Left Colectomy Research Articles

Totally Laparoscopic Left Colectomy With Preoperative Simulation Using 3D CT Angiography and Intraoperative Navigation Using the Indocyanine Green (ICG) Fluorescence Method

Introduction Laparoscopic reconstruction after left colectomy is mostly performed with functional end-to-end anastomosis through about 5–7 cm sized incision. However, this procedure poses some problems, including increased intestinal mobilization range and parietal destruction, insufficient blood flow to the intestinal tract due to arterial arch malformation, and dominant artery dissection. In this paper, we present a case of descending colon cancer for which totally laparoscopic surgery and intracorporeal anastomosis could be performed safely with preoperative simulation and intraoperative navigation. Case presentation A 34-year-old male was complaint fecal occult blood positive and a colonoscopy was performed. The patient was diagnosed with descending colon cancer cT2N0N0 Stage I. Preoperative CT angiography findings showed that the inferior mesenteric artery (IMA) branched into the left colic artery (LCA) and the sigmoid arteries (S1, S2) in order and showed LCA and S1 as the dominant arteries, and a totally laparoscopic descending colectomy (D2 dissection and S2 artery preserving) was scheduled. At his operation, for investigate blood flow of anastomotic region, ICG was used. After an intravenous injection of ICG, blood flow was evaluated and intestinal dissection was performed at the scheduled dissection line. Intracorporeal anastomosis was then performed using the overlap method and a linear stapler. Conclusion Although the intracorporeal anastomosis procedure has a high degree of difficulty, the use of preoperative simulation and intraoperative navigation may reduce the surgeon's intraoperative stress and enable safe and accurate intestinal dissection and anastomosis in the totally laparoscopic surgery.

Metastatic Malignant Melanoma to Colon from Cutaneous Melanoma: A Case Report

Metastatic melanoma to the Gastrointestinal (GI) tract is rare and the colon is a less common site of GI tract metastasis for this cancer. We report a case of a 76-year-old male with history of cutaneous malignant melanoma since 2018 and two years later he developed metastasizing to the brain, axillary lymph node and descending colon. He was treated with stereotactic radiosurgery (SRS) for single brain metastasis, he subsequently underwent a combined left axillary node dissection and left colectomy. Importance of long-term surveillance and role of 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) and colonoscopy are discussed along with the role of surgical resection in improving survival. Nevertheless, metastatic malignant melanoma to the colon is difficult to identify diagnosis and treatment, multidisciplinary team discussion is necessary to determine the most appropriate treatment strategy.

Metastatic Malignant Melanoma to Colon from Cutaneous Melanoma: A Case Report

Metastatic melanoma to the Gastrointestinal (GI) tract is rare and the colon is a less common site of GI tract metastasis for this cancer. We report a case of a 76-year-old male with history of cutaneous malignant melanoma since 2018 and two years later he developed metastasizing to the brain, axillary lymph node and descending colon. He was treated with stereotactic radiosurgery (SRS) for single brain metastasis, he subsequently underwent a combined left axillary node dissection and left colectomy. Importance of long-term surveillance and role of 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) and colonoscopy are discussed along with the role of surgical resection in improving survival. Nevertheless, metastatic malignant melanoma to the colon is difficult to identify diagnosis and treatment, multidisciplinary team discussion is necessary to determine the most appropriate treatment strategy.

Preserving Inferior Mesenteric Artery during Elective Laparoscopic Sigmoidectomy for Diverticulitis

Background: To evaluate results after Laparoscopic Sigmoid Resection (LSR) with Inferior Mesenteric Artery Preservartion (IMAP) and Superior Rectal Artery Preservation (SRAP), regarding the incidence of anastomotic leakages, denervation of the hypogastric nerves with consequent genitourinary and defecation alterations. Methods: A retrospective PUBMED research from January 2000 to January 2020 was conducted enrollying studies about patients with symptomatic diverticular disease and a surgical indication. Results: A total of 1685 patients with IMAP and SRAP were included in the study. Conclusion: This retrospective review showed that patietns with IMAP-SRAP demonstrated lower leakage rate with reduced incidence of stoma, lower incidence of defecation disorders and a good Quality of Life (QoL) compared with laparoscopic left colectomy with no IMAP.

