopic assisted surgery, and does not increase the probability of abdominal contamination.

Metastatic colon cancer derived from a diverticulum incidentally found at herniorrhaphy: a case report

BackgroundThere are few reports of metastases from colon cancer to an inguinal hernia sac, and few reports of colon cancer originating in diverticula. We report a patient with carcinoma of the sigmoid colon arising in two diverticula, who presented with peritoneal seeding to an inguinal hernia sac, and a review of the literature.Case presentationA 55-year-old male underwent open herniorrhaphy for a left inguinal hernia. At operation, a nodule in the inguinal hernia sac was resected and histologic examination revealed adenocarcinoma, which was suspected to be a metastasis from a distant primary lesion. Postoperative evaluation included colonoscopy and positron emission tomography which showed two suspected lesions in sigmoid diverticula. Laparoscopic subtotal colectomy was performed, and pathology revealed adenocarcinoma in two sigmoid diverticula.ConclusionsIf a nodule is found in an inguinal hernia sac, especially in older patients, peritoneal metastases should be considered. Resection of the nodule with histopathologic evaluation is essential. Colon cancer arising in a diverticulum should be considered as a possible site of the primary lesion.

Outcomes of laparoscopic subtotal colectomy with cecorectal anastomosis for slow-transit constipation: a single center retrospective study

Purpose: To study the safety and efficacy of laparoscopic subtotal colectomy (LASC) with cecorectal anastomosis for slow-transit constipation (STC).Methods: This study was a retrospective review of all patients undergoing LASC with cecorectal anastomosis for STC between March 2010 and May 2017. The main variables included the operative time, blood loss, length of postoperative hospital stay, complications, and long-term outcomes.Results: In this analysis, 56 patients were included. There were 17 males and 39 females aged between 34 and 80 years old. The mean operative time was 208 ± 21 min, and the mean perioperative blood loss was 116 ± 48 mL. The mean postoperative hospital stay was 7.7 ± 3.5 days, and the incidence of perioperative complications was 19.6%, with no mortality. One patient required reoperation because of intra-abdominal bleeding. During the follow-up period, 26.8% of patients suffered from chronic pain and bloating, with no recurrence of STC. The causes of these symptoms included small bowel obstruction (7.1%), slow transit (10.7%), anastomotic stenosis (5.4%) and gastroptosis (3.6%). Postoperatively, after 12 months, the frequency of defecation was 2–4 times per day. Patients with follow-up of at least 60 months, the mean frequency of defecation was 0.9 ± 0.5 times per day. The percentage of satisfaction was 82.1%.Conclusion: LASC with cecorectal anastomosis is a safe and effective surgical approach for STC, with the majority of patients being satisfied with the outcome of surgery.

Postoperative course of laparoscopic subtotal colectomy is affected by prolonged preoperative anti-TNF therapy in patients with acute colitis complicating inflammatory bowel disease

The aim of medical treatment of severe acute colitis (SAC) complicating inflammatory bowel disease (IBD) is to avoid surgery, but in 20 to 50% of the cases, colectomy remains necessary. This study aimed to determine the impact of the different lines of medical therapy (i.e., steroids, anti-TNF, or ciclosporin) on postoperative course after laparoscopic subtotal colectomy for SAC complicating IBD. All the patients who underwent laparoscopic subtotal colectomy for SAC were included and divided into two groups: those who presented with postoperative morbidity (group A) and those with an uneventful postoperative course (group B). Preoperative physical, endoscopic and radiological data, and medical treatments were compared between groups. From 2006 to 2015, 65 consecutive patients (32 males, median age=35 [17-87] years) operated for SAC were included. Postoperative morbidity occurred in 19 patients (29%, group A) and was mainly represented by surgical morbidity (n=15), including ileus (n=9), stoma-related complications (n=5), and intra-abdominal abscess (n=4). Lichtiger score, endoscopic and radiological evaluations were similar between groups. Patients with morbidity had more frequently presented two previous episodes of SAC (26%) than those without (7%, p=0.04). Duration of anti-TNF treatment was more frequently longer than 2months in group A (67%) than that in group B (14%, p=0.04). No significant differences between groups were noted regarding other preoperative medical treatments and number of lines therapy. This study suggests that postoperative course after laparoscopic subtotal colectomy for SAC is affected by prolonged preoperative anti-TNF therapy, and in the case of recurrent SAC.