ICG-Guided Lymphadenectomy during Surgery for Colon and Rectal Cancer-Interim Analysis of the GREENLIGHT Trial.

Lymphadenectomy is crucial for an optimal oncologic resection of colon and rectal cancers. However, without a direct visualization, an aberrant route of lymph node (LN) diffusion might remain unresected. Indocyanine-green (ICG) lymphatic mapping permits a real-time LNs visualization. We designed the GREENLIGHT trial to explore in 100 patients undergoing robotic colorectal resection the clinical significance of a D3 ICG-guided lymphadenectomy. The primary endpoint was the number of patients in whom ICG changed the extent of lymphadenectomy. We report herein the interim analysis on the first 70 patients. After endoscopic ICG injection 24 h (n = 49) or 72 h (n = 21) ahead, 19, 20, and 31 patients underwent right colectomy, left colectomy, and anterior rectal resection. The extent of lymphadenectomy changed in 35 (50%) patients, mostly (29 (41.4%)) for the identification of LNs (median two) outside the standard draining basin. Identification of such LNs was less frequent in rectal tumors that had undergone chemoradiotherapy (26.3%) (p > 0.05). A non-significant correlation between time-to-ICG injection and identification of aberrant LNs was observed (48.9% at 24 h vs. 23.8% at 72 h). The presence of LN metastases did not affect a proper fluorescent mapping. These data indicate that ICG lymphatic mapping provides relevant information in 50% of patients, thus increasing the accuracy of potentially curative resections.

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.

Does the extent of lymphadenectomy and the presence of positive lymphadenopathy influence survival and disease-free interval after left hemicolectomy?

Background: Colorectal cancer currently represents the second leading cause of cancer death in men and the third in women. It is known that approximately one third of these patients will relapse after treatment. It is known that patients with negative lymph nodes have a longer survival than those with tumour lymph nodes. However, the extent of lymphadenectomy in left colectomy is controversial, perhaps because of its technical difficulty. In our study we wanted to relate the extent of lymphadenectomy and the presence of tumour lymphadenopathy to survival time and disease-free interval.

Solid tumor of the spleen: A challenging diagnosis

A 46-year-old man presented with the diagnosis of solid splenic tumor through ultrasonography. History included a laparoscopic left colectomy performed 22 months before for poorly differentiated adenocarcinoma, stage T3N1M0. He was given 4 cycles of adjuvant chemotherapy with capecitabine and oxaliplatin, followed by 4 cycles of capecitabine alone owing to thrombocytopenia. At admission, physical examination and laboratory tests were unremarkable, including serum tumoral markers. Computed tomography (CT) showed a 3 cm attenuating, ill-defined solid mass in the lower third of the spleen, with heterogeneous contrast enhancement (Fig 1).

Robotic left-stapled total intracorporeal bowel anastomosis versus stapled partial extracorporeal anastomosis: operative technical description and outcomes

BackgroundAlthough there is extensive literature on robotic total intracorporeal anastomosis (TICA) for right colon resection, left total ICA using the da Vinci Xi robotic platform has only been described in short case series previously. In this study, we report on the largest cohort of robotic left total ICA, provide a description of our institution’s techniques, and compare outcomes to robotic left partial extracorporeal anastomosis (PECA).MethodsPatients who underwent robotic left colectomy for any underlying pathology from July 1, 2016 through April 30, 2020 were identified by procedure code. A technical description is provided for two unique techniques performed at our institution. Outcomes included operative time, length of stay, supply cost, post-operative ileus, post-operative morbidity and mortality and need for complete mobilization of the splenic flexure.ResultsFrom a review of our institution’s data, 83 robotic TICA cases were identified and 76 robotic PECA cases were identified. Common procedures included low anterior resection, sigmoidectomy, left hemicolectomy, and rectopexy with resection. TICA was associated with significantly shorter intraoperative time compared to PECA.ConclusionsOur series shows that TICA is a safe and feasible technique that does not increase the risk of adverse outcomes. Using either the anvil-forward or anvil-backward technique, we were able to reliably reproduce this method in a total of 83 patients undergoing left colon resection for either benign or malignant diseases.

Factors Determining Postoperative Ileus After Surgery for Colon Cancer: Comparison of Right- and Left-Sided Resections.

The passage of flatus and stool, as well as tolerating a solid diet, represents a crucial moment in recovery after colonic resections. The present study compares functional recovery after left and right colectomies for colon cancer. This is a retrospective analysis. Consecutive patients with elective left and right colon resections were examined. Primary analysis compared time to first bowel motion and development of postoperative ileus. Secondary analyses tried to define risk factors for prolonged restoration of bowel function in right- and left-sided resection groups. In total, 147 patients were included. While laparoscopic approach was preferred for both sides (87% vs. 87%; p=0.496), left colectomies took longer (183 vs. 153 min; p=0.012), the lymph node harvest was smaller (16 vs. 20; p=0.005), and there was an increased need for perioperative fluids (4451 vs. 4039ml; p=0.006). Epidural use, postoperative potassium level, and glycemia were similar. Also, no significant differences were observed for complications and length of stay. First flatus was observed at postoperative day 1, 9 (left), and 2.5 (right), respectively (p=0.002). There was no significant difference in passage of first stool and intake of first solid food. Twenty-seven patients (35%) needed a postoperative nasogastric tube after right colectomy compared to 11 patients (16%) after left colectomy (p=0.012). Right-sided colectomies required the tube for longer (6.1 vs. 3.4; p=0.005). Postoperative ileus was more frequent after right-sided colectomies despite shorter operative time. The reason for this finding is currently unknown and deserves further attention. For the time being, we can just be more cautious with early feeding after right colectomy.

Emergency Digestive Oncological Surgery in Yaounde (Cameroon): Indications and Short-Term Results

Background: Data on emergency digestive oncology surgery are limited in Cameroon. The aim of this work was to give the short-term results of emergency digestive carcinological surgery in our context. Patients and Methods: We conducted a descriptive and analytical observational study with retrospective data collection in four reference hospitals in the city of Yaoundé. Files of patients who had emergency digestive oncological surgery, for an acute complication, from January 1, 2016 to December 31, 2020, were included. The outcomes of the patients in the 30 days following the surgery had to be known. Results: We collected 41 patients, representing 20% of the digestive oncological surgery activity. Their average age was 51.76 ± 16.59 years with a male predominance (63.4%). The cancer complication was inaugural in 27 patients. The main tumor sites were colic (56.1%), rectal (19.5%), and gastric (9.7%). The indications for surgery were: acute bowel obstruction (60.9%), acute generalized peritonitis (29.3%), and gastrointestinal bleeding (4.9%). The tumor was diagnosed intraoperatively in 10 patients (24.4%). The main operative procedures were left colectomy (21.9%) and Hartmann’s intervention (19.5%). The morbidity and mortality rates were 60.9% and 43.9%, respectively. Preoperative anemia (p = 0.019), peritonitis as indication for surgery (p = 0.039) and TNM stage 4 (p = 0.015) were identified as associated with an increased risk of death. Conclusion: In our context, one-fifth of digestive oncological surgery is done urgently in front of an acute complication which is inaugural for cancer in nearly two-thirds of patients. Postoperative morbidity and mortality are significant.

Simultaneous Operation on Pump Coronary Bypass Grafting and Left Hemicolectomy in Patient with Reduced Ejection Fraction

This is written so as to report the case of a 75-year-old male with a diagnosis of sigmoid adenocarcinoma accompanied by critical coronary artery disease and angina, which was subject to simultaneous surgical treatment. Was performed first an on – pump coronary artery revascularization and then a left colectomy. Our case suggests that performing an on-pump bypass in patient also with reduced ejection fraction procedure prior to cancer surgery can be a safe surgical in appropriately selected cases.

Fitz-Hugh-Curtis syndrome

Fitz-Hugh-Curtis syndrome is characterized by inflammation of the liver capsule and the production of adhesions, leading in pain in the right upper quadrant. It´s a rare chronic form of pelvic inflammatory disease that affects women of childbearing age. Curtis described adhesions between the anterior surface of the liver and the abdominal wall in patients with unusual gallbladder episodes during laparotomies in 1930. Similar cases of right upper quadrant abdominal pain were described by Fitz-Hugh, Jr. in 1934. A 40-year-old Caucasian male presented with a progressively abdominal right quadrant pain and left side quadrant pain. He had no medical history but he referred a follow-up for colon diverticulosis from 3 years. He referred satiety and abdominal pain without weight loss fever, nausea and vomiting. Vital signs were within normal limits. Laboratories showed a haemoglobin of 14g/dl, white blood cells (WBC) 8.5x103/ul, platelets 130x103/ul. Liver function tests were normal. CT SCAN showed a diffuse colon diverticulosis and no signs of chlecystitis or other pathologies. A Clisma Abdomen demonstrated sub-stenosis due to inflammatory diverticulitis. He was referred to operating room.During laparoascopic left colectomy,we found adhesions between the anterior surface of the liver and the abdominal wall violin-string like perihepatic adhesions as Fitz-Hugh-Curtis syndrome that justified the right upper quadrant pain too.

Radiofrequency Ablation as an Option to First Stage in Context of Two Stage Hepatectomy for CRLM

A 70-year-old man with a medical history of Hypertension, Coronary Heart Disease, and Coronary Angioplasty. Diagnosed with differentiated tubular adenocarcinoma with liver metastasis (cT3N0M1 EC IVa). The liver metastases located in segments III, IV and VII. Initially submitted to video-assisted radical left colectomy with favorable evolution, in addition to adjuvant chemotherapy. New staging shows secondaryity limited to the liver, resection of the compromised segments supposed a future liver remnant of approximately 31%, for which two-stage liver resection is proposed. Due to comorbidities, the need for a short operating time and minimal bleeding, he underwent radiofrequency ablation of lesions in the left liver associated with ligation of the right portal vein. 12 weeks later, hypertrophy of the left liver was confirmed with a future liver remnant of 49%, without disease progression, completing the right hepatectomy. Control at 18 months without evidence of disease progression.

OV16 MASSIVE COMPLEX INGUINAL HERNIA

Abstract Aim Massive complex inguinal hernias can be exceptionally difficult to repair, especially when they are associated with loss of domain (LOD). We aim to demonstrate an open preperitoneal approach to a complex massive inguinal hernia extending into the scrotum with severe LOD. Material and Methods Footage from clinic, diagnostic imaging, and all operative procedures was included. This included botulinum toxin A (BTA) injection, diagnostic laparoscopy and placement of a peritoneal catheter, outpatient pre-operative progressive pneumoperitoneum (PPP), and the preperitoneal hernia repair. Results A 53-year-old male construction worker with a known inguinal hernia presented with worsening groin and scrotal pain, associated with fever. CT imaging showed an abscess secondary to perforated diverticulitis within his massive inguinal hernia, as well as massive loss of domain with almost all small and large intestine within the hernia. He was treated with antibiotics and percutaneous drainage in preparation for surgery. He received pre-operative bilateral BTA injection in the oblique abdominal musculature. Subsequently, he underwent diagnostic laparoscopy and peritoneal catheter placement. He received 2 weeks of outpatient PPP. He then underwent open inguinal hernia repair with left orchiectomy and total abdominal colectomy. The hernia was repaired with a biologic mesh placed in the pre-peritoneal plane. The patient recovered very well and had no wound complications post-operatively. He has since followed up in clinic multiple times with no recurrence and excellent cosmetic results. Conclusions In this patient with a complex massive inguinal hernia and loss of domain, we demonstrate a successful open preperitoneal repair following pre-operative BTA injection and PPP.

The effect of operative duration on the outcome of colon cancer procedures.

Prolonged operative duration has been associated with increased post-operative morbidity in numerous surgical subspecialties; however, data are limited in operations for colon cancer specifically and existing literature makes unwarranted methodological assumptions of linearity. We sought to assess the effects of extended operative duration on perioperative outcomes in those undergoing segmental colectomy for cancer using a methodologically sound approach. We conducted a retrospective cohort study of patients undergoing segmental colectomy for cancer between 2014 and 2018, logged in the National Surgical Quality Improvement Program datasets. Our primary outcome was a composite of any complication within 30days; secondary outcomes included length of stay and discharge disposition. Our main factor of interest was operative duration. We analyzed 26,380 segmental colectomy cases, the majority of which were approached laparoscopically (64.95%) and were right sided (62.93%). Median operative duration was 152 (95% CI 112-206) minutes. On multivariable regression, increased operative duration was linearly associated with any complication (OR = 1.003, 95% CI 1.003-1.003, p < 0.0001) in the overall cohort, as was length of stay (p < 0.0001). All subgroups except for the laparoscopic left colectomy group were linearly associated with operative duration. In the laparoscopic left colectomy group, an inflection point in the odds of any complication was found at 176min (OR = 1.39, 95% CI 1.20-1.61, p < 0.0001). This study suggests that the risk of perioperative complications increases linearly with increasing operative duration, where each additional 30min increases the odds of complication by 10%. In those undergoing laparoscopic left colectomy, the risk of complications sharply increases after ~3h, suggesting that surgeons should aim to complete these procedures within 3h where possible.

A pilot randomized controlled trial comparing THUNDERBEAT to the Maryland LigaSure energy device in laparoscopic left colon surgery

BackgroundThe THUNDERBEAT is a multi-functional energy device which delivers both ultrasonic and bipolar energy, but there are no randomized trials which can provide more rigorous evaluation of the clinical performance of THUNDERBEAT compared to other energy-based devices in colorectal surgery. The aim of this study was to compare the clinical performance of THUNDERBEAT energy device to Maryland LigaSure in patients undergoing left laparoscopic colectomy.MethodsProspective randomized trial with two groups: Group 1 THUNDERBEAT and Group 2 LigaSure in a single university hospital. 60 Subjects, male and female, of age 18 years and above undergoing left colectomy for cancer or diverticulitis were included. The primary outcome was dissection time to specimen removal (DTSR) measured in minutes from the start of colon mobilization to specimen removal from the abdominal cavity. Versatility (composite of five variables) was measured by a score system from 1 to 5 (1 being worst and 5 the best), and adjusted/weighted by coefficient of importance with distribution of the importance as follow: hemostasis 0.275, sealing 0.275, cutting 0.2, dissection 0.15, and tissue manipulation 0.1. Other variables were: dryness of surgical field, intraoperative and postoperative complications, and mortality. Follow-up time was 30 days.Results60 Patients completed surgery, 31 in Group 1 and 29 in Group 2. There was no difference in the DTSR between the groups, 91 min vs. 77 min (p = 0.214). THUNDERBEAT showed significantly higher score in dissecting and tissue manipulation in segment 3 (omental dissection), and in overall versatility score (p = 0.007) as well as versatility score in Segment 2 (retroperitoneal dissection p = 0.040) and Segment 3 (p = 0.040). No other differences were noted between the groups.ConclusionsBoth energy devices can be employed effectively and safely in dividing soft tissue and sealing mesenteric blood vessels during laparoscopic left colon surgery, with THUNDERBEAT demonstrating some advantages over LigaSure during omental dissection and tissue manipulation.ClinicalTrial.gov # NCT02628093.

Minimally invasive right versus left colectomy for cancer: does robotic surgery mitigate differences in short-term outcomes?

Studies comparing right (RC) and left colectomies (LC) show higher rates of ileus in RC and higher wound infection and anastomotic leak rates in LC. However, prior studies did not include robotic procedures. We compared short-term outcomes of laparoscopic and robotic RC and LC for cancer, with sub-analysis of robotic procedures. In a retrospective review of a prospective database, preoperative factors, intraoperative events, and 30-day postoperative outcomes were compared. Student's t tests and Chi-square tests were used for continuous and categorical variables, respectively. A logistic binomial regression was performed to assess whether type of surgery was associated with postoperative complications. Between January 2014 and August 2020, 115 patients underwent minimally invasive RC or LC for cancer. Sixty-eight RC [30 (44.1%) laparoscopic, 38 (55.9%) robotic] and 47 LC [13 (27.6%) laparoscopic, 34 (72.4%) robotic] cases were included. On univariate analysis, RC patients had significantly higher overall postoperative complications but no differences in rates of ileus/small bowel obstruction, wound infection, time tofirst flatus/bowel movement, length of hospital stay, and 30-day readmissions. On multivariate analysis, there was no significant difference in overall complications and laparoscopic surgery had a 2.5 times higher likelihood of complications than robotic surgery. In sub-analysis of robotic cases, there was no significant difference among all outcome variables. Previously reported outcome differences between laparoscopic RC and LC for cancer may be mitigated by robotic surgery.

Risk of anastomotic bleeding after left colectomy with preservation of inferior mesenteric artery for diverticular disease: preliminary results.

The inferior mesenteric artery (IMA) preservation in elective laparoscopic left colectomy for diverticular disease may reduce the risk of anastomotic leakage. However, an increased risk of bleeding is assumed. The aim of this study was to investigate the risk of colorectal anastomosis bleeding when IMA is resected or preserved during left colectomy. A retrospective study of a prospectively collected database was performed. All patients who underwent elective left colectomy, from December 2018 to September 2020 were included. Patients' data and clinical information were collected and analyzed. Patients were categorized in two groups: IMA resected (IMA-R) and IMA preserving (IMA-P) left colectomy. Perioperative outcomes between the two groups were compared. Sixty-three consecutive patients who underwent left colectomy over a period of three years were enrolled: 42 in IMA-R group and 22 in the IMA-P group. There were no significant differences in demographic and intraoperative characteristics between the two groups, except for patients' age and primary disease. Six patients (9.37%) developed anastomotic bleeding during recovery, more frequently in the IMA-P than IMA-R group, although the difference is not statistically significative (13.6% and 7.3%; P=0.406). All bleedings were self-limited and only one needed red blood cells transfusion. Using the bioabsorbable staple line reinforcement (BSLR) has proved to be advantageous in preventing anastomotic bleeding in the IMA-P group. IMA preserving left colectomy seems to be associated with a higher risk of mostly self-limited anastomotic bleeding during recovery. BSLR seems to be effective in this group of patients.

Management of intraoperative complications during laparoscopic left colectomy.

Minimally invasive surgery has gained a major role in the current management of colorectal disease since the introduction of laparoscopy in the early 1990s for colorectal procedures. The laparoscopic approach, in fact, is not exempt from the risk of intraoperative complications, some of which can occur outside the field of view. The aim of this chapter was to review the different types of complications that can happen during left colectomy, analyzing the causes, how to prevent them and what to do in case they occur. A literature search was carried out using the MEDLINE and PubMed databases for studies published between January 1980 and October 2020. The following terms were used for the search: "complications," "risk factors," "colorectal surgery," "colorectal resection," "laparoscopy," "left colectomy," "intraoperative complications," "splenic injury," and "intraoperative bleeding." From our literature search we identified twenty-four studies, including two systematic reviews and metanalyses, that were the most pertinent to the subject. Many different complications can occur during laparoscopic left colectomy. Maintaining control of the situation is important to provide a prompt solution to the occurred injury. Increasing the reporting rate of complications may help, in the future, to analyze the causes and improve management strategies, keeping in mind that the only surgeon who does not have complications is the one who does not operate.